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5*7- " - "rfTi*"^' . -^ *:n - ' - '
■ l^^*hi*'ii iiLliuJIiv^^-mpH^M
ihl^WilrOTTrirt
Boston
Medical Library
8 The Fenway
2=
T *V
«•
The American Physician
[Phila., January. 1922
Haa decide
tsides showing
more prompt ]
remarkable de-
inflammatio
i of freedom
congestion rcl
heart-depres-
properties t
kidney irritant,
Salicylates,
ting and cumu-
complex.
sffects.
Information, Lilen
& GLATZ, INC.
Ample Trial Quantity from
150 Maiden Luo, New York
RHEUMATISM
IABETIC FLOUR
Starch-free. Produces Bread.
Muffins. Pastry that makes the
distressingfeatures
TEs
Grow
Lessand
Litter* prepared catcia Diabetic Floni — telf ruing. A month'* tupply cf 30 boxes $4.85
LISTER BROS. Inc., 405 Lexington Avenue, New York City
Vol. U No. 7. Pvbliihid monthly— Th* Taylort; C. C. Taylor, Publuher; Mrs. J. I. Taylor, Ed. Mgr.
rid at iicond-clati mattir Fib. IS, 'W, «* '*« t<"t <>$" «' Phitadilfhia, Pa., uniir Act of March }, rSn,
"Moil Widely Circulated Medical Monthly" The American Phytician continuing the quartet century of diitinctive lei-vice of
Copyright 1922, by The Taylor,. Publuher.; 420 Walnut St.. Philadelphia. U. S. A.
An Honest j/grfcgj Place
]VJ ORE people die from pneumonia than
any other disease.
Approximately 25 out of every 100 cases end
fatally. Dr. Gustav Goldman has demon-
strated that at least twenty of these twenty-
five deaths may be prevented by employing
Bacterial Vaccines.
Why delay and chance a fatal termination?
Dr. CujIeV GoUman'i article ofipealtl in American hftdiciue. March, 1921
Bi(ltrltlfl(lcil IjibonturieB of
G. H. SHERMAN, M. D.
DETROIT, U. S. A.
You can buy with Confidence — See "Service Guarantee to Reader^' on page 82
The American Ph\/sician [pui*.. jnur* 193a
. ■ • \
Fat Soluble A and Rickets
"In cases where rickets or growth failure or xero-
phthalmia are already well established, a daily dose
of cod-liver oil is essential to all other procedure."
What modern science has done to assure pure
milk, it has also done (or cod-liver oil.
The "S. & B. PROCESS"
Clear Norwegian (Lofoten) Cod-liver Oil
is pure oil from selected, healthy livers of
fresh caught True Gadus Morrhuae, that
may be prescribed with the same confi-
dence that you would certified milk.
Produced in Norway Liberal sample* to
and re fined in America. phyeician* on request.
SCOTT & BOWNE, BLOOMFIELD, N. J.
Makers of Scott's Emulsion
.J
AN IDEAL ARSENICAL
SODIUM DIARSENOL
SODIUM ARSPHENAMINE
Sodium Diarsenol marks a distinct advance in syphilology. It. dissolves
very quickly in water, giving a solution ready for immediate injection. No
addition of sodium hydroxide is necessary. It has the therapeutic advantage
of arsphenamine with the solubility and convenience of neoarsphenamine,
and gives clinical results equal to or better than either of the two latter com-
pounds. Neutralization with alkali being obviated, there is no undue hand-
ling and consequent decomposition of the highly reactive solution.
SODIUM DIARSENOL has been accepted by the Council on Pharmacy and
Chemistry of the American Medical Association for inclusion in "New and Non-
official Remedies."
Smmpl** *mf Litmratmrm on pf— 1 1
DIARSENOL COMPANY, Inc.
BUFFALO BOSTON ATLANTA
You can buy with confidence — See "Service Guarantee to Readers" on page 82
The American Phjiidio]
An Honest Market Place
LOESER'S INTRAVENOUS SOLUTIONS
Accepted by the Council
I LOESER'S INTRAVENOUS SOLUTION
OF
MERCURY OXYCYANIDE
oule. See contain! 8 milligram! (JJ8 gr.) Mercury Oxycyantit
The result of years of study of the chemical, physical, and
clinical properties of mercury salts employed in syphilis. The
evident irregularity of absorption, the pain and irregular clinical
results have long suggested the intravenous administration of
mercury.
Intravenously, Mercury Bichloride, and other so-called sol-
uble acid salts have proved impractical as they cause phlebitis
and hardening of the vein, preventing continued routine of injec-
tions. We have ascertained that this fault is associated with the
ionization of the solution employed.
Mercury Bichloride solution, 1 6 milligrams ( J4 grain) in
5cc has H-ion Cone of Ph 4.5-5. LOESER'S INTRAVENOUS
SOLUTION OF MERCURY OXYCYANIDE shows H-ion Cone,
of Ph 7, approximately the H-ion of normal blood. We offer
this solution as being free from the objectionable qualities of
other soluble salts of mercury, permitting an intensive and con-
tinued routine of mercury in syphilis.
Tested Chemically, Clinically and Biologically
TOXICITY TEST of
LOESER'S INTRAVENOUS SOLUTION «f
MERCURY OXYCYANIDE
(Animah used — White Rati)
Intravenous Method employed.
15 timet normal human Jan.
New York Intravenous Laboratory
100 WEST 21ST STREET
NEW YORK, N. Y.
Producing Ethical Intravtnciu
Solution tor At Medical
Ptofeuion Exclusively.
Mentioning The American Physician Insures Prompt, Careful Service
The American Physician tPbai., j«,u«ry, i«2
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The American Physician]
An Honest Market Place
THE REMEDY FOR HEMORRHAGES
STYPTYSATE
Not Subject to Narcotic Law
Two Cases of Interest Where Styptysate Was Used
Mrs. E. M., age 30. Menorrhagia of five years, with menses
of ten days' duration, at times more profuse than at others, some
dysmenorrhea which caused her to go to bed.
January 10, 1921, 8 a. m. — Patient unable to sit up. Pre-
scribed Styptysate in dose 15 gtts., t. i. d 9 p. m. — Better,
less pain, less discharge. January 11, 1921 — Improving.
January 12, 1921 — Feeling O. K. Menses four days in-
stead of ten as heretofore. Expect to see less trouble next
time, as action in this case was remarkable in the light of
previous experience.
Mrs. A. S., age 39. Uterine hemorrhage following miscar-
riage at five months.
Called January 11, 1921, 2 a. m. Administered Styptysate
as indicated hemostatic. Reult very satisfactory.
I believe from clinical observation thus far made you have
in Styptysate a meritorious hemostatic, etc.
B. H. M., M.D., Kansas City, Mo.
Dose: gtts. x-xv or more by mouth, or in ampules for
intra-muscular injections. Prescribe in 10 c.c. bottles.
Samples and literature on request
INTRODUCTORY OFFER
One Dozen Bottle* of STYPTYSATE for $5.00
«
Fill out, detach and mail the corner coupon with N. Y. draft
for $5.00, and we will send you one dozen bottles of Styp-
tysate. 85
For
$5. enclosed send
1 dozen bottles of
STYPTYSATE as
per Introductory Offer
rtvfem. 9+m*w* ti ■ - ^-». • of Ernst Bischoff Co.
ERNST BISCHOFF CO., Inc. ,■■■"'
7 Name
85 W. Broadway
New York Address
Mentioning The American Physician Insures Prompt, Careful Service
8
Contents
Copyright, 1920. by The Taylors, Publishers.
Editorials
Are Not Remedies for Ordinary Ailments Unduly Neg-
lected? Active Drugs Fallen Into Disuse 19
Modifying Milk for Sick Adults 20
Our Medical Schools Over-Manned 21
Gastric Neuroses 21
The Treatment of Tuberculosis In General Hospitals... 22
Original Articles
Comparison of the Old and the New In the Treatment
of Syphilis
By D. Alexia Myers, M.D., D.D.S 23
In the treatment of syphilis the old saying aptly
applies, that medicine is an art as well as a science.
Laboratory findings must never, and cannot, usurp
the results of clinical findings. Injections of this or
that medicament are not to be regarded as all that is
required, and all cases are not to be treated alike.
Diagnostic Difficulties and Treatment of Empyema of
the Antrum of High more
By D. T. Atkinson, M.D 27
"The pain incident to a diseased antrum is often
referred to the eye or the temporal region, la attrib-
uted to neuralgia or eye strain," or teeth, or even
abdominal or pelvic morbidities. Considering the
diagnostic difficulties and the Importance of the sub-
ject, the paper of Dr. Atkinson's should receive the
wide attention it is justly entitled to.
The Proper Function of Radium
By A. L. Blesh, M.D., F.A.C.6 29
Radium is the talk of the hour. The hope of multi-
tudes of sufferers, pierced by the deadly tentacles of
the cancerous octopus, is focused upon this agency.
Will tfyese expectations be realized? Will the problem
of the day be solved? What are really the possibili-
ties, probabilities and potentialities of this thera-
peutic star? Dr. Blesh is neither dreamer nor con-
demned He has studied radium in the practical
domains of the hospital clinic and surgical laboratory
and narrates his findings in this excellent paper.
Reasons for Anesthetics In Obstetrics
By Frank R. Fursey, M.D 31
The anesthetic in obstetrics is a little question of
"great" importance. The safety of the mother, the
life of the baby, the duration of labor, the degree of
suffering, the anxiety of the family and the reputation
of the physician are all factors demanding considera-
tion. The discussion and recapitulation of these
points by Dr. Fursey In this practical, clear, short
paper are certainly well worth reviewing.
A Result With Acid Fruits In Typhoid
By D. W. Reed, M.D 32
One Hundred N euro -Psychiatric Cases Emphasize the
Importance of Prophylaxis and Early Recognition
By W. W. Young, A.B., M.D 33
The nervous system is a sensitive apparatus, con-
stantly registering impressions of intensities and
degrees proportionate or non-proportionate to result-
ant effects. The average mind is normally stable and
tenaciously recuperative. Often, though, physical,
pathologic or emotional actions are followed by
untoward reactions which badly dissociate psychic
equilibrium — and the mental kingdom "goes wrong."
From this point of view the "Impressions" of Dr.
Young are as interesting as instructive.
A Case of Tuberculous Peritonitis, and a Case of Post-
Diphtheritic Paralysis
By A. MacKensle Forbes, BCD 35
The eleventh paper of a series of clinics published in
monthly installments, each paper complete in itself —
a practical post-graduate course.
(Content* continue** on pagm 10)
HINOSOL
"A POWERFUL ANTISEPTIC, SOMEWHAT STRONGER IN
THIS RESPECT THAN MERCURIC CHLORIDE AND CONSID-
ERABLY STRONGER THAN PHENOL."
(COUNCIL ON PHARM. AND CHEM. A. If. A.)
'AsepmkonS"
/ VAGINAL
^SUPPOSITORIES
producing complete antisepsis
But
Non-poisonous, Non-irritating and No injury to membranes
Indicated in cervicitis, leucorrhea,
specific and non-specific vulvo-vaginitis, in all cases
where complete vaginal antisepsis is desired.
PARMELE PHARMACAL CO., 47-49 WEST STREET, NEW YORK.
You can buy with Confidence — See "Service Guarantee to Readers" on page 82
The American Physician]
An Honest Market Place
A remarkably efficacious
remedy in furunculosis
The curative effects of yeast
described by physicians and physiological
chemists
The successful use of yeast in certain maladies has been dem-
onstrated by careful tests. In leading institutions in New York
and Philadelphia the yeast treatment was given in 17 cases of
furunculosis.
The tests were carried on under
the direction of Philip B. Hawk,*
Ph.D., by Frank Crozer Knowles,
M.D., Martin E. Rehfuss, M.D.,
and James A. Clarke, M.D., with
the collaboration of Olaf Bergeim,
Ph.D., H. Rodell Fishback, M.D.,
Sc.D., Clarence A. Smith, Ph.D.,
and Robert A. Lichtenthaeler, M.S.
The cases covered such condi-
tions as single large boil; boils a
week apart for two months; and
periodic boils for years. One pa-
tient had several large boils which
did not yield to vaccine. After
three cakes of yeast daily for two
weeks the boils disappeared. A
boil started on the leg after yeast
was stopped. The yeast treatment
was resumed. The boil soon cured.
Fleischmann's Yeast was used
throughout the investigation — as
being not only the most readily
available, but also because it gave
assurance of absolute uniformity
and purity.
The conclusion of Dr. Philip B.
Hawk and his associates is: "In
furunculosis, yeast is a remark-
ably efficacious remedy. Its cura-
tive action in these cases is no
doubt aided by the leukocytosis
which is developed."
The usual dosage in these cases
was three cakes a day — plain or
suspended in water, beef-tea, or
orange juice — generally before
meals. In some cases, because of
the laxative action of the yeast,
it was necessary to reduce the
dosage.
With patients troubled with gas
formation, it was found prefer-
able either to administer yeast
between meals, or else to "kill"
the yeast by placing it in boiling
water for a few minutes. The
action of the "killed" yeast proved
to be much the same as that of the
living yeast.
A full report of this test can
be found in the Journal of the
A.M.A. for October 13, 1917, ynder
the title: "The Use of Baker's
Yeast in Diseases of the Skin and
of the Gastro-Intestinal Tract."
Fleischmann's Yeast may be ob-
tained fresh daily from all grocers.
Physicians may write to The
Fleischmann Company in the
nearest large city and a supply
will be mailed direct on the days
wanted.
The Fleischmann Company, 701 Washington Street, New York, N. Y.
Mentioning The American Physician Insures Prompt, Careful Service
The American Physician
[PhiU.. jinusry. 1923
Light and Hut in Skin Dim mi boa
been Proven,
In the microbic skin diseases,
such as acne, furunculosis, erysipe-
las, tinea sycosis, and similar infec-
tions, the
STERLING
THERAPEUTIC
LAMP
baa been found of distinct value. Heat
waves bring pure arterial blood to the
part and take away the venous blood
by dilating the smaller vessels in the
periphery. The main action of the
lamp, however, in germ or microbe dis-
eases is, that the germs cannot live in
light. The penetrating effect of the
2000 c.p. lamp is fatal to most germs
in 10 minutes' time.
Illustrated booklet and literature sent on
Sterling Therapeutic
Lamp Co.
546 Garfidd Ave. Chicago, IB.
Dub 203
Contents—™,
tinned from pa ft 8
Importance of Differential Diagnosis In Acute Eye I
By L.. F. Long. M.D 34
To the general practitioner the eye appears to be a
subject not worthy of serious study. The result Ls
., — — j,., — ..,_.,,__ _ ~«wajdiy but profoundly dls-
t condition
mllar
glau
a and Iritis, 1
often regretfully confused. Such being the case, a r
view of the important points on the usual inflamma-
tions of the eye Is certainly not out of place.
Chronic Bronchitis and Pulmonary Infections Other
Than Tuberculosis 42
Skilled Tachnlc Required for Best Results In Tonsil-
lectomy Under Local Anesthesia
By F. A. Grafe, A.B., M.D 43
Recently a dictum pervaded the medical press that
"anybody can remove a tonsil." Alnsl solt 11! Just
as readily as anybody can play a piano, and the
longer you watch Faderewskl. the easier It appears.
But those who have never put their capabilities Into
actual practice, may well consider a few preliminary
details before giving a public exhibition.
An Efficient Future for Medical Practice
Is the Government Letting Down the Bars to Quack-
ery T _ ■
ntt„ „ - .„
have the medical services of Army and Navy, the
Public Health, or the American Medical Association,
done In protest against it?
Harmony Where General Practitioners and Specialists
* Come In Contact
By H. W. Champltn, M.D 47
Bast Current Medical Thought
Danger from Automobile Exhaust Oases..-,.. 60
Sale of Horsehair Shaving Brushes Prohibited... SO
Shall the Calories Be Forgotten! BO
The Effects of Undernourishment M
The Path of Infection In Pneumococclc Invasion of the
Lungs In Man »4
Treatment of Tuberculosis 86
Health Insurance"! «•
Symptomatic Treatment of Pneumonia S»
Orthostatic Albuminuria »•
Book Reviews
Tropical Ophthalmology ,-. BS
Injuries to Joints 8?
Pharmaceutical Botany of
1 Methods SO
Dial
SUBSCRIPTION TERMS
33.09 for Two Years (31. SO s ye
3S.0Ofor Four Year. ($1.25 aye
310.00 for TerfYesrs (Oniy $1.00 „ Y.
Canada, ZSc; Foieign, 60c a
Monmy Back Gat
The American Physician is published to give truly batata
service ef s needed practical character in the problem* of every
day practice.
If any subscriber feels that The American Physician la ■
firing him full measure of such service and is dlssstlstid. If
■ill write as <rc will cheerfully refund the money he paid I
subscription, without question.
The American Physician seeks only satisfied. Interested n
Where this Is not the subscriber's wish It
Subscribers are expected to
ess to stop the journal if j
You can buy with Confidence— See "Service Guarantee to Readers" o
The American PfeysfcUn]
An Honest Market Place
11
IN JANUARY. 191?
the: bacillus acidophilus
was introduced and made available to tbe medical profession
FOR THE FIRST TIME
tbrougb
BACID PREPARATIONS
wbicb "were created solely to make possible tbe tberapeutic use of tbis
antiputrefactive organism wbicb has now been used continuously
for nearly five years tbrougb tbis exclusive distribution.
BACID PREPARATIONS
TABLETS- CAPSULES-LIQUID CULTURES
do not now and never have contained tbe
B. bulgaricus — eitber Type A or Type B
LITERATURE-BIBLIOGRAPHY-ON REQUEST
Guaranteed and Majntfactared ONLY by
ARLINGTON CHEMICAL COMPANY
YONKERS, N. Y.
THE
MM«
*mm
u
Home Treatment In
Tuberculosis
With over a million active cases of tuberculosis, home treatment is
absolutely necessary. It consists of rest, food and fresh air supple-
mented by proper medical attention and medication.
Dr. Beverly Robinson has stated "that we have absolutely no medi-
cal treatment of pulmonary tuberculosis at all equal to the creosote
treatment properly used and insisted upon."
Mistura Creosote Comp. (Kilgore's) contains the genuine wood
creosote unchanged by the addition of chemicals and will meet all the
requirements of the creosote treatment.
Dose : — Teaspoon ful in one-third of a glass of milk or water after
meals.
Sample Sent To Physician* On Request
CHARLES KILLGORE
Manufacturing Chemist Established 1874
82 FULTON STREET NEW TORE
1
Mentioning The American Physician Insures Prompt, Careful Service
The American Physiaatx
WINTER COLDS
often manifest their greatest activity in connection with the respiratory tract.
The resulting bronchitis may be resistant to treatment. The use of creosote in
these cases of acute inflammation of the respiratory tract has yielded beneficent
results.
CALCREOSE is a mixture containing in loose chemical combination, approxi-
mately equal parts of creosote and lime.
CALCREOSE has creosote action, but does not cause any unto-
gastTo-intestinal tract.
■ be taken in comparatively large doses— ^ in
olution — without any disagreeable by-effects;
it is particularly suitable for the treatment
patients.
;tite is increased; digestion is stimulated ; nutri-
roved; weight added; expectoration dimin-
is in the sputum is lessened; physical resistance
is increased.
Pricai — Powder, lb., $3.00 (prepared by adding
1 lb. to I gallon of weter).
Tablet*, 4 gr., 1,000, $3.00; 500, $[.60; 100, 40c.
Sample* (tablet*) and literature free.
The Maltbie Chemical Co., Newark, N. J.
The Prevention of Weak, Tender Feet
is one of the notable benefits that
logically result from wearing
O'Sullivan's Heels
It is a well known fact that abnormal conditions of the foot structures
are often brought about by shoes with hard, rigid heels, and lacking
in flexibility. Free movement of the muscles is prevented, muscular
tone is lost, and sagging of the arch naturally tends to follow.
The UK of O'Sullivan's Hull, therefore, is a simple but
exceedingly effective mean* of promoting the health and
strength of the feet.
0'SULUVAN RUBBER CO., he
New York City
i Confidence — See "Service Guarantee to Readers" on page 8
The American Physician]
An Honest Market Place
SANTYL
■REATJ
The Neutral SoUeytie
Ester of Samtalol
for the INTERNAL TREATMENT of
Dose: 3 capsules 3 or 4 times daily
I.iltraturi and icmjilii from
K. BILHUBEK, Int. 45 John St. New York
\7T? A Q TPafXTW TT7 jm The purified active principles
I E/\.5 1 V-/LNE and VlTAMINES OF YEAST
GIVEN IN PLACE OF YEAST FOR MEDICINAL PURPOSES
Keeps well Pleasant to take Reliable
Literature and Sample on request
MERCK 8C CO. 45 Park Place New York
KgcKag)!
When the Lumen of the Alimentary Canal is
Contracted by Adherent Fecal Material
THOUSANDS of patienti have a daily movement of the
bovreli, yet they suffer from constipation, auto- intoxica-
tion and intestinal absorption.
b J6 feet of h _. ,
irdened feces, the toxitin from which ara constantly
being taken up Dy the system.
Ordinary laxatives have llltle or no affect on this condition. The
mass must first be lubricated and loosened from Its point of contact.
McKesson & Rabbin. Liquid Albolene — refined from pure Russian
Mineral Oil — far Its principle of "mix. spread and lubrication", softens
and lubricates this mass. It facilitates its cxpulilon, thereby over-
coming auto -intoxication and the disturbed metabolism brought
about by this condition.
Remember that Sir Atbuthnot Lane's experiments, which definitely
with dried a
establish
,*rE
,tive. v
It la the only n
ral oil fro
i which r
o/f/amo.
ults
s made with
mfidently fa
McKESSON & ROBBINS, Inc.
Manufacturing Chemist
I 1833 NEW YORK CITY
Whaa
Ha prescribe
UanUAIbotSB*
Mentioning The
Physician Insures Prompt, Careful Service
The American Physician
i
Two Effective
Vitamine Preparations
u normally pwMnt in
B (amineuriiicl— i wattr-eoluble vinmtot found abundantly
uu and the pericarp and germ of Bra Int.
C (anHacorbutlc)— ■ water-eohible vitamine of clout fhilu
and certain vegetable*.
Prescribe Metagen in all cases of vitamine deficiency— rickets, scurvy, mal-
nutrition, marasmus and other disorders of metabolism. It Is a valuable
adjuvant in the dietetic treatment of tuberculosis, anemia, and the asthenia
incident to the convalescence from acute infections.
EMULSION METAGEN AND COD-LIVER OIL
This product exhibits not only the native fat-soluble vitamine of the
finest Norwegian oil, but also Metagen— the fat-soluble vitamine from vege-
table sources, as well as the water-soluble vitamlnes.
Considering the pathogenesis of rickets, no available medicament more
clearly meets the therapeutic indications than Emulsion Metagen and Cod-
Liver Oil— a powerful tonic and metabolic stimulant, containing active con-
centrates of all the vitamines and an augmented supply of the antirachitic
vitamine.
The Emulsion naturally suggests itself as a suitable prescription also in
cases of malnutrition, scurvy, and other conditions due to vitamine impov-
Parkc, Davis & Company
You can buy with Confidence — See "Service Guarantee to Reader/1 on page 8
An Honest Market Place
END0FERAR5AN
(Anenuu)
v frva and Arsenic
ENDOQUIN
(Malarias)
Quinine Hydrtx/i/a,jj*
f ND0-S00IUM IODIDE
(Asthma)
2 Am or ■JsMfium JbdXe
ENDOMETHYLENAMIN
ENDOARSAN
(3yj>h.Ur)
ri — u../ '-,/lhntjr
Direct Medication by the Intravenous Method
To the modern physician,
awake to the advantages of
Direct Medication, we offer
a complete line of pure and
stable products which may
be injected into the blood
stream with the certainty of
no untoward effects.
Send for catalogue giving
complete formulae of our s pe-
dalnee. Reprints of interest-
ing articles and price list will
accompany it. Correspond-
ence is invited and wul be
promptly replied to by one of
the physicians on our staff.
ENDOGLOBIN
ENDOSAL
ENDOCRE001N
(bndtf WKfaiuH Affecting
ENDOCAODIN
(Tuberculmis)
Ctfautl, V/iln&HiiM/.
END0MER5AN
(ftrabro-5piji»^ .Willis)
Mtiiwy.Diml
Intravenous Products Co. of America, Inc.
121 Mad i3ort Avenue, Ne-w? \&rk. City
Mentioning Tht American Physician Insures Prompt, Careful Service
16
The American Physician
[Phil*., January, 1922
After All the Patient Is the
One Most Concerned
THE patient is the sick man.
He is the sufferer. It is he
who seeks — and expects — relief.
He is the one most concerned.
What do you do for him?
You diagnose, you prescribe, and
sometimes you proscribe certain
foods. But do you unreservedly
rule out for every case eggs, milk,
tomatoes, strawberries, red meat,
and dozens of other foods for
which some few people have
idiosyncrasies? No! You first de-
termine what f oods, if any, would
be harmful in each particular case,
and rule accordingly.
Then why issue, as is too fre-
quently done, a sweeping dictum
against coffee?
As you know, coffee can fre-
quently be enlisted as a therapeutic
aid. It is a mild cardiac stimulant ;
it relieves muscular and mental
fatigue; it accelerates peristalsis;
is mildly laxative; is an antidote
for certain poisons ; and is an appe-
tite excitant. What greater stimu-
lus to appetite is there than the rich
aroma of steaming coffee? And
maintaining a patient's appetite is
important !
Dr. Julius Friedenwald and Dr.
John Ruhrah, of the University of
Maryland School of Medicine, Bal-
timore, in their joint work, "Diet in
Health and Disease" frequently
include coffee in the breakfast
dietaries ; and Dr. Torald Sollman,
of Western Reserve University,
Cleveland, in his "Manual of Phar-
macology" says coffee "increases
mental and physical efficiency,
psychical stimulation, comfort and
relief from muscular and mental
fatigue and from their attendant
unpleasant sensations. These ef-
fects may be useful in certain con-
ditions, as in those exposed to
severe hardship, hunger, fatigue,
etc."
We believe a study of the cases in
your own practice will convince
you conclusively that there are few
patients, indeed, for whom coffee is
contra-indicated. We believe that
such a study will convince you, too,
that coffee can be enlisted as a
beneficial agent bordering on the
field of active therapy.
Why impose an unnecessary re-
striction on your patients? Why
overlook a possible therapeutic aid?
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STRENGTH FOR
THE ASTHENIC
Suprarenal insufficiency is one of the marked features of the asthenias.
The blood pressure in these individuals is almost always low and the cir-
culation poor. The activities of other glands of internal secretion are
always impaired. That is why pluriglandular therapy gives better results
than suprarenal substance given alone.
Hormotone
which is a combination of
thyroid (1/10 gr.), entire
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increases blood pressure and
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three times daily before meals.
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The Am
encan
Physici
ician
>'
^1
0-
3
V*L 27
January, 1922
Afc. 1
Are Not Remedies for Ordinary Ailments
Unduly Neglected?
Active Drugs Fallen Into Disuse
OLD MEDICAL LITERATURE deals with
many drugs empirically, ascribing curative
powers to many substances that modern sci-
ence shows are possessed of little definite activity.
Yet science may overlook an important point in drug
activity, even as science ascribed no value to the
tomato as a food while blissfully ignorant of the
role played by vitamines and that the tomato is rich
in these substances. It is wise for the scientist to
be becomingly modest and to make an effort to ex-
plain why the clinician finds value in certain reme-
dies concerning the activities of which science affords
no light.
It is not to be wondered at that many undetermined
remedies have fallen into disuse, and it is probably
true that a large number of them never will be
justified because actually possessed of no essential
remedial value; but it is not that phase of the
matter that we wish to discuss, but, rather, to direct
attention to certain drugs of defined physiologic ac-
tivity and that have, for various reasons, failed to
obtain general favor in the eyes of the clinicians.
Armcm
Arnica in moderate doses slows the pulse and
slightly raises the blood-pressure, while in larger
doses it stimulates the vagus nerves and toxic doses
paralyze these nerves; it is also a gastroenteric irri-
tant
The vagus may be involved from neoplasms on
the floor of the skull, from the toxins of syphilis
or diphtheria, or by alcoholic excesses, for instance;
but muscarine and pilocarpine also stimulate- the
vagus, as do other drugs, especially the anesthetics;
but the action of arnica is so uncertain, and in
adequate doses it is so irritating, that when vagus
stimulation is necessary it is better accomplished
by drugs with less irritating qualities than by arnica.
Here is a drug which has been recommended in a
host of conditions, and which really does possess
definite activity, yet with the extensive drug
sources of modern times available arnica is going
out for the simple reason that it is unnecessary.
This is an exceedingly unpalatable drug which is
usually vomited if administered in adequate dose,
and it is quite toxic; yet there is no doubt at all
that it possesses a specific toxic action on tapeworms,
a solution of one part of its proximates in ten thou-
sand in ten minutes causing their death. The drug
contains four alkaloids naturally combined with tan-
nin, in which the drug is rich; and pelletierine
tannate has displaced the crude drug almost entirely,
for this modern substitute for the crude drug, is al-
most insoluble in the stomach. Here is an instance
wherein a drug with valuable properties is too disa-
greeable to use in the crude form and had almost
passed out until its active principles became available.
This drug belongs to the uncertain coniine group;
it paralyzes the respiratory and motor centers, as
well as the pneumogastric, when given in large doses.
The long use of sparteine as a heart remedy is not
based on any proved action on the heart, and its
use therein was probably based on the definite diuretic
action of seoparius, from which sparteine is derived.
We know now that it is the scoparin in seoparius
that is diuretic, not the sparteine, and sparteine is
rapidly going out of use. Here is an instance of
the wrong proximate principle being used. Yet
scoparin is uncertain in action and a decoction of
seoparius is the better diuretic.
Stmegm
This drug has been proved to be quite toxic, for
if its gluooedde is injected into the circulation in
large doses it kills promptly from paralysis of the
respiratory center. Yet senega is a very active
stimulating expectorant, useful only in chronic con-
ditions. As the glucoside is absorbed very slowly
from the stomach there need be no fear of toxic
effects when used in moderate dosage, but it aggra-
20
Active Drugs Fallen into Disuse
[The American Physician
vates acute conditions. Senega is a drag that has
largely gone out because it was wrongly used.
These drugs were formerly well used, and some
practitioners employ them properly today, never
giving for over forty-eight hours and always in small
dosage in sthenic conditions, never in asthenic ones.
The use of the alkaloids derived from these drugs
is never, in the opinion of the present writer, justi-
fied in internal medicine, and the misuse of these
alkaloids brought two exceedingly useful drugs into
disrepute. These drugs were wrecked by the alka-
loidal craze but should come back into favor again.
There is no doubt whatever of the activity of
lobelia. Consult any text-book. There are plenty
of rational uses for lobelia; yet it has largely gone
out of use because its advocates were erratic and
extreme in their claims for it. Of recent years it
was even urged as a sure thing for diphtheria, given
hypodermatically or intravenously, while antitoxin
was held up to ridicule by the lobelia cranks. This
was pure folly and has caused discriminating physi-
cians to abandon lobelia, which was and is a very
useful drug. From the time of the Thompsonian
craze lobelia has been the innocent cause of acrid
discussion and all sorts of therapeutic nonsense.
Here is a drug largely used in the South but
which has never attained to any extensive vogue in
the North, and its advocates have steadily maintained
that its toxicity is almost negligible. It is probably
less toxic in the southern fevers than in the north-
ern uses thereof in diseases of the nervous system;
but gelsemium is very toxic and has fallen into dis-
use because employed in excessive dosage. The drug
is one of marked activity and great usefulness, es-
pecially in the treatment of certain nervous condi-
tions. Doctor, read up gelsemium, both in Regular
and Eclectic literature; then try it carefully, and
you will be surprised at your former neglect of a
fine remedy.
Theoretically, this drug and its chief alkaloid fills
many indications; it is assuredly very active and
its very discreet use is often productive of much
good; but, in general, it is too depressing. Here is
a drug of known activity largely going out of use:
doctors are afraid of it, and they use other and
less depressing drugs to fill its indications. In a
hospital ward, where the patient can be watched,
pilocarpine is often of the greatest usefulness. The
whole tendency is against the use of very depressing
drugs, specially when they are, like pilocarpine, of
little service except in dosage verging on the danger-
ously toxic.
This is another drug of great activity, but its
preparations are notoriously unreliable and uncertain.
When one is sure of his preparation, the drug is very
useful within a narrow range. Consult the textbooks.
Perhaps some of the ultra-modern physicians will
consider this subject as unimportant Not so! In
this day of advanced pathology and diagnostics,
remedies for ordinary ailments are unduly neg-
lected. Remedies must not be neglected, and we must
do all we can to bring into modern usefulness the
comparatively few defined drugs we have, even those
which meet minor indications and meet them well.
Symptomatic medication is important, despite our
advances, and we cannot afford to allow really useful
drugs to be discarded.
But there is always a reason, and this editorial
which uses a few drugs as illustrations is to empha-
size the fact that our present neglect of drugs, or
certain ones, may be founded on the following facts :
first, a drug may be neglected for the just and suffi-
cient reason that it is unnecessary, a comment ap-
plicable to many remedies long in use; second, the
wrong proximate principle may be used and the
mistake be readily corrected, either by employing the
right proximate or the whole drug; third, the whole
drug may be too nasty to use, whereas its active
principle should be used and may be very useful;
fourth, the drug may be used under entirely wrong
indications, whereas when used properly the agent
is most valuable; fifth, the drug may pass into the
discard by reason of some modern craze or style
that runs its course, leaving therapeutic wreckage
and nihilism behind; sixth, erratic and extreme
claims for a drug turn the profession against it,
whereas conservative claims may establish a proper
place for the drug; seventh, a toxic drug may be
used in excessive dosage, thus bringing it into dis-
repute, whereas proper dosage may show the great
value to clinical medicine of a toxic agent; eighth,
a drug may be so depressing that physicians are
justly afraid of it, and lastly, the pharmaceutical
preparations of a drug may be unreliable and thus
an intrinsically useful remedy be neglected.
Modifying Milk for Sick Adults
TOP-MILK feeding for infants has been so suc-
cessful in our hands that it was no surprise
to find it equally useful in the case of many adults.
There is great lack of tolerance for milk in many
cases of achlorhydria, hy^erchlorhydria, achylia gas-
trica and various gastro-intestinal diseases marked
by hypersecretion, and unmodified milk seems to be
really poisonous to some persons. We are inclined
to attribute this intolerance to the casein content.
Phil*., January, 1922]
Gastric Neuroses
21
Benvall made a good suggestion that has worked
oat well in practice: he feeds dilated cream. We
have employed it by procuring a good doable cream
and whipping it up stiff, or procuring it already
whipped from the nearest soda fountain. With an
ordinary rotating egg-beater very gradually add
water, continuing the whipping actively during the
process, until the mixture is one-fourth cream and
three-fourths water, add a little salt, and feed cold or
iced. Carbonated water may be used as a diluent.
Remember that ordinary cream will not whip.
Another good plan is to prepare malted milk by
adding the powder to fairly warm water and incor-
porating well; then add pure cream to the mixture,
put on ice for an hour, and serve with a little grated
nutmeg and a spurt or two from a siphon of car-
bonated water. Powdered milk may* be used if malted
milk does not agree. In both of these products the
casein has been flaked or modified.
If a hot drink is desirable, we find a reversal of
the usual coffee and cream mixture, viz., cream flav-
ored with coffee, to work nicely. Use ordinary cream
and heat it in a double boiler; add a little strong
coffee, and serve.
they knew almost nothing of these subjects and vi-
tally needed to know them. These students are
angry at their professors for failing to teach them
the things they need in order to make a living from
practice. It is time for about five thousand profes-
sorial resignations.
Our Medical Schools Over~Manned
AN ARMY with too many officers and few pri-
vates is often played up in comic opera, but it
actually exists in real life, much to the disadvantage
of the army. Yet such a condition exists in our
medical schools. Eliminating the nondescript schools
and those giving only the first two years of a medical
course, there are 14,132 medical students enrolled in
the schools of the United States, and 7589 professors,
assistant professors, assistants, demonstrators, etc.,
to instruct these students, or 1.87 students to each
teacher — one teacher to less than two students. What
a situation! It is pedagogically ridiculous and eco-
nomically wasteful.
There is almost no parallel to this situation in
schools giving instruction along other lines, but it
is actually growing worse in the medical schools. No
wonder that medical education is costing too much
and that our courses are unbalanced, as all of these
specialist professors insist on giving lectures, demon-
strations, etc., filling the hours with predigested smat-
terings of a lot of inconsequential s and leaving in-
sufficient time for things of greater weight and im-
portance to the student.
This condition is largely due to a host of practi-
tioners, few of whom are real teachers, crowding on
to facilities to boost their own practices, and it is
Tastly unfair to the students. We have met three
recent graduates lately who have just entered prac-
tice, and every one was studying therapeutics and
materia medica, for they had suddenly discovered
Gastric Neuroses
Nervous dyspepsia is a very frequent complaint.
It is characterized by both gastric and nervous symp-
toms. On the gastric side we have as prominent
symptoms anorexia, nausea and vomiting, and gaseous
and acid eructations. Among the nervous symptoms
are general depression, dizziness and headache. There
is a total absence of demonstrable anatomical lesions
in the stomach, and a predominance of gastric and
nervous symptoms as above. These cases are fre-
quently classified under neurasthenia. Occasionally
they may and do occur in connection with definite or-
ganic lesions. Refiexly, disturbances of the nervous
system may result from gastric troubles.
Classifying the drugs for the nervous symptoms we
have: (1) sedatives and antispasmodics, as valerian,
the bromides, cannabis indicae and sumbul; (2) gen-
eral tonics and stimulants, as strychnine and nux
vomica; (3) narcotics and antineuralgics, as codein,
opium, veronal and aspirin.
Certain disturbances of the stomach are secondary
to nervous affections, notably the gastric crises in
syphilis, the vomiting of meningitis and brain tumor,
and the various psychoses. Then, too, irritants such
as tobacco acting on the secretary nerves, also pylo-
rospasm, chronic appendicitis and diseases of the
gall-bladder and genitourinary tract not infrequently
give rise to various gastric symptoms.
The neuroses are classified as (1) motor; (2) sen-
sory; (3) secretory. For the sensory group sedatives,
narcotics and antineuralgics are used. For the de-
pressive group the stimulants are indicated. For the
secretory and motor, the alkalies, HC1 and the bitter
stomachics.
Gastric lavage is also of use in prolonged pyloro-
spasm with distension, and in the depressive and ir-
ritative conditions.
Hydrotherapy is of value in the form of hot water
bag to the epigastrium, hot and cold water coil, ice
bags, general baths as cold sponges in the morning,
and sometimes a hot bath at night with a hot drink
to induce sleep. Many needless abdominal sections
are performed in these cases, hence a correct diag-
nosis is of paramount importance.
Pylorospasm may be due to a number of organic
conditions as ulcer, erosion, carcinoma, etc. The chief
symptoms are sudden shock, cramp-like pain in epi-
gastrium with eructations and vomiting. The treat-
ment consists in regulation of diet, change of scene,.
22
Announcements
[The American Physician
if possible, gastric lavage, belladonna internally and
hot applications.
In Hypochlorhydria there is a general diminution
of all secretions. This also occurs in chronic gastritis
and carcinoma of stomach. The treatment is dietetic,
a carbohydrate diet, small feedings at frequent inter-
vals, and dilate HC1, 10 to 20 minims in water.
Nervous vomiting occurs in young women, and the
nervous symptoms are predominant. The vomiting
may sometimes persist for months. The condition
may be controlled by regulation of diet, building up
patient, change of scene, mental and physical rest,
and rectal or duodenal alimentation if necessary. For
the gastric symptoms, sod. bicarbonate, gentian and
gastric lavage, in addition to above. For the nervous
symptoms, give sod. bromide, veronal at bed-time, and
after two week's gentian before meals. Where the
gastric symptoms predominate, we use Tr. cannab.
ind. and valerian in place of bromides. Cerium
oxalate and bismuth are useful for nausea.
It is the general treatment, physical and mental
rest, and a thorough search for and removal of the
cause, if possible, which are most important in this
distressing condition.
Coming In Next Issue
Treatment of Tuberculosis in General
Hospitals
IN 1916 the National Tuberculosis Association ad-
vocated the plan of opening tuberculosis wards
in general hospitals, and at the 1921 meeting of the
American Medical Association this plan was endorsed.
There are at least two million tuberculous persons
in the Union and it is possible to admit only a small
proportion of them to special tuberculosis institu-
tions. The help of the general hospital is needed.
Not that we approve of the plan of herding large
numbers of the tuberculous indiscriminately together,
for we do not; but there are many cases needing
hospitalization and that ought to have it near to their
homes, not at some far distant point.
The public generally, as well as the incipient case
of tuberculosis, have a horror of the special tuber-
culosis institution, and for this horror there is quite
a little statistical basis, as well as some very human,
even if mistaken, reasons. Furthermore, this plan
would keep the family and the family physician in
touch with the patient, which is a very desirable
thing. The half-way house to this plan is the recently
advocated county tuberculosis institution, a plan not
yet proved out as regards efficiency.
We believe it is a mistake to shoo the general
practitioner off the field of tuberculosis work; for,
rather, the sensible thing to do, and the practical one
as well, is to engage the interest and active aid of
every capable physician in the fight against tuber-
culosis; it is too big a proposition to entrust wholly
to the specialist or to special institutions.
Surgery of the Thymus Gland, by Albert J. Ochsner,
M.D., LL.D., and Frank H'Doubler, M.D.,
Ph.D.
The thymus belongs to the so-called group of
glands of internal secretion, being particularly
closely related to the thyroid. In cases of hyper-
plastic thymus which cannot be relieved by deep
X-ray therapy, in the young or adult, thymec-
tomy is indicated if there have been grave signs
or symptoms of tracheal stenosis or if there is
ground for fearing them.
The operation may be expected to accomplish
several results: mechanical relief, decreased se-
cretion and stimulation to subsequent normal
tissue regeneration.
Ovarian Hemorrhage, not Due to New-Growths or
Pregnancy— With Report of Two Cases, by J. L.
Bubis, M.D., F.AC.S.
Abdominal hemorrhage is a grave condition and
requires serious and prompt attention. To know
clearly where the bleeding is from, and conse-
quently to know how to proceed, is always a
pressing question — a question of life and death.
Dr. Bubis differentiates ovarian hemorrhage from
the usual entities it is often confused with. It
goes without saying this short and practical paper
is well worthy of consideration and should not
be overlooked.
Unscientific Practice — Are You a "Pill Doctor?" by
John U. Fauster, M.D.
Dr. Fauster says that while he has due respect
for the responsible pharmaceutical producers, and
realizes that the refinements in therapy are in a
large measure their handiwork and that the de-
velopment of the biologicals is an epoch which
could be realized only with their co-operation,
yet, on the other hand, the nostrum vender,
whether he solicits patronage from the medical
profession or from the laity, cannot be too
strongly condemned.
Some Common Forms of Nasal Obstruction in the
Adult, by L. F. Long, M.D.
Dr. Long says it should be remembered that a
deviated septum does not call for operation unless
ventilation and drainage are interfered with.
Also it is important to carefully examine these
cases and institute proper treatment, since nasal
obstruction causes great discomfort and pro-
duces many diseased conditions.
Acromegalia— With the Report of a Case Having
Lymphatic Leukemia, by Hyman I. Goldstein,
M.D.
Few diseases are as puzzling as acromegalia is.
For some obscure reason, the pituitary body "goes
wrong," becomes disturbed, appears to over-
function, and the skeletal tissues, like wild weeds,
begin to thicken, enlarge, grow and overgrow.
Both body-anatomy and body physiology become
perverted, controlless, helpless and hopeless. Dr.
Goldstein's case of acromegalia, complicated by
lymphatic leukemia, studied thoroughly and pre-
sented in detail, is illustrious, interesting and in-
structive. It is one of the diseases rarely met
ajid the paper should attract unusual attention.
The following papers
are contributed exclu-
sively to this journal.
Republication is per-
mitted if credited as
follows: AMERICAN
PHYSICIAN, Phila-
delphia.
Original Articles
Sublets, Iki nitons, ton Mont wfeii Mtt canuM*
We are not respon-
sible for the views ex-
pressed by contribu-
tors; but every effort
is made to eliminate
errors by careful edit-
ing, thus helping the
reader.
Comparison of the Old and the New
in the
Treatment of Syphilis
Has Sufficient Time Elapsed to Completely Establish Ultimate Value of New Treatment?
By D. Alexis Myers, M.D., D.D.S.
Professional Building, 1831 Chestnut Street,
Philadelphia, Pa.
Assistant Oral Surgeon to Temple University Dental
School, Philadelphia; late Syphilographer and
Dermatologist to Walter Reed U. S. General
Hospital, Washington, D. C. ; late Derma-
tologist, Camp Merritt, N. J.
Treatment h intwiimd; Never Remtime
In the treatment of syphilis the old say-
ing aptly applies, that medicine is an art
as well as a science. Laboratory findings
must never, and cannot, usurp the results of
clinical findings. Injections of this or that
medicament are not to be regarded as all
that is required, and all cases are not to be
treated alike. — The Editors.
THE COMMANDING importance and the ap-
palling prevalence of syphilis can be best
appreciated through a statistical consideration, as
recorded through certain registration areas. In 1915,
the number of deaths from syphilis in the United
States was 5819. And yet we must, from every
day experience, conclude that even these figures are
far too low, for physicians hesitate to inscribe such
a cause of mortality in filling out the death certifi-
cate. It would be interesting to know how many
persons die annually in the United States from syph-
ilis. Cases that are reported as due to general pa-
resis of the insane, apoplexy, tabes dorsalis, and
other medical entities, are too often the sequelae of
syphilitic infection.
It is the opinion of the Hibbs (Journal of Socio-
logical Medicine*) that practically all deaths re-
ported under "general paralysis" result from syph-
ilis; but he is extremely doubtful whether such cases
as congenital debility, icterus and scleroma are at
•An excellent resume* of Hlbb's elaborate and painstaking
study appears In The Urologic and Cutaneous Review, Jan-
uary, inf.
all due to syphilis, although at times they are be-
lieved to be by some of the profession. He also
emphasizes the fact that, estimating the prevalence
of the disease as judged by morbidity statistics, two
methods of diagnosis must be distinguished. The
first is what may be called the "clinical method,"
i. e., by means of scars, history and symptomatology;
the second method, which is, of course, the more
scientific, deals with specimens of blood or spinal
fluid and brings into consideration the results of the
Wassermann blood test.
But, at best, as just remarked, the prevalence of
disease is very much greater than was ever presented
in any statistical table. How, then, can the investi-
gator approach nearer to the truth in forming a
correct estimate of the inroads of this grave malady
upon the social fabric f
SUtittics
This is best accomplished by studying the statis-
tics of certain representative groups. These include
the reports of examination by medical men of em-
ployes, applicants for licenses, army recruits, etc
Also by examining the records of hospitals and ob-
serving the proportion of syphilis found among pa-
tients treated in dispensaries, as well as those ad-
mitted to the wards. Thus, an estimate made by
the United States Marine Hospital showed : all cases,
53,344; of these 11,414 were venereal, comprising
6974 cases of gonorrhea and 4440 of syphilis.
With the introduction of the Wassermann reaction
the study of syphilis rested upon a firmer scientific
foundation; for it has been found that two and a
half times as many cases of the disease are found
in comparison with diagnosis by the older clinical
method. Has, then, the older method any usesf To
this we emphatically answer "yes." The data of the
bedside must and will always appeal as the logical
and correct method, for when our data are computed
by this method, we need but multiply the result by
two and a half to find the approximate number of
syphilitic cases by the most modern method at man's
command.
24
Old and New in Syphilii — Myers
[The American Physician
In the treatment of syphilis the old saying aptly
applies, that medicine is an art as well as a science.
Laboratory findings must never, and cannot, usurp
the results of clinical findings. Injections of this
or that medicament are not to be regarded as all that
is required, and all cases are not to be treated alike.
Per contra, syphilis is not a medical entity with an
undeviating symptom-complex; but may exhibit
certain morbid tendencies, inherited or acquired, in
association with well-defined constitutional taints, be
this alcoholism, tuberculosis, plumbism, the gouty or
rheumatic diathesis, etc., that may modify the dis-
ease and demand modified or additional treatment.
Syphilitic treatment is individual and never routine.
Because of the limitations of space and irrelevancy,
I will not detail treatment of syphilis as concerns
medicaments employed, technic of application, or the
physiological effects produced; but, rather, I would
emphasize the fact that at the present time the prin-
cipal drugs at our disposal, in the treatment of
syphilis, are mercury, salvarsan and its allied prod-
ucts, and the iodide of potassium.
A serious obstacle to the employment of mercury
is the great length of time necessary to effect a
cure. The patient rebels against this lengthy period
and often disappears before the curative effect has
been established.
In the early history of medicine mercury was
classed as a cure for syphilis, and down through
the ages this powerful drug has sustained its repu-
tation as a cure, which in the darkened period of
the world's history was widely employed by means
of "inhalations" and "rubbings."
Mcrcmrids
Beside the usual methods by mercurial treatment
by ingestion, inunction, fumigation and introduction
through the rectum, Scarzenio, in 1864, introduced
to the notice of the profession the subcutaneous and
intramuscular soluble injections, given daily or on
alternate days, or by insoluble injections given
weekly. The injection of insoluble preparations is
made intramuscularly, although Lang, who introduced
gray oil injections, made them into the subcutaneous
tissue. Soluble preparations are adapted for subcu-
taneous or intramuscular use. The advantages by
this method are, exactness of dosage, control by the
specialist himself, and secrecy. The disadvantages
are, pain, the formation of nodosities at the point of
injection and very rarely the occurrence of pulmonary
embolism.
According to Schamberg and Kolmer, the toxic
effect of mercury is due to the amount of metallic
mercury present in the mercurial salt and is variously
manifested as a stomatitis, a gastroenteritis, as
cutaneous eruptions, or in general disorders of nu-
trition.
AncnicmU
The arsenical treatment of syphilis was commended
to the notice of the profession by Paracelsus in 1529.
Fowler's solution came into vogue in 1756, and was
supplanted by the administration of Donovan's solu-
tion in 1788. In 1863 Bechamp, a French chemist,
discovered atoxyl, from which was derived a whole
series of organic preparations of arsenic. Atoxyl
was the first of these substances to be synthesized
and applied to the treatment of protozoon diseases.
When the microorganism of syphilis was isolated and
was regarded as a protozoon, atoxyl was energeti-
cally administered, but was soon abandoned because
of the resultant optic atrophy which was prone to
assert itself.
Then followed the memorable labors of Ehrlich
and other German collaborators. Upon the assump-
tion that drugs act upon an organism when they
enter into chemical combination with its cells, Ehr-
lich developed a theory as affecting parasites in in-
fective diseases, namely, the trypanosomes and tht
spirochaetes, and asserted that the protoplasm of the
parasite exhibits certain receptive cellular elements
or "chemoceptors," showing a marked affinity for
certain drugs and combining with them to produce
death of the parasite, and he declared these effects to
be parasitotropic, as distinguished from organotropic
action, wherein the cells of the host were affected,
producing a toxic action.
Sdvmrmm
As previously stated, the discovery of atoxyl (the
name a misnomer, since the term signifies "free
from" or "against" poison) marked an epoch in medi-
cal science, for it and its associated substances were
widely tried in the field of medicine; but the toxicity
of the drug (which became to be more familiarly
designated sodium arsanilate) forbade its adminis-
tration, and the reputation that the new medicament
had so suddenly acquired was soon lost in the disas-
trous results reported. Early in the present century,
Ehrlich, acting upon the theory above noted, suc-
ceeded in obtaining a chemical substance that exerted
a parasitotropic action, and after experimenting for
the six hundred and sixth time he announced the dis-
covery of dioxy-diamido — arseno-benzol, and in 1911
this chemical was patented under the name of Sal-
varsan.*
The first trials of the drug by Alt offered little
•With the announcement of this discovery, the following
chemically equivalent compounds of new arsenical prepara-
tions were soon placed upon the market : The French intro-
duced Arsenobenzol-Billon. England offered Kharstvan and
Arsenoblllon. Diarsenol appeared in Canada. Arspbena-
mine in the United States. Other closely allied products
are Neosalvarsan (a modification of Salvarsan) and simi-
larly, Neokharsivan, Novarsenobenzol, Novarsenobillon,
Neodiarsenol and Neoarsphenamine. Among widely em-
ployed French preparations are: Galyl, Hectine and 8ul-
pharsenol. Luargol contains, in addition to arsenic, anti-
mony and silver. Quite recently the Germans introduced
Silver Salvarsan. Among a large number of syphilographers,
this last substance, it is asserted, is more active than neo-
salvarsan and, while perhaps less active than salvarsan, it
Is surely less toxic.
Phila., January, 1922]
Old mad New in Syphilis— Myers
25
encouragement in a. large series of eases, although
in certain of these cases the Wassermann reaction be-
came negative, and a safe and correct dosage was
determined, i. e., 0.3 gramme. Shortly thereafter,
Wech&elmann employed salvarsan extensively at the
Rudolf Virchow Hospital in Berlin, and published
the results of treatment in 1400 patients comprising
all forms and stages of syphilis, a large number of
which had no treatment with mercury. ,
There are certain untoward effects or reactions
that may follow these injections, but the general opin-
ion in the profession seems to be, that seldom as they
occur they are even less common with neosaivarsan
than with salvarsan. They include flushing of the
face, headache, dilatation of the pupils, dyspnea,
rapid pulse and, at times, cyanosis and some edema
of the face. One hour or longer after injection, such
symptoms as high temperature, rigors, vomiting and
urticaria have been noted. French writers lay stress
on a condition, not common in this country, which
is characterized, days after injection, by a sympto-
matology quite analogous to hemorrhagic encephalitis,
and which, as pointed out by Ehrlich, would seem to
be the expression of the toxicity of the oxidation
products of salvarsan. Other reactions may manifest
themselves in suppression of the urine, erythema and
jaundice.
With these possible .complications in mind, the
writer cannot help but arrive at the conclusion that
while they may occur in the very best of hands, he,
nevertheless, inclines to the belief that many of these
ill-effects are due to faults in technic, imperfect
asepsis and want of precaution on the part of both
operator and patient, for with a large experience
both in civil and military practice, the writer has
found that skill and understanding on the part of
the physician and precaution on the part of the pa-
tient are the best possible safeguards against many
of these so-called reactions.
CmrMt Tedmc
In brief, the operator needs .be most mindful of
his technic, his asepsis, of the purity and the fresh-
ness of the water used in making up the solutions,
and of the rate of flow of the injecting fluid. There
are a number of other influencing factors, but we
emphasize that at times, there are differences, how-
ever slight, in different samples of the same prepara-
tion; as salvarsan and its modifications, as well as
closely allied products, are not stable chemical com-
pounds, and certain toxic properties are alleged to
have arisen in the course of manufacture.
Again, many persons have an idiosyncrasy to arse-
nic and to compounds containing it; and, lastly, the
great mass of endotoxins that are liberated with the
destruction of many spirochaetes may engender these
reactions. The latter theory was first announced by
Ehrlich.
As late as 1913 the modus operandi of drugs
of this class was more or less in an experimental
stage and the causation of reactions not well under-
stood. In 1920, a committee of German specialists
reported that in 225,780 injections of old salvarsan,
sodium salvarsan and neosaivarsan, they found only
twelve deaths attributable to the drug, or one death
in 18,dl5 cases. They also found that the dose
played an important part in the mortality, especially
with neosaivarsan; the mortality with this drug was
only one in 162,800, with doses not exceeding 0.6
gramme, but if this was exceeded it rose to 1 in
3,000. The only absolute contra-indications to the em-
ployment of the drug are in grave visceral disease,
hemophilia, and it is asserted in Addison's disease.
Albuminuria is not a contra-indication, as was for-
merly taught.
fat Wm-rmm Tut
The effect of salvarsan upon the Wassermann re-
action appears to be neither constant nor permanent.
Indeed, it seems to be the result of common expe-
rience that drugs of this class are less capable of
transforming a positive into a negative reaction than
when combined with energetic mercurial treatment,
such as inunction. It would be impossible in our
brief space to attempt to give all the effects of treat-
ment upon the Wassermann reaction, but it can be
incontrovertibly stated that the Wassermann test by
itself is no criterion of a cure of syphilis, but is only
of value when compared with the results of clinical
experience.
Hunt* points out that a latent syphilis should al-
ways be thought of as a possibility, especially when
myocardial involvement is associated with nervous
lesions due to this cause, with high arterial tension
or definite thickening of the arteries. He maintains
that a negative Wassermann is no proof that clinical
observations are faulty. He advances the thoughts
that negative Wassermann reactions are not infre-
quently evidenced in late syphilis, and that an error
in technic may have been committed in making the
test. Hunt also insists that, although the cerebro-
spinal fluid may give a negative reaction, the thought
of latent syphilis should never be abandoned until
the collodial gold test or the lutein test has been
resorted to, and, if necessary, the administration of a
provocative test of salvarsan, for such a test will
make the blood positive when before it was negative.
lafcctic Costa
Intraspinous therapy in urology and syphilis is
still in the stage of experimentation and the re-
sults attained offer a wide field for discussion and
speculation. Howard, quoting Swift,** emphasizes
fact that the relatively impervious state of the arach-
noid and the pia may at times explain why in some
instances the therapeutic agent does not reach the
cerebro-spinal fluid by way of the blood stream and
*New York Medical Record. March 29, 1919.
••Northwest Medicine, February, 1919.
26-
Old and New in Syphilis— Myers
[The American Physician
why effect is so often perceived by placing the agent
directly into the cerebrospinal fluid. When syphili-
zation of the meninges occurs, then a perivasculitis
occurs, and one is prone to find that irritation of the
sensory nerve roots causes pain and paresthesia, and
depending upon the nerves involved may simulate
prostatitis, cystitis, renal colic, etc It is, therefore,
of paramount importance to determine the presence
or absence of tabes, and he frequently finds this to
be the cause of the urinary disturbance complained
of. In the same paper is a quotation from Coulk,
showing that a syphilitic perivasculitis is responsible
for urinary disorders when he says that in an analysis
of 117 cases "almost 50 per cent, of the patients
suffering from diseases of the central nervous system
may have as their initial symptom a disturbance of
the bladder function, such as frequency, dribbling
and the like/'
Intraspinous therapy for syphilis of the cerebro-
spinal system is the replacement of a certain amount
of fluid by an equal amount of a suitable menstruum
containing the specific drug. The most suitable men-
struum is the patient's own blood serum, and Swift
employs arsenobenzol and mercury. Both can be
added directly or indirectly, or both ways at the
same time; indirectly in the case of arsenobenzol,
by it being recovered in the serum of a patient pre-
viously injected intravenously; and in the case of
mercury in the serum, by it being administered by
inunction. However, the indirect administration of
mercury into the cerebro-spinal fluid has been prac-
tically abandoned because of the infinitesimal amounts
secured ; but the indirect administration of arsenoben-
zol into the cerebro-spinal fluid is very popular and
effective and is known as the Swift-Ellis method.
The direct method of administering arsenobenzol, he
asserts, with serum as a vehicle, is not so popular as
that of mercury in the form of bichloride.
In further observations on intraspinal treatment,
Thomas states:0 "It is not claimed that such therapy,
either intravenously or intraspinally, can restore de-
generated spinal cords or rescue victims from impend-
ing institutional care. And although patients, even
tabetics, respond to general or intravenous treatment,
the accessory employment of intraspinal treatment ac-
celerates the restoration of the spinal fluid to normal,
arrests degeneration and insures greater likelihood of
permanent therapeutic results." He also underscores
the circumstance that intraspinous treatment should
only supplement the intravenous method when ac-
tually and positively necessary and never as a routine
or as a mere addition for complete treatment Cases
of endarteritis with vascular or circulatory disturb-
ances, and those with exudative gummatous menin-
gitis and certain cases of tabes require the intravenous
administration only.
•PeonajlTania Medical Journal, March, 1919.
No hope is to be held out to those suffering with
tract or cortical degeneration! Mercury and the
iodids are indispensable adjuncts and should never
be discarded in the treatment of cerebro-spinal syph-
i118- Cmre?
Regarding the criteria as to cure in syphilis, this
opens up a lot of bitter controversy. One state-
ment offers no room for argument, and it is this:
that injection treatment with the newer drugs can-
not be accurately gauged, as compared with the
ultimate results of mercurial treatment. LeComte
forcibly illustrates this point, in that sufficient time
has not elapsed to learn of the true value of sal-
varsan and its allied products. Under the older
method probably fifteen or more years would elapse
before paresis or other late manifestation developed,
the intervening years having been spent in apparent
good health. If, he insists, in 1925 or 1930, it can
be shown that the late lesions have developed con-
siderably later than under mercurial medication, giv-
ing the patient a longer period of healthy life, or
that, if they do occur, they are less severe and
more amenable to treatment, we may consider the
drug an advance; while if none of these are proved,
it must be considered only as an agent for the rapid
control of symptoms. He furthermore avers that
mercury has not been superseded by the more recent
drugs, and should be used in every case, both early
and late, and after the more powerful spirochaeticide
has controlled the acute features of the infection.
Although the writer clings to the belief that in
this disease, as in so many other instances in modern
medicine, the best possible results are to be attained
by retaining all that is good in the old and wel-
coming the signal advances in the great march of
progress, he feels it incumbent to mention the opin-
ion of many Canadian specialists0, in this field whose
opinions are so well represented by the following
telling sentences: "Today the former treatment has
given way to intravenous injections of one of the
arsenical compounds, supplemented by the former
treatment, or at least by hypodermic injections of
some mercurial compound. Can the results achieved
by tnis form of treatment be termed successful f
Are we any better off than with the old treatment f
And which is the remedy, the arsenical compound
or the mercury T" And again: "And considering
the class of cases that we dealt with at our clinic
(Toronto General Hospital), the results are not at
all discouraging." This latter statement is of ex-
tremely doubtful meaning and value.
Daw! /at cctm
It is impossible in the succinct space allotted to a
medical contribution even to hint at many important
and practical thoughts that present themselves to
the clinician or inquiring physician. One thought,
* Canadian Med. Aaa'n Jour., July, 1919.
Phila., January, 1922]
Empyema of the Antrum of Highmore — Atkinson
27
however! seems most important ; so that in conclusion
we refer, although all too briefly! to the occurrence
of tuberculosis concurrently with syphilis, and in
passing say a word as to treatment.
Previous to the year 1900, it was customary to
treat patients with the dual infection by means of
mercury, and as a result of treatment many of these
eases progressed most favorably. As late as 1908,
Wright reported a series of uncomplicated cases of
tuberculosis treated with succinimide of mercury in-
jections, all of whom showed improvement. - As a
control test he treated forty-one additional patients,
all tuberculous, without these injections, but under
the same hygienic regime. The condition of the
forty-one remained stationary. With still further
study he observed that this class of patients steadily
improved, and with this therapy, his death-rate fell
from 1L29 to 4.76 per cent, following the energetic
employment of the drug. But the use of mercury
in syphilitic patients with tuberculosis soon fell into
ill-repute. It had been found that the patients
were apparently, not actually, improved; for im-
provement was fleeting, and bodily deterioration was
just about in proportion to the amount of mercury
received. The slogan adopted was: It is hygiene
rather than mercury that improves the patient.
Elliott* is sure that the profession realizes the
danger of this procedure and that clinicians hailed
the advent of salvarsan with great enthusiasm, and
many optimistic opinions have been recorded from
its use. He reports a series of cases from which
he concludes that one can justly assume that mercury
should be used with great caution in tuberculous pa-
tients, that the injurious effects are not immediate, but
appear three to six months after administration, that
salvarsan or its modifications or its allied drugs should
be the choice in such cases, to be given in small dose
at wide intervals, and the case to be most carefully
watched; for larger doses seem to influence pernici-
ously the focal tubercular areas, and seriously aggra-
vate, instead of ameliorate these latent lesions.
Diagnostic Difficulties and Treatment
of
Empyema of the Antrum of Highmore
By D. T. Atkinson, M.D.,
516-17-18 State Bank Bldg.,
San Antonio, Texas.
Jmsdy EmtkUi to Wide Attention
"The pain incident to a diseased antrum
is often referred to the eye or the temporal
region, is attributed to neuralgia or eye
strain/' or teeth, or even abdominal or pelvic
morbidities. Considering the diagnostic dif-
ficulties and the importance of the subject,
the paper of Dr. Atkinson should receive the
wide attention it is justly entitled to. — Edi-
tors.
THE ANTRUM OF HIGHMORE is perhaps
more frequently affected by inflammatory and
suppurative processes than are any of the other ac-
cessory sinuses, though a diagnosis of existing disease
within its cavity is less easily made than it is in
similar conditions of the other sinuses of the nose.
The reason for this may be that the pain incident to
a diseased antrum is often referred to the eye or the
temporal region of the head, is attributed to neural-
gia or eye strain, or is thought to be suggestive of
reflex conditions resulting from disordered stomachs,
misplaced uteri or other abnormalities of abdominal
or pelvic organs. The pain, too, is often referred to
the teeth, the antrum being suspected only after all
the dental defects are corrected with no cessation of
the symptoms.
Anatomy and Pathology
The location of this sinus, and its imperfect drain-
age, make it particularly liable to involvement. The
ostium maxillaire or normal opening, its only com-
munication with the outside world, lies high above its
floor, sometimes even as high as the floor of the orbit.
With the position of the normal opening so unadapted
to adequate drainage, except where certain positions
of the head are assumed, it is not strange that secre-
tions are easily pent up and become infected with re-
sulting sinusitis. Occlusion of this opening occurs
from various causes. Hypertrophic rhinitis, with
swelling of the middle or inferior turbinals, may
obstruct the normal opening. Polipi springing from
the other sinuses may wedge themselves between the
turbinals so that drainage of the antrum is entirely
cut off. An acute coryza, with incident swelling of
the mucous membrane, may close the opening, or
crusts may form between the turbinals, their presence
acting as a dam, entirely shutting off the cavity. De-
viated septi are often instrumental in producing a
maxillary sinusitis, and spurs of the septum, en-
croaching upon the normal opening, are a very proli-
fic cause in producing a like result.
The maxillary sinus is sometimes infected by an
ulcerative process at the roots of the bicuspid or
♦American Journal of Syphilis, April, 1919.
28
Empyema of the Antrum of Highmore — Atkinson
[The American P&ysicUn
first molar teeth which often jut into the cavity, being
covered only by the mucous membrane lining it.
Extraction of these teeth sometimes open up avenues
of infection from the mouth. Errors in nasal and
dental surgery not infrequently leave an infection of
the sinus. Packing the nose after nasal operations,
or as a means of controlling hemorrhage, render lia-
ble to infection not only the antrum of Highmore,
but the other sinuses as well. Some time ago I re-
moved from an infected antrum a dental bur which
had been lost in the sinus during the excavation of a
first molar tooth at some previous time.
Symptomatology
The symptoms of maxillary sinusitis are, first, pain.
This may be periodical or constant, but is usually
worse during the night or early morning hours. As
has already been noted, the pain may be in the gums,
teeth, walls of the antrum, temples, eye, or it may be
far removed from the point of infection, as, for in-
stance, the occiput, a not unusual location. The pain
is nearly always increased by stooping. This position
also causes more or less vertigo. Because of the gen-
eral distribution of the pain, and because disease of
the other sinuses may occasion pain in the same re-
gions, no particular stress can be put upon this fea-
ture of the disease as a factor in determining the
nature of the condition. The tenderness produced by
pressure is of some service to us in diagnosis. There
is usually soreness to the touch in the gums over the
cheek bone and the lower floor of the orbit. The
skin over the sinus is sometimes drawn taut and may
be glistening and reddened. Where a pronounced
empyema of the antrum exists the thin walls may
bulge, causing a crowding upward into the orbit and
a consequent protrusion of the eyeball. A bulging
of the inner wall of the antrum may occur which,
though seldom seen, as surely indicates antral em-
pyema as does a protrusion of the posterior wall of
the auditory canal mean pent up pus or cholesteatoma
in the mastoid. The teeth are tender and more or
less discomfort is experienced during the act of
chewing. I operated a case at one time who had a
pronounced empyema of the sinus, tne principal
symptom of which, besides pain in the temporal re-
gion, was a soreness of the gums and an inability to
masticate.
The temperature is usually elevated, though it sel-
dom runs over 101 or 102. Sometimes there is no
rise whatever in the temperature. If the drainage is
not entirely cut off there will be seen pus in the mid-
dle meatus between the superior and inferior tur-
binate. This oozes constantly when the patient is
erect or lies on the side opposite to the one affected.
When lying on the back or on the affected side no
discharge will be seen. This accounts for the f reeness
of the discharge in the mornings, the patient, as a
matter of course, maintaining during a part of the
night, positions of the head which hold the normal
opening above the level of the pus. While the patient
is in the erect position the pus flows over the top of
the inferior turbinal. If it is wiped away with cot-
ton on a probe, it quickly reappears. This symptom
should always be looked for and when found, provid-
ing the pus oozes up from under the middle turbinal,
is pathognomonic of empyema of the antrum.
Diagnostic Aids
Transillumination is a valuable aid in diagnosis.
When performed in an absolutely dark room with a
suitable electric bulb placed as high up and as far
back in the mouth as possible, an empyema of the
sinus may be outlined by the darkened area over the
fluid which is in pronounced contrast to the same
surface of the opposite side. A high leucocyte count
is usually to be had. The X-ray is another valuable
aid in diagnosis. A skiagraph made for me in a case
of suspected maxillary sinusitis showed a heavy
shadow over the right antrum and verified a diagnosis
based upon a very incomplete and obscure chain of
symptoms. An operation was done and the antrum
was found to contain fibrous polypi, which were re-
moved, followed by prompt recovery. I am doubtful
if I should have operated this case had it not
been for the verification of my diagnosis by the X-ray
picture. It is well to remember, however, that the
X-ray is not a diagnostic certainty in every case.
Treatment
The treatment is mechanical, and may be divided
into two classes, palliative and radical. The palliative
treatment consists of daily douching the antrum
through its normal opening. This, though not often
fruitful of good results, may be resorted to before a
radical operation is attempted. The old method of
removing a first or second molar tooth and irrigating
the cavity through the opening left by it is now con-
demned because of the uncertain results to say noth-
ing of the impropriety of destroying a good tooth.
The Intra-Nasal Operation
The intra-nasal operation gives very good results in
cases of moderate severity where there is no evidence
of bony necrosis. This consists of opening the nasal
plate of the antrum and inserting a drain through
which the cavity is to be washed daily. The front
end of the inferior turbinal is to be removed prepara-
tory to opening the antrum. With the room offered
by this procedure it is an easy matter to curette
through the antral wall and enlarge the opening by
means of the Rongeur forceps. This operation may
be accomplished under cocaine anaesthesia in all but
the most sensitive patients.
The MoMed CaMwell-Luc Operation
In severe cases of necrosis a modified CaldwelULuc
operation may be chosen. Under general anaesthesia
the lip should be retracted and an incision one and
one-half inches long should be made over the roots of
the molar teeth extending through the periosteum
Phila., January, 1922]
The Proper Function of Radium — Blesh
29
down to the bone. The periosteum is now elevated
and with a mastoid curette or a chisel an opening is
made through the antral wall and is enlarged suffi-
ciently to admit the index finger. The cavity is now
explored- Polipi, if present, should be removed, and
their pedicles thoroughly curetted away. Areas of
necrotic tissue should be sought for, and, when
found, completely obliterated. An opening is now
made through the inner wall into the nose, the inferior
turbinal having been previously removed, and an
iodoform packing introduced, its distal end extending
into the nasal cavity. The external wound is now
closed, subsequent dressings being applied through
the nasal opening. The sinus should be redressed
daily for a week or so, after which the dressing may
be discontinued, but daily irrigation with antiseptic
solutions should be carried out until all evidence of
suppuration ceases.
The Proper Function of Radium
Dangerous Operative Ri*k* Often Made Safe
By A. L. Blesh, M.D., F.A.C.S.,
Chief of Staff and Surgeon in Chief, Wesley Hospital,
308 Patterson Bldg., Oklahoma City, Okla.
TheTMfi&t Bmr
Radium is the talk of the hour. The hope
of multitudes of sufferers, pierced by the
deadly tentacles of the cancerous octopus, is
focused upon this agency. Will these ex-
pectations be realized f Will the problem of
the day be solvedf What are really the pos-
sibilities, probabilities and potentialities of
this therapeutic start Dr. Blesh is neither
dreamer nor condemner. He has studied
radium in the practical domains of the hos-
pital clinic and surgical laboratory and nar-
rates his findings in this excellent paper. —
Editors.
THIS PAPER will not deal with the history of
radium, nor with the rapidly growing literature
of the subject, but will be an exposition of our work
with it, in the hands of the Oklahoma City Clinic, at
Wesley Hospital.
Out of our work, here, has come certain positive
findings upon which we believe it profitable to dwell.
One of the greatest of American humorists once re-
marked, that "it is better to not know so much, than
to know so much that is not true." One of the
greatest faults of our profession has been to rush into
print with half-baked theories which, when uttered
with due pompousness by some "big gun/' was fol-
lowed literally by too many of the "rank and file"
to the discredit of the profession. What we say
here in this short paper has been learned by the
actual use of the radium in concrete cases.
To the surgeon the use of radium may be indi-
cated broadly in two classes of cases :
L Malignant conditions.
2. Non-malignant conditions.
Of the former, we have used it as the primary
treatment only in inoperable cases. Where opera-
tion is feasible we have used it consistently as a
preliminary and post-operative measure.
In non-malignant conditions it has also been used
sometimes as a preliminary treatment, as, for ex-
ample, in myoma uteri, with prolonged and exhaust-
ing metorrhagia. Here it is used to change a bad
surgical risk into a good one in a disease essentially
surgical.
Malignant Conditions: In the present state of our
knowledge of radium, in the treatment of malignant
neoplasms, it must be rated as an adjuvant to radi-
cal surgery on the one hand, or palliative surgery on
the other. Unquestionably the radium rays will pene-
trate further than the scalpel can go in even the
most skillful hands. Also since the fixing infiltration,
which always accompanies and is a part of the
process of malignancy, adds to the dangers and diffi-
culties of radical surgical removal, irradiation will
often loosen to a degree this fixation and render in-
operable conditions operable. These anchoring in-
filtrations are not always composed only of malig-
nant cells. Often they are inflammatory and due to
secondary infections. In fact, there is little differ-
ence in the process of infiltration, whether malignant
or inflammatory. Indeed the routes and process even
of metastasis are the same in both cases.
We have observed in many cases of seemingly
advanced malignancy which were inoperable, because
of extensive fixation, become relatively mobile after
one or two irradiations.
Aipmcti Ctaes W Matignmmcy
Advanced cases of malignancy with extensive de-
struction of tissue can rarely be dealt with satisfac-
torily surgically. Primary surgical mortality is ap-
palling and ultimate results as to cure are prac-
tically nil. These have been the hopeless cases
which haunt first one and then another doctor's office.
It makes little difference as to the location of the neo-
plasm, whether in breast, uterus or stomach, or on
the face. These advanced inoperable cases, together
with those which by location are surgically inacces-
sible, and those the removal of which, by operation,
30
The Proper Function of Radium — Blesh
[The American Physician
would produce such hideous deformity that the sur-
geon would be averse to advising surgery; and cer-
tain superficial epitheliomata of the skin, especially
of the face, constitute the class for which we advise
irradiation as the primary and sole treatment.
In the treatment with radium we are dealing with
the same uncertainties as to when metastases have
begun or how extensive and far distant they may
have become. Upon this fact hinges ultimate result.
There can be no doubt of the fact that radium exerts
a selective destructive action on malignant cells.
The selective action is probably because the malig-
nant cells, being. embryonic in character, are less re-
sistant. At any rate it is a well-known fact that
the cells will succumb to a smaller dose of radium
than will the more highly differentiated cells of the
normal tissue. But it must not be overlooked that
they, too, are deleteriously affected and may also be
destroyed.
Sample Skim Growths
Simple skin growths can be removed with little, if
any, scarring. If distant metastases have not oc-
curred they are permanently cured. But who can
tell when metastasis has occurred t Hence time alone
can tell the story of permanent cure. Many have
been reported cured after several years have elapsed.
In order that a reported cure may be depended
upon, a microscopic diagnosis must have been made
by a competent pathologist, for it is especially true
in malignancy that "things are not always what they
seem." In our clinic we no longer doubt that in this
class of cases irradiation is superior to the scalpel
in that it penetrates much deeper and wider than is
possible with the knife.
Advanced Carcinoma W Cervix — Remkant Fistmlae
In advanced carcinoma cervicis uteri the problem
presents some special features. Frequently there
will be invasion of cancer cells into the recto and
vesico vaginal septi. The destruction of these by any
method whatsoever, whether with the Percy so-called
cold cautery or the knife or radium, will be followed
by fistulas. Indeed fistulas will often occur, and for
the same reasons, in untreated cases. Such results
are in no wise to be charged to the treatment in this
class. Nevertheless a leaking bladder and spilling
rectum are very distressing sequellaa. To escape
unjust blame, warning should be given before insti-
tuting treatment of any kind. The death of a clump
of cells in either of these septi is almost sure to result
in a fistula and it is equally as certain that a proper
dosage of radium will kill the cells.
The thing that has most surprised us in this class
of advanced cases, otherwise hopeless even as to pal-
liation, has been the remarkable improvement mani-
fest in all of them and the occasional seeming cure.
We hesitate to say cure for the reason that, as stated
above, ample time (at least five years) must elapse
without recurrence before the word "cure" can be
permitted. But right here again is the crux of the
whole question. Some cancers far advanced, locally,
have not metastasized to distant points, but for some
unknown reason have been content with invasion by
infiltration, while others, which locally seem almost
innocuous, have given rise to distant metastases which
far overshadow the original growth. Indeed it has
often happened that such a metastatic neoplasm has
been surgically attacked by the best of surgeons who
was unaware of this fact, until a carefully made
pathologic study has given him the hint.
Rodham a* am Adjuvant to Surgery
It is here that a large field of usefulness is opened
to irradiation. Metastases far beyond the reach of
the most radical operation are influenced by the rays.
Especially is this true in carcinoma cervicis uteri.
It will continue to be the exception that these cases
will present themselves surgically early. In the his-
tories of our cases, numbering over 400, late pres-
entation is the most striking feature. Yet a large
percentage consulted us soon after the first symptoms
patent to them appeared. It seems they are doomed
to destruction on the Scylla of Fear, inspired by the
constant frequenting of the physician's office for ex-
aminations, the direct result of the widespread cancer
propaganda on the one hand, or the horrible Charyb-
dis of a cancer death on the other.
Our histories show another striking fact: Most
of these patients who are living today consulted us
for something else and in making the thorough
routine examination, which is our custom, early can-
cer especially of the cervix was discovered, the pa-
tient having had no symptom referable to the uterus.
It is now our custom to irradiate these cases the
day before operation. Since most of the patients
are over or near the menapause, and since in cancer
the entire internal genitalia are surgically sacrificed
anyway, we do not hesitate to give them 1200 mg.h.
This, in turn, is followed after operation, for many
months, at regular intervals. In one or two instances
my associate, Dr. M. £. Stout, has left the radium in
the pelvis, attached to a string, which is brought
through the unclosed vagina, to facilitate removal.
In malignancy anywhere, we follow surgery by
systematic irradiation whenever possible. In malig-
nancy of the face and neck we are fond of using the
cautery knife, as described recently by Scott, of
Temple, Texas, with subsequent irradiation.
Non-malignant Conditions
Menorrhagia and metorrhagia, without determi-
nable cause, have yielded over ninety per cent, of the
cases. As this often occurs in young women during
the child-bearing period, great care must be exercised
in dosage, so as to avoid causing premature mena-
pause. Our initial dose here does not exceed 300
mg.h. This can be repeated, if necessary. Formerly
many of these cases had to be hysterectomized.
Syphilis, as a cause of metorrhagia and menorr-
hagia, is well known. The cause of the hemorrhage
being an endarteritis, usually it will not yield to
Phila., January, 1922]
Anesthetics in Obstetrics — Fursey
31
antisyphilitic treatment any more than an aneurysm
from the same cause will yield. But it will yield to
radium.
Fibromi Uteri with hemorrhage! in these cases with
ezsanguination and an anemia so pronounced as to
render operation most dangerous, irradiation will
stop the blood loss and convert a dangerous into a
safe risk.
Leucorrhoea, many times the betenoir of the doctor,
will yield to radium, according to Curtis, in eighty
per cent of the cases. Of course, any surgical cause
such as endocervicitis, the result of lacerations, if
found, should be corrected by appropriate surgery.
Our results agree with those of Curtis.
In Hodgkin's Disease we have had most brilliant,
though temporary results, no cases being perma-
nently benefited.
Caajcfatiaa) tni, Sbmmfj
In conclusion, we do not feel that radium is to be
offered the public as a certain cure-all for malig-
nant conditions. We do feel that we should urge it
as a valuable aid to any and every other legitimate
means we possess to fight this, the most hopeless of
life-destroyers. Without doubt it may often, in
widespread dissemination, be supplemented with
X-ray "showering" to advantage.
L In our hands radium has proven a valuable
aid to surgery in malignancy. For this purpose it
is best used both before and after operation.
2. Radium has been a valuable measure in our
bands in the palliation of inoperable malignant con-
ditions. In inoperable carcinoma of the uterus we
have been able to prevent exsanguinating losses of
blood. It often allays the pain as well
3. In superficial skin epitheliomata radium easily
outranks any and all other treatments.
4. In widespread malignant conditions it should
be supplemented with X-ray showering.
5. Fibromata of the uterus, which are practically
inoperable because of exsanguination, can be rendered
operable by first controlling the bleeding with radium.
6. Intractable leucorrhceas, without surgical cause,
are curable by the use of radium in a large percentage
of the cases.
7. Caution must be exercised in its use for the
reason that an overdose is capable of precipitating
premature menapause in the young woman. It can
also damage normal tissue and cause severe intract-
able burns. It is not to be used in inflammatory
conditions. It is capable also of producing a most
stubborn cystitis and proctitis, hence these viscera
are to be held from contact by properly placed
packing.
The annoying, useless, nagging, "cutting" pains of
the pnmipara, and for that matter of the multipara,
may often be alleviated or converted into labor con-
tractions by means of a warm enema of one quart
of hot water with an ounce of glycerin.
Reasons for Anesthetics in Obstetrics
A "Little" Question of "Great9* Importance
By Frank R. Fursey, M.D.,
719 Paulsen Bldg., Spokane, Wash.
Fectora Dtmmiimg Cmudcrdtim
The anesthetic in obstetrics is a "little"
question of "great?* importance. The safety
of the mother, the life of the baby, the dura-
tion of labor, the degree of suffering, the
anxiety of the family and the reputation of
the physician are all factors demanding con-
sideration. The discussion and recapitula-
tion of these points by Dr. Fursey in this
practical, clear, short paper are certainly
well worth reviewing. — Editors.
THE PRINCIPAL reason for using any drug
during labor is to relieve pain. There are still
some men who believe that to relieve pain during
the agony of labor is unnecessary, that nature in-
tended that a woman should suffer, therefore nothing
is used.
Pain is a great producer of shock, and for that
reason alone the use of an anesthetic should be urged.
When an anesthetic is used, if it acts promptly
enough, the attendant is able to control the uterine
contractions and thus control the speed with which
the presenting part conies over the perineum and in
that way save the perineum that in many cases would
otherwise be lacerated.
On occasions when instrumentation has to be done,
or in fact any internal uterine manipulation, the
demand for an anesthetic becomes almost imperative.
The relief of pain, saving the perineum, preventing
shock as much as possible and the various forms of
instrumentation are all, in the opinion of the writer,
valid reasons for the use of an anesthetic during
labor.
maa^raraaacaCf ar or AtHithitit
To be useful, the anesthetic must be safe for the
mother and baby. It must act well. It must act
quickly. It must not shorten labor and if it be
cheap and easily accessible, so much the better.
Ether
One of the commonest in use is ether. It is com*
paratively safe for the mother, but after a deep ether
anesthesia all breathe easier as soon as the baby
cries. While I believe that infant mortality from
ether alone is not very common, still it undoubtedly
does happen. It does not, however, act quickly
enough so that it can relieve each pain and have the
32
Acid Fruits in Typhoid — Reed
[The American Physician
patient normal between pains. If enough is given
to relieve the discomfort to any worth-while degree,
the pains are quite markedly decreased and the course
of the labor lengthened to a corresponding degree.
Once in awhile it is well to lengthen labor, but
usually not. However, ether is cheap, and almost al-
ways at hand.
Chloroform
Chloroform is used in much the same way as ether.
It acts quicker than the latter, lengthens labor slightly
more and is not quite as safe as ether, and, because
of this, ought to be given, if at all, by a trained
anesthetist, thus making it not quite so accessible as
ether.
"Twilight Sleep"
The so-called "Twilight Sleep" method of anes-
thesia was used quite extensively some years ago and
even today is used to some extent. Its use has been
highly lauded by those mothers whose babies suffered
no accident through its use. But by far the big
majority of obstetricians today believe that to get
even approximately safe results requires too much
time on the part of the physician, and even then the
death rate among babies is greater than with any
other method of anesthesia, therefore it is hard to
justify its use.
Nitrous Oxide and Oxygen
Nitrous oxide and oxygen combination has proven,
in the hands of the writer, to be the anesthetic most
nearly ideal of those at our command. It is pleasant
to take. It is safe for the mother and, I believe, the
babies are safer when it has been used than when
not. I have reference, more especially for the baby's
sake, to the use of oxygen, a tank of which goes with
the apparatus used in administering the combination.
It has been my practice in cases in which version has
been done, or in difficult forceps deliveries, to use
pure oxygen freely for the mother for a few minutes
before the baby is born, and in this way, still-born
babies are almost unknown.
Pour deep inhalations taken quickly, one after the
other, will produce a degree of analgesia which in
most cases will cause the mother to declare that she
felt no pain at all. It does not lengthen labor be-
cause there is no fear on the part of the mother and
she is thus encouraged to use her abdominal muscles
to the best advantage.
Morphine
One-eighth of morphine, given at the onset of labor
and repeated when labor is nearing the end of the
first stage, will make the labor, up to that time, bear-
able and then, with the nitrous oxid and oxygen com-
bination, a patient can be taken through labor .with
very little, if any, distress. She can be put to sleep
in one minute. When the baby's head is about to
pass over the perineum, so that the head can be de-
livered with very little contraction on the part of
the uterine muscle, therefore lessening the danger of
lacerating the perineum and yet, if need be, the mask
can be removed and in another minute the patient
will strain as hard as before. She will recover much
more quickly because of the absence of shock.
The gas is passed out of the system so quickly that
there is no demonstrable bad effect on any of the
organs. Taken all in all, it is the best combination
to use in the majority of deliveries. There is not
enough relaxation for a version, but the oxygen should
be used freely a short time before the baby is born.
A Result with Acid Fruits
In Typhoid
A Cote Report
A little more than a month ago I was called to see
a little patient that seemed to be dying of typhoid
fever.
I made a careful examination of the little girl and
concurred in the diagnosis, and also in the opinion
of the attending physician, that there was little hope
that the child would live until night.
I told the friends of the patient to retain the physi-
cian in charge of the case, as I did not wish to take
charge of a hopeless case. They said the other physi-
cian had been dismissed and would not be in again
and implored me to do all I could to save the child.
I at once told them to give the patient no more
sweet milk as food, but instead to give her buttermilk
and any kind of acid fruit juice — apple sauce, cran-
berry juice, lemon juice — but especially plenty of
juice of black (Concord) grapes.
I left some tablets of sulpho-carbolates of lime,
soda and zinc, to be given every two hours, and
gave a mild saline laxative to free the bowels of the
decomposing curds of sweet milk. I also instructed
the nurse to wash out the bowel with tepid saline
solution three times daily.
When I first saw the patient she was delirious and
moaning at every breath. On the next day when I
called she was still delirious, but the temperature had
dropped from 104.5° F. to 102.5° F.
On the third day the child was conscious and the
temperature was 101.5° F. The improvement was
constant and the child is now convalescing nicely.
I report this case to show what can be done by
cutting out sweet milk from the diet of typhoid fever
patients. I forgot to say, also, that all the water
allowed the patient to drink was acidulated with hy-
drochloric acid. Curds and undigested food particles
soon disappeared from stools. I hope this report will
save some valuable life.
Saquache, Colo. D. W. Reed, M. D.
Phila., January, 1922]
One Hundred Neuro-Psychiatric Cases — Young
33
One Hundred Neuro-Psychiatric Cases Emphasize
the Importance of
Prophylaxis and Early Recognition *
By W. W. Young, A.B., M.D.,
Assoc in Neuro-psychiatry, Emery University,
78 Forrest Ave., Atlanta, Ga.
As Imstrwctwe as ImUrtstimg
The nervous system is a sensitive appara-
tus, constantly registering impressions of in-
tensities and degrees proportionate or non-
proportionate to resultant effects. The aver-
age mind is normally stable and tenaciously
recuperative. Often, though, physical, path-
ologic or emotional actions are followed by
untoward reactions which badly dissociate
psychic equilibrium — and the mental king-
dom "goes wrong." From this point of view
the "Impressions" of Dr. Young are as
interesting as instructive. — Editors.
FOR THIS PAPER an attempt was made to as-
certain, as nearly as possible, the percentage of
the various types of nervous disorders. Of course, it
is difficult to arrive at an absolute mean, and, too, this
paper does not, by any means, contain all the dis-
orders grouped under the head of "Nervous." How-
ever, they are the more common types. The hundred
cases to be cited were taken at random from between
two and three hundred patients treated, and represent
a mean of the whole.
The results are as follows: Exhaustion neurosis,
or what is commonly classed as neurasthenia, those
following influenza, 15 per cent; of another etiology,
5 per cent., or 20 per cent, in all; hysteria, 16 per
cent.; hyperthyroidism, 11 per cent.*; dementia prae-
cox (schizophrenia), 10 per cent; epilepsy, 8 per
cent.; psychasthenias, 6 per cent.; cerebro-spinal
syphilis, 5 per cent.; manic-depressive psychosis, 4
per cent.; peripheral neuritis, of which the sciatic
nerve gave 3 per cent.; brachial, 1 per cent., and
eighth cranial nerve, 1 per cent., making 5 per cent,
in all; encephalitis, following influenza, 2 per cent.;
coccygodynia, 2 per cent. ; intermittent claudication, 2
per cent; constitutional psychopathic inferiority, 1
per cent.; anxiety neurosis, 1 per cent.; Jacksonian
epilepsy, 1 per cent; hemiplegia, 1 per cent.; trans-
verse myelitis, 1 per cent; feeblemindedness, 1 per
eent; facial palsy, 1 per cent; hypopituitarism, 1
per cent. ; paranoia, 1 per cent.
There are certain thoughts which rise out of this
•Dead before the Fulton Co. Med. Soc.
array of diseases. Of course, the picture is modified,
to a certain extent, by the influenza epidemic, during
and after which many of these cases came to our at-
tention. And to just that degree the percentages vary
from what might be expected at a more nearly nor-
mal period.
Exhamstiom Ncwrosis
However, I think, we shall always find the exhaus-
tion neurosis heading the list just as they do here.
These are the fatigue types, and in the foregoing
cases the larger percentage were consequent upon an
attack of influenza. Whether these same individuals
might have developed a fatigue syndrome had there
been no influenza is debatable, but, most probably, a
majority would have done so. For, given an attack
of influenza, in order that there may be a subsequent
neurosis, the soil must be of a suitable character;
namely, the particular nervous system must be in-
herently below standard and more susceptible to
fatigue than normal. And this type of soil is always
present, needing only the sewing of the seed of undue
strain which, in turn, in this era of strenuousness is
also ever present. So, in this instance, most probably
under any circumstances, the exhaustion neuroses
would predominate.
Tha Hysterias
The next most numerous of our group are the
hysterias and here we also are probably running true
to form. In a time when the individual is confronted
with more vexatious problems than ever before, and,
too, when, to a large extent, these problems have been
cast at them with untoward suddenness, there is a ten-
dency to seek escape. This attempt at escape, because
of a predominance of this type of character, takes
on the form of hysteria in a large number of in-
stances. Unemployment or necessary expenditures
out of proportion to incomes make it a temptation
to try to obtain means of support either through dis-
abilities acquired accidentally or through seeking
charitable aid, which is apt to create morbid hyper-
suggestibility and hysterical tendencies (traumatic
hysteria) ; the temptation to seek escape from mount-
ing responsibilities, etc., brings on other forms of
this disease.
Hyperthyroidism
Third on the list, with 11 per cent., comes hper-
thyroidism, which again will probably always claim
approximately this place. In the influenza epi-
demics of 1917 and 1918 we saw a long line of
broken manhood who escaped death but were left
34
One Hundred Neuro-Psychiatric Cases — Young
[The American Physician
with more or less severe sequelae. Hyperthyroidism,
being consequent upon either intoxication or oft-
repeated emotional traumata, naturally increased
with the increase of the "flu." Intelligent studies
in basal metabolism and various tests, such as the
Ooetsch test, have made our diagnoses more accurate,
and consequently an * earlier treatment possible.
But here as everywhere preventive medicine has a
tremendous opportunity, not yet touched, in the
prevention of thyroid intoxication.
Peripheral Neuritis
Peripheral neuritis, of which there were 5 per cent,
in the series under discussion, was another result
of the influenza; also encephalitis, either the acuter
form, which presented a picture of the so-called "sleep-
ing sickness," which has aroused so much verbostiy
with its long array of polymorphous symptoms
and sequela; or the more chronic, with symptoms
of irritation of a cortical nature. In the 2 per cent,
coming to our attention, the latter was the form.
In one there were peculiar athetoid movements of
the hand, arm, foot, and leg on one side, with a
spastic paresis; in the other, irritations affecting
the faee zone.
Dtmtntim Praecox, Mamc-Depreuhm and Paranoia
With the influenza the war stands as an unusual
event, and caused much that would not otherwise
have happened. So, most probably, dementia praecox
with 10 per cent, would not ordinarily stand quite so
high in the list. The war with its need for young
men, snatching them from ways of peace to face
unknown terrors, precipitated many a borderline
case over into mental oblivion. And dementia
praecox, being primarily the psychosis of youth,
was increased in proportion. Many of these indi-
viduals might otherwise have gone to their grave,
having lived a mentally wobbly but apparently men-
tally sound life. These same facts stand in the case
of manic; — depression and paranoia (4 per cent, and
1 per cent., respectively). Here again preventive
medicine has yet untried possibilities.
General EpUepty
Of general epileptics, and under this head we
place all cases with the earmarks of epilepsy
whatever the etiology, there are 8 per eent. We
can no longer call epilepsy a disease, but merely
a symptom complex with multiple etiology. Of all
our cases, the majority were syphilitic in origin.
Of those who would submit to proper treatment,
all were benefited, but none, after from three months
to a year of treatment, were absolutely free from
symptoms. In every case grand mal gave away
to petit mal and, at that, at long intervals; but
there the improvement stopped although in every
ease a four plus Wasserman became negative. Too
much nervous tissue apparently had been destroyed.
The treatment consisted of from five to ten intra-
spinal injections of Byrne's mercurialised serum,
which rendered the choroid plexus hyperpermeable,
this hyperpermeability reaching its maximum in six
hours. This was followed by an intravenous injection
of salvarsan which consequently passed into the spinal
fluid, giving the patient the benefit of both mercury
and arsenic where he most needed them. This method
is probably superior to both the Swift-Ellis and For-
duce-Oglevie methods. In the remaining cases, as is
so often sadly true, we had to be content with keeping
the attacks as much as possible in abeyance. Of all
the agents, that giving the best results and the least
trouble is Luminal. The percentage of cere-
brospinal syphilis is rather low, 5 per cent. But
it would be brought up to 10 per cent, if those
cases grouped under epilepsy were to be added,
which would be about the correct proportion. The
results of the treatment, outlined above, are most
gratifying. The trend of thought seems more and
more toward treating every case of syphilis as a
possible cerebro-spinal subject. Certainly, every
case should have a thorough spinal fluid examina-
tion, for the nervous system has been invaded as
early as the later days of the primary sore. Fewer
distressing cases of a nervous type would be seen,
were this always done, and, certainly, an ounce of
prevention is worth a pound of cure, because once
nervous tissue has been destroyed, it can never be
regenerated.
Intermittent Claudication
Of the remaining cases only intermittent claudi-
cation is of particular interest. This disease has
been placed by some in one class with Raynaud's
disease, and on the thyroid has been placed the
blame. Some cases have arterio-sclerosis; others
vascular spasms. It is probably true that arterio-
sclerosis is dependent often upon the thyroid, that
is, there is some change in metabolism due to thy-
roid insufficiency which, in turn, causes the laying
down of fibrous tissue in the vessel walls. On the
other hand, vascular instability comes with perver-
sion of the thyroid function. Cases of this type
respond well to thyroid medication.
Of all the lessons gained from this rather in-
adequate review, the most important points to remem-
ber are: First, prophylaxis in exhaustion neuroses
by recognition of early types and protection; in
hysteria and the psychoses by the recognition of
tendencies in youth and proper education; second,
thyroid prophylaxis by proper protective measures;
third, to recognize epilepsy as a syndrome and search
for etiology; and lastly, to view every case of syph-
ilis as a possible cerebro-spinal subject, and where
the spinal fluid is positive, institute proper treat-
ment.
Doctor Mackeaxie Forbes9 Pott-Graduate DiagMstk Clinic*
A Series of Thirty Clones Emphasizing Diagnosis thai ShomU he hiost Hslpful to the Central Practitioner
By A. Mackenzie Forbaa, M.D., 615 Unhraraitjr St., Montr— J. Canada
A Case of Tuberculous Peritonitis
Tstenty-nWsi Ctsme
THIS LITTLE PATIENT, V. S., number 144/20,
age six years, was brought to the Out Door of
the Children's Memorial Hospital on March 18, 1920.
The mother brought him, complaining that the boy
was ruptured When she was questioned she state'!
that she noticed this "rupture" first about one month
ago, and on cross-examination she conceded that he
had been losing considerable flesh lately, although his
appetite was good.
The boy was examined by my associate, Dr. F. P.
Yorston, who states in his record that the child was
poorly nourished, that the right testicle was normal,
while the left testicle was enlarged, but not tender.
The epididymis was enlarged and hard. The sper-
matic cord could be palpated to the external ring.
Here there was a small mass about the size of a bean.
The abdomen was large and swollen. The abdominal
wall was tense, verging on rigidity, indeed, resistant
to the touch all over. A distinct mass could be pal-
pated in the right hypochondrium.
The patient was admitted into the hospital. His
temperature during the first week was normal, al-
though on one or two occasions there was a slight
rise to 99° or 99%°. The temperature taken during
the subsequent weeks was very similar to that of the
first week, although on several occasions it rose as
high as 100° or even slightly higher.
I am bringing this child before you today because
you will remember that last week I discussed the sub-
ject of hernia with you. The mother of this child
has brought him to this hospital complaining that
he is ruptured.
I want you to examine his inguinal regions in
order to ascertain whether he is ruptured. I want
you to tell me whether he is suffering from this con-
dition or whether he is not, and, again, I would like
to draw your attention to the fact that Dr. Yor-
ston has made some very definite statements regard-
ing the condition of this boy's abdomen. For this
reason I think that you should consider the past and
the present condition of the abdomen when you con-
sider the condition of the contents of the inguinal
canaL
Will one of you gentlemen report your examination
of the inguinal canal and later perhaps another will
be good enctagh to report the result of his examina-
tion of the abdomen. Then, gentlemen, we will ask
for a diagnosis.
A student: I have made an examination of the
inguinal canals in this boy and of the spermatic
cords and testicles.
The right canal, cord and testicle seem to be per-
fectly normal, while the left testicle and spermatic
cord are enlarged, especially the latter. This feels
hard and solid. It can be felt as a distinct funicular
process under the skin in the inguinal canal running
up as far as the internal ring. It feels entirely
different than did the cord in the little child who suf-
fered from hernia whose history was considered at
our last clinic.
A second student: I have examined the patient's
abdomen. It is swollen and tumid in character. The
muscular wall is very tense. On palpation there
seem to* be irregular areas of dullness separated by
tympanitic areas. The umbilicus seems to be un-
folded and on its apex is seen the opening of a sinus
from which pus is exuding.
The clinician: You have all had an opportunity of
examining this patient. You have heard the his-
tory. You have seen the temperature chart. May I
ask for a diagnosis t
A student: We have consulted one with another
and we feel that this might be a case of tuberculous
peritonitis.
The clinician: Yes, this is a typical case of tuber-
culous peritonitis and as it is necessary that you
shall be able to recognize this condition, as it is a
fairly common one, we will now -discuss the charac-
teristics and treatment of this disease.
(1) General Consideration
Tuberculous peritonitis is seen broadly in two
forms — (a) a plastic peritonitis, (b) as an ascites.
.The plastic form is much more common. Indeed,
there are probably ten cases of plastic tuberculous
peritonitis to one of the ascitic form.
The frequency of tuberculous peritonitis has been
36
A Case of Tuberculous Peritonitis — Forbes
[The American Physician
suggested by Mr. Still! who says that in children
under twelve years of age 16.8 per cent, of all cases
of fatal tuberculosis were those of the peritoneum
and, again, Mr. Still found twelve cases of tuber-
culous peritonitis in one hundred tuberculous in-
fants.
(2) Etiology
Tuberculous peritonitis sometimes starts from
caseous mesenteric glands, but in the majority of
cases it probably begins independently of any tabes
mesenterica. It may be secondary to a tuberculous
lesion elsewhere. In some instances it may begin as
a primary infection, although it must be remembered
that the peritoneum has a marvelous power of re-
sistance to tubercle bacilli.
(3) Age Incidence
The age incidence corresponds closely with that
of tuberculosis in children. According to Mr. Still
the greatest number of cases of fatal tuberculosis of
the peritoneum occur between the first and second
years. This disease in a fatal form becomes de-
creasingly rarer until the twelfth year.
(4) Symptomatology
In early cases of tuberculous peritonitis of the
plastic form, the symptoms are very similar to those
seen in tabes mesenterica. If we epitomize the symp-
toms seen in more advanced cases we would say :
(1) The abdomen is tumid in form.
(2) It is podgy or doughy to the feel.
(3) There is often a transverse band-like tumor
lying across the epigastrium which comprises really a
thickened caseous mesentery.
(4) There may be an unfolding of the umbilicus.
(5) There may be redness about the umbilicus.
(6) This may be followed by perforation of the
skin of this part with extrusion of fluid and caseous
material, or even an outpouring of faecies.
On the other hand, tuberculous peritonitis of the
ascitic form presents quite different symptoms. In-
deed, it is almost impossible to distinguish it from
ascites due to other causes. Indeed, if we suspect
an ascites to be of a tuberculous nature we must
search for such confirmatory evidence as (a) the pro-
duction of tuberculosis in a guinea pig by the injec-
tion of the ascitic fluid removed by an exploratory
needle, (b) a tuberculous focus elsewhere, such, for
instance, in the lungs or (c) tuberculosis of the
epididymis or testicle.
(S) General Consideration of Tuberculous Ascites
(Tuberculous peritonitis, ascitic form.)
Patients suffering from this form of tuberculous
peritonitis seem to die but rarely. As a rule, under
suitable treatment, the fluid disappears. Unfortu-
nately, however, in certain cases, as the fluid disap-
pears the plastic form as an underlying cause for
the ascites is revealed and the prognosis becomes that
of the more common variety already described.
It is important in dealing with tuberculous peri-
tonitis to realize that this condition should not be
considered as cured unless the patient has been with-
out symptoms for twelve to eighteen months.
($) Prognosis
The peritoneum has a marvelous power of resist-
ance to tuberculosis. We can infer that the prognosis
is best in the later years of childhood. It will be re-
membered that in certain instances the greatest num-
ber of deaths have been reported between one to two
years of age and that the death rate decreases yearly
until the twelfth year.
Gentlemen, having studied the natural history of
tuberculous peritonitis, let us take into consideration
the history of the child who has been examined by
you. The child is six years old. He was brought to
this hospital because of some trouble of the left
testicle and epididymus. His weight has been de-
creasing for some weeks until now the boy is poorly
nourished, yet the emaciation from which he suffers
is not seen in the abdomen which is enlarged and
resistant to the touch with a tenseness which verges
on rigidity. Now we know that the abdomen of a
patient suffering from tuberculous peritonitis is tumid
and doughy to the feel. In our case the abdomen is
certainly enlarged and tumid, but it is resistent and
not doughy to the feel, but this resistance is simply
due to muscular spasm and an increase in the con-
tents of the abdomen. Indeed, if we are dealing
with a tuberculous peritonitis we are dealing with
a patient who presents the symptoms of a later stage
and not the doughy-podgy sensation to the touch seen
in earlier cases.
In tuberculous peritonitis we often find a trans-
verse band-like tumor lying across the epigastrium.
In this case, while this has never been found, the
percussion of the abdomen leads one strongly to sur-
mise that solid masses have formed therein, although
this cannot be confirmed by palpation because of the
tenseness or rigidity of the abdominal wall.
In the patient before us there was originally an
unfolding of the umbilicus with redness about it. It
was felt that this was due to a localized abscess. On
palpation it was decided to leave this abscess undis-
turbed until sufficient time had elapsed for the forma-
tion of adhesions about it. When this time had elapsed
it was decided to drain this abscess, but before this
could be done a perforation occurred at the umbili-
cus accompanied by an escape of faecies and gas.
This, as you may imagine, caused us some alarm, but
our fears were soon relieved by the cessation of the
discharge of this character, although a discharge of
pus has continued to flow from the sinus through the
umbilicus.
A student: Can you tell us what is the probable
Phila., January, 1922]
A Case of Post Diphtheretit Paralysis — Forbes
37
cause of this faecal fistula at the umbilicus t
The clinician: In tuberculous peritonitis the bowel
may become perforated either by an ulceration within
its walls or by an ulceration from without due to
adjacent and p*- aetrating tuberculous focus. In our
ease the bowel evidently became adherent to the
peritoneum lining the umbilicus. Then there was a
perforation which included the skin covering the
umbilicus, which was already under tension. Through
this fistula gas and faeces escaped. Later some at-
tempt at repair must have caused a walling off of
the intestine, although the tuberculous focus outside
and perhaps including the abdominal wall has still
continued to break down and cause the outpouring
of pus through the perforated umbilicus.
The student : What is the prognosis in patients suf-
fering from such perforation t
The clinician: Such perforation is ordinarily fol-
lowed by the extrusion of tuberculous fluid and case-
ous material. In these the prognosis is good. If, on
the other hand, there is a perforation of the intestine
into the peritoneal cavity or through the umbilicus
before adhesions have formed walling off the fistulous
opening the prognosis is much more serious. In the
patient before you* this accident has been of little
moment. Tou will notice that he is as well as he has
been for some weeks before this accident and, in-
deed, his temperature and pulse rate are low and he
is lively and seems to be in reasonably good general
condition.
I think that the diagnosis of tuberculous peritonitis
of the plastic form has been borne out by a study of
the symptoms in this case. The original complaint
was rupture. This condition was suspected by the
mother because of an enlargement of the epididymus
and testicle due to a tuberculosis of these parts, and
as we have already said, a tuberculosis of these parts
may be used as confirmatory evidence in making a
diagnosis of tuberculosis of the peritoneum.
(7) Treatment
Tuberculous peritonitis should be treated, as are all
forms of tuberculosis, by rest, fresh air and proper
diet. In this hospital we believe in recumbency in
the fresh air and proper diet. In earlier years it
was the custom in the majority of patients to per-
form a laparotomy. Empirically speaking, this was
the thing to do. As I remember this seemed to be a
successful form of treatment in the majority of
patients treated in this hospital. But, of more re-
cent years, physicians have felt that it has not been
proven that the success following this treatment was
due to it. They have claimed that these cases were
improved by the general treatment which had been
carried out — indeed, physicians have stated that good
results were simply coincident with surgical treatment
and not due to it.
We must all realize that it is impossible for us to
produce any form of scientific argument to justify
the performance of a laparotomy. This form of
treatment was purely empirical. In the particular
case which we have studied the patient has been
treated by rest, fresh air and suitable diet. He has
been treated in one of our tent wards from late spring
until the first of November. In spite of this treat-
ment carried out by our medical department he has
not improved. At the same time I would consider
that it is very doubtful whether he would have im-
proved under surgical treatment, and one hesitates
to employ purely empirical measures.
Indeed, it is impossible to say whether the improve-
ment found after operation performed in patients
suffering from tuberculous peritonitis is post-hoc or
propter-hoc.
In some cases we may use in addition treatment
by tuberculin. In other cases treatment by the inter-
nal administration of iodine in some form has been
of benefit.
A Case of Post-Diphtheritic Paralysis
dime
THE LITTLE BOY who is brought before you
today is Jimmy P., aged two years and three
months, No. 139/20, Children's Memorial Hospital.
His mother brings him to the hospital because he is
suffering from general weakness, inability to stand,
and more especially because his head hangs forward
when he is tired.
We have had a number of children brought to this
hospital recently with the complaint that there seems
to be some lack of support to the head, or that they
support their heads with their hands. What condi-
tion first presents itself to your mind when a child
is brought with such complaint f
A student: One always thinks of the possibility
of cervical Pott's Disease when a child is brought
to the hospital with the complaint that he continually
endeavors to hold or support his head with his hands.
The clinician: Yes, this is true, but in Pott's Dis-
ease the first symptom to come and the last symptom
to go is muscular spasm. In cervical Pott's Disease
the muscles surrounding the cervical vertebrae are
held in spasm. Examine the patient who is before
us and note that the cervical muscles are not held in
spasm. The patient seems to be suffering from a
flaccid paralysis.
What are the most ordinary causes of a lower
motor neuron or flaccid paralysis t First, poliomye-
litis; second, neuritis, and third, an obstetrical
paralysis. Is there any possibility of this being a
poliomyelitis t Yes, this is a possibility, but not a
38
A Case of Post Diphtheretic Paralysis — Forbes
[The American Physician
probability. Sometimes, but rarely, . other muscles
as those of the trunk are affected, but usually in
conjunction with those of the lower extremities.
For instance, the patient may have a paralysis of the
muscles of the back, abdomen or even the muscles of
respiration which may accompany a paralysis of the
extremities, especially the lower extremities. An un-
usual site for this affection is a sign of a more or
less general infection of the organism of polio-
myelitis.
On the other hand, we know that a flaccid paralysis
of the cervical muscles is common in a post-diph-
theritic neuritis. Indeed, it is almost characteristic
of this disease.
Pott-Diphtheritic Pandytu
Would it not be well, then, for us to consider the
possibility of this child, whom we are examining,
being affected with a post-diphtheritic paralysis t
Let us study the subjective symptoms. The his-
tory states that about the beginning of January, 1920,
the child was quite ill for about six weeks. The
mother says that he was suffering from "poisoning
in his system." The symptoms at that time were
inability to sleep, languor, dark rims under the eyes,
lack of appetite and crying spells. The child recov-
ered from this attack and was comparatively well for
one week when he developed an attack of measles.
Fortunately one of our medical men was called in
by the mother to attend this patient during his attack
of measles. He observed the general weakness in the
patient's neck and made a diagnosis.
Let us now cross-examine the mother. We find that
the child had suffered no previous illnesses. Two
months ago, viz., in January, 1920, he had the attack
already described. The mother says that the fever
was accompanied by swelling of the glands on both
sides of the neck. The mother also states in the
witness-box that one week after the onset of the fever
she noticed weakness of the neck evinced by the
head falling forward and, further, the boy's voice
was weak, that he regurgitated fluids through his nose
and he was unable to stand.
Fortunately, to complete the list of subjective
symptoms, I may say that our associate who attended
him during his attack of measles, which you remember
followed the most interesting illness which we have
described, confirms the mother's statements and tells
us that the symptoms already noticed by the mother
became more marked during the attack of measles.
Regurgitation of food due to paralysis of the soft
palate, ocular symptoms, such as squint, paralyses of
the muscles of the neck, and pareses of the muscles
of the lower extremities are often due to the toxines
eliminated by the bacillus of diphtheria and follow
an attack of this disease. There is another symptom
which might almost be considered pathognomonic of
post-diphtheritic neuritis. This is an early loss of
patellary reflexes without any paralyses. Let us, then,
make a careful examination of our patient in order
to ascertain what are the objective symptoms. The
child is well formed. The pupils of his eyes are
equal and active. There is no strabismus or nystag-
mus. One of our attending physicians, Dr. Lind-
say, reports that there is nothing abnormal about the
heart or abdomen. There is definite weakness of the
neck muscles. The head falls forward and cannot
be held in the erect posture. There is no loss of
power in the arms. The legs, however, show marked
weakness. He is unable to stand without support
and he cannot walk. The tone of the leg muscles is
definitely diminished.
None of the tendon reflexes are obtainable. The
knee jerks are definitely absent. There is no clonus.
There is no Babinsky. The voice is very definitely
husky ; the few words which the child pronounces are
nasal. The palatal does not move on stimulation.
Let us epitomize. There is a definite history of
an attack of fever in January when the cervical
glands were enlarged. From the subsequent develop-
ment of weakness of the neck muscles, hoarseness,
nasal speech, the regurgitation of fluids and from the
entire absence of tendon reflexes there can be no
doubt that the attack of fever, in January, 1920,
accompanied a pharyngeal diphtheria and that the
condition from which the child is suffering now is
a post-diphtheritic paralysis.
A student: You have mentioned that the weakness
of the neck muscles always makes you think of a
post-diphtheritic paralysis. Do many cases present
themselves at the hospital with such complaints t
The clinician : Just a week or two ago a little boy,
Dominique V., aged four and one-half years, No.
88/20, was brought to the Children's Memorial Hos-
pital with the complaint that he was suffering from
weakness of the neck and legs, which had come on
only a few days before his visit to the hospital.
The mother in this case was interrogated and it
was found that the child had had a swelling about
the neck just two weeks previous to the onset of the
weakness of the neck and legs.
A careful examination was made and the child
was found to have a post-sterno-mastoid cervical
adenitis on both sides. There was convergent
strabismus. The child was unable to hold up his
head, which tended to fall forward. The muscles of
the back, chest, abdomen, including the diaphragm
were apparently normal, as were those of the upper
extremities. The legs were definitely weak. There
was no clonus, no Babinsky, but a definite absence
of the knee jerks.
There was no history of the child ever having
regurgitated food through his nose. On examination
Phil*., January, 1922]
Acate Bye Inflammation*— Long
39
there was no apparent paralysis of the soft palate.
The urine, however, showed albumin, with a few
hyaline and granular casta.
In this patient two possibilities were considered:
First, the possibility of the weakness complained of
being due to poliomyelitis, and, second, the possi-
bility of it being due to a post-diphtheritic neuritis.
It was felt, undoubtedly, that it was a case of the
latter. Although there was no history of regurgita-
tion, this may not have been noticed. Although there
was no paralysis of the soft palate and although
there was no paralysis of the extremities, there is a
definite history of ocular paralyses. There is a
marked flaccid paralysis of the posterior cervical
muscles and the knee jerks are absent. The distribu-
tion was enough to differentiate between poliomye-
litis and a post-diphtheritic neuritis. The indefinite
history of a feverish attack might have been elicited
in either affection, but the distribution of the paraly-
ses was characteristic of a post-diphtheritic neuritis.
Again — while it is quite possible that one may have
a nephritis coincident with an attack of poliomyelitis,
an attack of nephritis more frequently accompanies
diphtheria. Lastly, there is a definite history of the
patient having suffered from cervical adenitis only
two weeks before the advent of the cervical paralysis.
Surely these symptoms are sufficient to justify us
saying that this case also was one of post-diphtheritic
paralysis.
The prognosis is good in these cases. With treat-
ment and even without treatment the paralysis seems
to clear up.
Importance of Differential Diagnosis
m
Acute Eye Inflammations
Particularly Pertinent to the General Practitioner
By L. F. Long, MJX,
114 N. 6th Street, Zanesville, Ohio.
Often RegrtthMy Cothud
To the general practitioner the eye ap-
pears to be a subject not worthy of serious
study. The result is that conditions similar
outwardly but profoundly dissimilar struc-
turally, such as glaucoma and iritis, are often
regretfully confused. Such being the case, a
review of the important points on the usual
inflammations of the eye is certainly not out
of place. — Editors.
THERE ARE A certain number of acute eye in-
flammations that usually pass through the hands
of the general practitioner first, and upon his diag-
nosis and treatment the fate of the eye may depend.
Quite frequently very reputable physicians treat iritis,
corneal ulcer, or even glaucoma, in fact, about all red,
inflamed eyes, as conjunctivitis, thereby losing valu-
able time and endangering the integrity of the eye.
And when we consider the all too common error of
treating acute glaucoma with atropine, thinking they
are treating iritis, thus doing the eye great damage,
sometimes total loss of vision resulting in a few days,
I believe every physician should carefully fix the diag-
nostic points of difference in these acute eye inflam-
mations, taking care of those he may be prepared to
take care of and promptly referring the others to one
who is qualified to take care of them. Diagnosis is
the most important problem to be considered. With
the diagnosis made, any treatise on the subject will
instruct one how to treat the condition.
I wish to emphasize a few cardinal points in diag-
nosis. I am purposely leaving out the ophthalmo-
scope, as few general practitioners are skilled in its
use. But every physician does need a magnifying
glass for careful examination of the cornea. A good
binocular loupe, used with oblique illumination, should
give excellent results. If you depend on your own
eyes, unaided, you will sometimes overlook a small
foreign body or a small point of ulceration. When
a patient comes in with a red, inflamed eye, giving a
history of a few hours or days duration, make a sys-
tematic examination of the eye and lids. Make a
careful examination of the cornea, with a magnifying
glass and good light, viewing it from different angles,
patient turning the eye up or down as you may direct.
Observe the size of pupils, whether they contract to
light; notice the condition of cornea as to clearness or
8teaminess. Inquire about discharge from eye,
Acute Eye Inflammations — Long
whether eyes are glued together in mornings or
whether eyes just "water." The tension of eaeh eye
should be taken by placing the index finger of each
hand upon the closed eyelid of the patient and alter-
nately pressing a little with one finger and then the
other. A high pressure is easily made out by com-
paring the two eyes, unless they both have high pres-
sure when they can be compared with some other
person's eye that is normal. High tension makes the
aye ball feel like a marble under the lid, while normal
tension is softer and somewhat pliable under the
pressure of the fingers.
The acute eye inflammations that are more com-
monly confused are: 1. Foreign bodies on cornea,
or under lids or misplaced eye-lash. 2. Conjuncti-
vitis. 3. Iritis. 4. Glaucoma. 5. Phlyctenular
keratitis. 6. Corneal ulcers.
Foreign Boditi ami Miiptattd Lathet
Foreign bodies and misplaced lashes should be seen
by careful examination with loupe or magnifying
glass with oblique illumination of cornea and inverted
lids.
Treatment: One or two drops of 4 per cent, co-
caine sol. in eye. Wait ten minutes and remove for-
eign body with a sterile eye spud. Foreign body and
corneal injuries, if wound becomes infected, may be-
come corneal ulcere.
Conjunctivitis
There are many forms of conjunctivitis, but we are
only considering those acute cases which have been
is reflected back on the eye ball. It does not cover the
cornea. Therefore we may have a violent conjunc-
tivitis with so much swelling and edema that the con-
junctiva may protrude between the closed lids and
yet cornea remain clear and not affected. The con-
junctiva is a mucous membrane and when inflamed
throws off mucous as any other mucous membrane
does. Therefore, when we have conjunctivitis we
have mucous discharge from eye and eye lids. The
eye lids are pasted together in the morning when
patient awakens. This is a diagnostic symptom. Vi-
sion is not affected in conjunctivitis, pupils are same
size and react fully to light; tension is normal, cornea
is clear and bright. Conjunctivitis may come at any
age.
Treatment varies because of the great variety of
conditions. Instil argyrol, 15 per cent, sol., two
drops, four times each day in eye. A few drops of
adrenalin added helps to clear the eye promptly. In
the old chronic forms silver nitrate, copper sulph., etc.,
are used. Zinc sulph. is very effective in some types
of infection.
Iritis is an inflammation of iris; sometimes, if se-
vere and of long duration, will include structures
close to the root of the iris (cyclitis).
Symptoms : No mucous discharge, but some watery
discharge present; no sticking together of lids. Pupil
contracted, sluggish, respond to light slowly or not at
all. Vision is hazy; fine pink zone immediately sur-
sounding the cornea. Pain is quite troublesome, often
ft""*.
%-_
s,.^frfrm^
Cot No. 1. Conjunctivitis : Mucous discharge. eves pasted
shut [q morning; pupils, vision and tension
norm (i 1. >
running a few days or weeks. Conjunctivitis is an
inflammation of conjunctiva which lines the lids and
Iritis : 1>
tenslon r
keeping the patient awake at night. Cornea looks.
rather dull and hazy. May occur at any age.
Phil*.. Juin.iT, 1923]
Acute Eye Inflammations — Long
41
These are the cases that need atropine, and need it
badly. Nothing else will quite take its place. Atro-
pine is the remedy par excellence. One drop of 1 per
cent atropine sol. in eye, fonr times a day, should be
used. If that does not dilate the pupil well, use it
oftener, or make it 2 per cent. sol. Keep the pupil
dilated until the redness leaves the eye, then discon-
tinue the atropine. Hot applications, sweats and
laxatives are often indicated. If the iritis can be
traced to some specific systemic cause, as rheumatism
or gonorrhoea or autointoxication those factors should
receive appropriate treatment.
Omkmm
Acute glaucoma very rarely occurs in patients
under forty years old. It is easily confused with
Other forms of glaucoma, such as simple glaucoma,
may have no pain, no redness, etc., but these should
not be confused with the acute troubles we have dis-
nifrttmlar Ktratkii
Phlyctenular keratitis is nearly always a disease of
children, usually in scrofulous or undernourished
Cut No. 4
"iritis," and if the treatment for iritis — atropine — is
applied to glaucoma great damage is done the eye,
possibly total loss of vision.
Symptoms of acute glaucoma: Eye is red and in-
flamed, uo mucous discharge, painful pupil, slightly
dilated (in iritis the pupil is contracted). Compare
the two eyes. In one there is increased tension of
globe and shallow anterior chamber. With a pupil
decidedly larger than its fellow and with a marked
tension we can make a diagnosis of glaucoma, while
"ith a pupil decidedly smaller than its fellow and
wry little or no tension we have iritis.
Treatment : Glaucoma is an unsatisfactory condi-
tion to treat. Ultimately the majority of eases be-
come blind; however, many years of useful vision may
be saved to some of these cases by timely iridectomy.
Esenn sulph., one grain to the ounce of water, is used
to stay the process and in some cases it seems to hold
tie eye for long periods of time.
children. We find on dose examination of cornea a
little whitish yellow ulcer at the junction of the cor-
nea and sclerotic, and from this little uicer a fan-
shaped mass of red congested blood vessels spread
out on the sclerotic. The eve is red and very sensi-
tive to light.
Treatment: Locally, one drop in eye, three times a
day, of atropine sol. 1 per cent. ; yellow oxide of mer-
cury eye ointment, 1 per cent., in eye at bedtime. The
best possible hygienic surroundings should be ob-
tained, especially fresh air and wholesome food. Cod
liver oil or syr. hydriodic acid internally may be
indicated. ' »
Corneal Ulcer
Ulcer of cornea can be seen by careful examination,
often as small as a pin head, a small dirty gray white
looking spot. The eye is red and inflamed and sensi-
tive to light. Pain is severe and deep. Sometimes
iritis develops. If the ulcer is not checked it may
perforate the cornea and the eye be lost. There are
many varieties of corneal ulcer, but we will not at-
tempt to describe them here. If an ulcer reaches
much size and depth it is sure to leave a white scar
when it heals.
Treatment: Atropine sol., 1 per cent., in eye four
times a day, argyrol 15 per cent, may be combined
with the atropine. The ulcer should be cauterized with
carbolic acid or the actual cautery. This should be
{TO* Amnion PhjncUn
done promptly, as it is the most effective means of
checking the extension of the nicer. These six eye
Chronic Bronchitis and Pulmonary
Infections Other Than Tuberculosis
conditions include practically all the commonly met
acute eye troubles.
QjMhduma JYfMMtaram
Ophthalmia neonatorium, a violent inflammation of
the eyes of the new-born babe, starts with a severe
conjunctivitis and often an ulcer of the cornea follows
quickly, with great destruction to the eye. It gen-
erally occurs within a few days after birth, the in-
fection coming from the birth canal of the mother.
Prompt instillation of one drop of 2 per cent, silver
nitrate sol. put in eye just once and followed with
one drop of argyrol sol. IS per cent, every three hours
is usual treatment. The infection is nearly always
gonorrheal. We sometimes get a combination of
two or more forms of eye inflammation, but this is
more apt to be after the trouble has continued for
some time. The most important thing to remember
is to make a careful examination, with a good glass
and good light.
(Eye illustrations drawn from life by the author).
It is a tax on the best of professional skill to
make a positive diagnosis of tuberculosis when there
are no tubercle bacilli to be found in the sputum.
Bloedom and Houghton have recently called at-
tention to the existence of Bronchial Spirochetosis
in this country (Jour. A. M. A., v. 76, p. 1569, 1921).
This disease was described by Castellani in 1906.
Many cases have since been reported from all cli-
mates. It ia apparently caused by Spirochaata Bron-
chiales.
In Ckerecteratir,
It may be acute, subacute, or chronic. It is char-
acterized by varying degrees of continued fever,
cough, blood streaked expectoration.
The chronic cases bear a marked, though perhaps
only a superficial resemblance, to tuberculosis. The
symptoms mentioned are, of course, confusing.
Loss of weight is apparently not a striking feature
of the disease. The patient may, however, gain in
weight under treatment.
While the disease seems most often limited to the
bronchi, the lungs revealing at most a few moist
rales, consolidation and even pleural effusions have
been observed as part of the picture.
ShomU N* Be CWxcJ With Tmbtralm
Not particularly serious in itself, if miscalled
tuberculosis, this disease may cause great loss and
worry to the patient.
Such a mistake would be particularly regrettable
in view of the fact that the cases have usually re-
sponded perfectly to a few doses of Arsphenamine.
The diagnosis is based on the presence of the
spirochetes which must be searched for immediately
after the sputum is expectorated. — Henry Phipps In-
stitute, Philadelphia.
The flea, louse, mosquito and fly have all been
convicted of transmitting disease, and the bed-bug
has been accused. The U. S. Public Health Service,
however finds that he is probably innocent. If
he ever does transmit disease, he does so by carry-
ing the germs on his month and not in his blood, and
he can do this effectively only under especially filthy
conditions, which would call for drastic methods to
exterminate all vermin.
Factors in Abdominal Operations
Rough handling of the abdominal viscera and need-
less dragging or pulling upon the mesentery favor
both post -operative tympanites and abdominal pain
and discomfort. Gentleness in the separation of ad-
hesions so far as possible along natural lines of
cleavage will lessen the number of new adhesions
that will form, and reduce the incidence of pulmonary
and cerebral emboli. Complete hemostasia should
always be sought. Whenever important vessels are
ligated, if they cannot be thoroughly isolated, a su-
ture should be introduced which will include enough
proximal tissue to prevent slipping. — R. Wallace in
Southern Medical Journal.
Phfla., Janvasy, 1922]
Tonsillectomy Umder Local Anesthesia— Grmf e
43
Skilled Technic Required for Best Results
m
Tonsillectomy Under Local Anesthesia
By F. A. Orate, A.B., M.D.,
7 East MacMillan St., Cincinnati, Ohio.
~Amyk*dy Cm Rmmet m Tims*," Bmt—
Recently a dictum pervaded the medical
press that "anybody can remove a tonsil."
ainsi soit il! Just as readily as anybody
can play a piano, and the longer you watch
Paderewshi, the easier it appears. But those
who have never put their capabilities into
actual practice, may well consider a few pre-
liminary details before giving a public ex-
hibition.
PrtHmmary
At irregular intervals the world reports results
of mistakes in technic, mistakes which are followed
with floral wreaths instead of banquets. Just recently
a well-known laryngologist of Paris was summoned
before the bar of justice because autopsy presented
evidence that the carotis interna had been severed.
While ordinarily the carotis interna is situated 20
mm. distal to the pars dorsolaterals capsule tonsillae,
still, occasionally, it approximates the capsula so
closely that a carefully performed close dissection
exposes a pulsating carotis in the bed of the fossa
tonsillaris — a picture which simultaneously fills you
with horror and joy — "how close, and yet, how
lucky !"
Vox populi ever and anon will whisper, "my child
is worse after the operation, than before," or, "the
operation affected my voice."
When you examine the field, view the contracting
scars — the severed arcus palatini, or the buried re-
mains of the Kunstfehler, you may well exclaim,
"Et tu Brute!"
A general knowledge of surgery, a thorough ana-
tomical knowledge of the field of operation here, as
elsewhere, is a conditio sine qua non. This granted,
let us next consider the anesthetic, the position of the
patient, the modus operandi and the after-treatment.
Amuthenm, Pothnrt, etc.
The East, the Athens of American erudition,
bounded by the north shore and the Charles River,
and the West, centered, as you all know, in "The
Queen of the West," have not fully agreed on the
preliminaries.
The East almost exclusively employs ether, the
sitting position, dissection plus snare, and recom-
mends the coaptation of the nude surfaces of the
"pillars" by means of two or three transverse catgut
sutures — "you can go to bed without worry."
The West favors local anesthesia in the adult,
ether in the child and the timid adult; the dorsal
decubitus; the snare without preliminary dissection,
except a few, who, dissentingly, employ the enuclea-
tor, or complete dissection; one operator still adheres
to "finger" enucleation; in case of necessity only the
pillars are coapted, with interposition of a bail of
gauze in the fossa tonsillaris. Will the East come
to the West? Whilst cogitating over future pos-
sibilities, let us calmly consider, ad interim, a few
of the leading points.
Ether has many friends and many enemies. The
same may be said of cocain, but ether has been
accused of "helping the enemy" pneumococcus, "if
it were so, it was a grievous fault and grievously has
Caesar answered it." Let's bury Brutus Cocain also,
and in his stead may novocain, surnamed the procain,
rule the destinies of Rome.
The sitting position, the natural position of choice
in local anesthesia of the adult, assumed by the dor-
mant child, offers many advantages. The position is
favorable to the position of the operator in facilitat-
ing the different stages of his operative procedure,
favorable to the patient, whose head may be bent
forward, preventing blood from being aspirated or
swallowed.
Tfu Operation
Let us consider the different stages of a dissection
operation. The anesthetic:
^— Novocain 0.25
Adrenalin sol (1 :1000) 5.00
Sodii Chloridi 0.90
Aquae dest. qs. ad 100.0
Misce.
To allay fear and nervousness in the patient, ad-
minister a hypodermic tablet of morphine 0.015, plac-
ing same on his tongue about half an hour before
the operation is to commence. The hypodermic ad-
ministration will often increase the fear and offers
no particular advantages.
The next step, the beginning of the operation,
demands a prevention of gagging consequent to the
introduction of the tongue depressor — the novocain
solution, applied by a suitable hand atomizer, emit-
ting a fine spray, will numb the mucosa pharyngis
sufficiently.
44
Tonsillectomy Under Local Anesthesia — Graf e
[The American Physician
An all-metal syringe, provided with an extension
arm not less than 90 mm. long, the distal part bent
at right angles, holding in its lumen a needle 10 mm.
long, will carry the novocain solution to the field
of operation. Introduce the needle into the tissues,
to its "shoulder." Commence in the fossa supra-
tonsillaris, plunging the needle through the mucosa,
then, directing it dorsolaterocaudalward, press about
half a gramma between the meshes of the tissues,
which connect the cranial part of the capsula ton-
sills to the walls of the fossa tonsillaris. Please
observe, you are not injecting the tonsil, nor the
walls of the fossa, merely the tissues which bind the
tonsil to its bed. Effusion will take ample care of
both the tonsil and the walls of the fossa. Whilst
awaiting the effects, permit me to introduce gramma,
the fluid equivalent of gram; "cubic centimeter" has
caused considerable confusion, and besides he can
be assigned to other duties. Milligramma, the infant
sister of Milligram, has also just recently been born
in the West.
We may now proceed with the anesthesia. The
next introduction of the needle should cause no pain
in the partially anesthetized cranial half of the ventral
part of the fossa. One-quarter gramma into the
meshes which bind the ventral part of the capsula
to the walls of the fossa.
Similarly treat the caudal half and the cranial
and caudal half of the dorsal part; then lift up the
tonsil so that the tissues which bind the dorsal part
of the tonsil to its bed be similarly infiltrated. Let
us wait five minutes. Meanwhile assure your patient
that he will not be hurt; that the operation is soon
over, and teach him how to hold the handle of the
tongue depressor in proper position.
The holding of the handle of the tongue depressor
keeps him busy and disengages his mind from the
point at issue. The simplex tongue depressor gives
very good services. Introduce the semi-sharp point
of the Tyding tonsil knife into the mucosa, overlying
the caudal margin of the capsula. Slide the knife
along just beneath the mucosa, cutting nothing but
the mucosa. Hug the outer surface of the capsula
closely, being careful not to incise the capsula; thus
circumcise the tonsil completely.
The loss of blood, thus far, has been minimal,
commencing at the bottom and working upward.
The escaping fluid did not obscure the vision for the
advancing knife. Now introduce the tonsil forceps —
not into the cranial and caudal poles of the tonsil —
leave the poles free, but internal to the pillars, then
direct the handle toward the opposite angle of the
mouth, to be held there by an assistant. With a
retractor, the blunt points of which are introduced
into the ventral parts of the fossa tonsillaris, with-
draw the arcus glossopalatinus from -the capsula
tonsillae. Introduce the blunt point of the Killian
tonsilknife between the capsula and the retracted
arcus, and sever the strands of tissue which bind the
capsula to the arcus. Move the handle of the tonsil-
forceps into the opposite angle of the mouth, retract
the arcus pharyngopalatinus and proceed with your
Killian as in the first instance.
The tonsil is now attached only .at the cranial
and caudal poles, and a very small area of the back.
Lift the tonsil cranialward, so as to put the tissues
which bind the caudal pole on the stretch. As close
to the capsula as possible, crush the binding tissues
with a pair of artery forceps — Kelly's are peculiarly
well adapted.
If the tonsil is normally hyperemic, presupposing
the presence of large vasa, introduce a No. 1 catgut
caudal to the crushing forceps, then tie carefully,
so as to prevent possible future hemorrhage. Now
sever the strand close to the capsula. Ordinarily
the introduction of a ligature may be omitted, the
crushing action being all sufficient. Similarly sever
the tissues which bind the cranial pole. The remain-
ing few strands which bind the pars dorsalis capsulae
may be severed by means of the Robertson tonsilknife,
hugging the capsula closely.
The operation is completed, bloodless as far as the
regions affected will permit. The tonsil has been
removed in toto; no harm has been done to adjacent
parts; the mucosa, excepting that which covers the
exposed surface of the tonsil, has been saved. The
resulting scar tissue should be of minimal quantity.
After Treatment
The after treatment consists in keeping the wound
clean. Frequent gargling with normal salt solution
will generally be sufficient, but the daily application of
iodo-glycerin, 5 per cent, sol., will facilitate matters.
Has the removal or cure of remediable defects in
school children had the great beneficial effects that
were expected f Nobody knows, for both time and
follow-up methods have been lacking. Now, how-
ever, the U. S. Public Health Service is making
arrangements to have such children in all parts of
the country followed up for some years to learn
how greatly they actually have profited by the help
given them. It will welcome additional information
along these lines from all sources.
Prostatic Troubles
With this gland as with other organs of the body,
the best prophylaxis seems to lie in seeking as normal
a life as possible. The seduction of the "skirt" seems
to promise great things to the young man in his
vigor, but in proportion as he yields, good old Dame
Nature seems to charge it up, and later in life may
give him some pretty serious occasion for thought
as, in one way or another, she puts a kink in this
unimportant little gland which causes the gentleman
afflicted to lose all interest in the rest of his anatomy,
until the trouble is allayed. — R. E. Dickson, in Boston
Medical and Surgical Journal
An Efficient Future for Medical Practice
and
1. lbmX**pu\&cm*k*i*faUmt
2. Tl«l
Id psovKx Ibfl
inttfdtptnoenL
defMfteMkt ii cooducted m * /bi
vital ttctoct in medical progrem.
Is the Government Letting Down the Bars
to Quackery?
Chiropractic and the Federal Board for Vocational Education
Dmcttr, What th Ym Tkimk W It?
What does the Medical Profession think
of this governmental letting -down of the
bars to quackery f What have the medical
services of Army and Navy, the Pub-
lic Health, or the American Medical Asso-
tion done in protest against itt
THE SENATE COMMITTEE appointed to in-
vestigate Government activities for the relief of
former service men made, about the last of October,
a report that was sweeping in its criticism of many
things and its condemnation of others, inclusive of
some hospitals. Among other recommendations it
suggested the elimination of politics from appoint-
ments, cancellation of certain contracts, reduction in
personnel and the necessity for a get-busy manage-
ment of affairs; and all of this largely due to the
fact, as reported, that only 5,050 ex'soldiers have been
rehabilitated out of 388,000 applicants. A part of
the fault is due to unsuitable and poorly managed
hospitals, some of them, it is alleged, selected and
the personnel appointed for political reasons. This
latter charge may or may not be justified, but if it
is warranted by the facts, it is simply another instance
of the fact that no sort of medical or hospital service
can be effective when politically controlled.
The American Physician does not care to em-
barrass any governmental board in its activities; but
we have been on the ground in Washington suffi-
ciently, and have talked with capable physicians in
governmental activities rather directly to the point,
and hence we are in position to assert that these
physicians have been embarrassed by political pressure
in their work, and therefore it is not at all remark-
able that special investigation by the Senate finally
became necessary and revealed the fact that too much
politics was at the bottom of the whole trouble. Cer-
tainly a Senate committee would not so report with-
out abundant justification.
HeJmi mi AfUfd Itaimf
While it is not our purpose to minimize in the
least any criticism directed against certain hospitals
and their medical management, we do wish to submit
a verbatim copy of a Government bulletin which sheds
a little light on the subject of what politics does when
it mixes up with medical affairs. This bulletin is as
follows :
Information No. 97
Information No. 81 re-
scinded hereby.
FEDERAL BOARD FOR VOCATIONAL EDUCATION
Division of Vocational Rehabilitation
Washington, D. C.
From:
To:
Re:
Assistant Director for Vocational Rehabilitation
All District Vocational Officers and Others Concerned
Chiropractic, Training in
(Of. Information Nos. 91 and 94.)
Under the conditions set forth below, district vocational of-
ficers are authorized to place men in training for the practice of chiro-
practic. Some districts, it will be noted, have optional opportunities.
July 14, 1921.
1.
46 Chiropractic and the Federal Board for Vocational Education l™* American Physician
Districts Nos. 1, 2, 3 and
Eastern College of Chiropractic, Newark, New Jersey
Districts Nos. 4, 5, 6 and 7
Universal Chiropractic College, Pittsburgh, Pa.
Districts Nos. 7, 8 and 14
National School of Chiropractic, Chicago, 111.
Districts Nos. 9, 11, 12, 13 and 14
Palmer School of Chiropractic, Davenport, Iowa.
Districts Nos. 10 and 13
St. Paul College of Chiropractic, St. Paul, Minn.
2. Before placing a man in training for the practice of chiro-
practic, the district vocational officer shall secure a written statement
from the man, embodying the following points:
(a) That he is choosing this course on his own initiative
and responsibility, and will not in any way look to the
Board for assistance in placement.
(b) That chiropractic may be legally practiced in his state
of residence or in the state in which he contemplates
residing after the completion of his course. In the
latter instance satisfactory evidence will be required
to support trainee's intention of change of residence.
3. District Vocational officers are directed to secure from the
Medical Examining Board of each state in their districts, a statement as
to the legal status of a practitioner of chiropractic A copy of this
statement must be filed in Central Office on or before August 10. This
Information No. 97
Page 2
is asked for in order that Central Office may have complete information
concerning legislation that has become effective during the year 1921.
No man should be put in training for the practice of chiropractic who is
a resident of a state in which such practice is prohibited by law except
under the condition stated in subparagraph (b) under paragraph 2 hereof.
4. Whenever possible men should be dissuaded from taking up this
work, but those who insist upon being trained for it will be assigned in
accordance with paragraph 1 hereof. If they desire to be transferred to
a designated school otherwise than as listed, they must pay their own
traveling expenses.
5. The district vocational officer Dist. No. 8 will negotiate a
contract at regular rates with the National School of Chiropractic,
Chicago, 111. ; the district vocational officer, Dist. No. 10, will negotiate
likewise with St. Paul's College of Chiropractic, St. Paul, Minn, and both
district vocational officers, numbers 8 and 10, will provide all other
district offices with catalogues of the two new schools designated herein.
The regular procedure in regard to transfers will be followed, except as
noted in paragraph 4.
R. T. Fisher,
Assistant Director for
Vocational Rehabilitation.
Doctor, note especially paragraph 4, which "lets We Wonder
the cat out of the bag"; for it is stated to us by 1. What do the medical services of the Army and
genetlemen in position to know, but not by officials, Navy think of this governmental letting down of the
that this chiropractic training was forced on the Board bars to quackery?
by congressional pressure; and it is quietly hinted 2. What does the United States Public Health Serv-
that there was much futile anger engendered by the ice think of it T
fact that the hands of the Board were forced by 3. What does the American Medical Association
politicians. think of it, and what did it do to protest against it T
Phil*., January, 1922]
Where General Practitioners and Specialist* Come in Contact — Champlin
47
4. Doctor, what do you think of itf
A Imam Fir U$
Some man is ambitious to be elected to the Legis-
lature. He tells his physician, who is not interested
and who smiles quietly to himself, believing that Mr.
Man has no chance for election. Mr. Man approaches
other phyisicians. Nothing doing!
Then a chiropractic is approached. Business of
handshaking and good fellowship. Mr. Chiro lines
up Mr. Man to his way of thinking and secures the
active help of all chiropractics and their friends in
the district Furthermore, the Chiropractic Associa-
tion advertises regularly in the newspapers, and says
a good word to the editors for Mr. Man. Don't forget
that Mr. Chiro is exactly the kind of man that loves
to break in as a political worker, while Mr. M. D.
seldom takes an active interest in politics.
Mr. Man is elected and becomes The Honorable
Frank Man. Then, when a bill comes up in the
legislature granting all sorts of powers to a Board of
Chiropractic Examiners, what does the Hon. Frank
Man dot Go ask the Federal Board for Vocational
Education.— T. S. B.
Harmony Where General Practitioners and Specialists
Come in Contact
Requires Understanding and Team Play
By H. W. Champlin, M.D.,
Towanda, Pa.
THE PEREMPTORY command of a general
practitioner to me to remove the segments from
a pair of bifocal lenses prescribed for one of his
patients and mine reminded me again of the antago-
nism between the family doctor and the specialist.
The former allows his jealousy to deprive him and
his patients of the help afforded by the practitioner
who specializes in certain lines; and he shows his
ill-feeling by assuming an air of superior knowledge
in the other fellow's specialty. The same doctor
sent a child back with the statement that his lenses
were not right, and that I must change them. The
eyes had been refracted under atropine, and some
latent eye-strain corrected. Of course there was
slight blurring of vision at first, but this was essential
to the relief of headaches and other symptoms of
eye strain. The doctor was a troublemaker instead of
co-operating with the specialist to his own very great
advantage as well as that of his patients.
It is to the eye specialist that the family doctor
manifests the worst spirit. He has some test letters
in his office, and desires to determine if the glasses
prescribed are right — being quite free with adverse
opinions and criticisms, or, perhaps, expressing an
equally unwarranted approval. His object is not to
be so really mean as he is, but to show that his knowl-
edge is not inferior to that of his fellow who has
fitted himself for special practice.
In another way, also, the general practitioner vents
his spleen most unworthily. According to him the
specialist has charged too much; he thus puts himself
in, right with the family to the disadvantage of
the specialist.
The bad motive is due to this: The specialist has
formerly been a fellow general practitioner who has
at the expense of much time, money, and office equip-
ment fitted himself for special practice. He has thereby
gotten away from his co-worker and seems to be
making more money with less hard work. Therefore
the yet general practitioner "has it in for" his erst-
while fellow-worker. Or the specialist is a young
man having had superior advantages, but has not had
the experience of the family doctor; he manifests an
over-weening desire to immediately acquire a highly
lucrative practice. Such an attitude is not acceptable
to the older men of the profession and accounts for
the want of harmony between the general doctors
and the specialists.
However, this animus is passing away, though, in
spite of the apparent optimism, there is still an
undercurrent of jealousy that does not tend to utmost
good feeling and co-operation in the profession.
A young lady calls on the eye specialist with
complaint of headaches hitherto incurable. She has
taken headache palliatives until the last doctor has
said it is not safe to take more; so as a last resort
he has sent her to the oculist for refraction. Why
has he not sent her first instead of last? He could
then have treated her with profit and credit to him-
self.
Reciprocity Bttt far AH
A most unworthy motive is that which prompts the
family doctor to send his patients to a specialist in
another town when entirely unwarranted by the sue-
48
Argyria from Argyrol — Goldstein
[Phila., January, 1922
cess and reputation of the specialists. His patients
are thus forced to incur extra expense and incon-
venience to gratify an unworthy and unjust ani-
mosity.
This want of helpful and happy harmony in the
medical profession has been the weakness that has
permitted the osteopaths, chiropractors and optom-
etrists to break into what ought to be and is strictly
and exclusively medical work. It is true that "team
work'7 is being practiced with more or less success
in recent years. The same co-operation should be
practiced by all medical practitioners whether nom-
inally team work or not. By helping others we help
ourselves if all adopt the method. But are we sure
of reciprocity from the other fellow? Perhaps no
one has ever tried it out more faithfully than the
writer, and so far he is convinced that the millennium
is not at hand.
The American Physician wants to print both sides
of a question; our pages are open. Doctor, what
do you think?
Caution Patient, Using Argyrol,
Danger of Argyria, Too Long Continued
Case Report
By Hyman I. Goldstein, M.D., Camden, N. J.
Assistant in Medicine, Graduate School of Medicine,
University of Pennsylvania, Phila., Pa.
I HAP OCCASION to see a man in Atlantic
City last summer who give the appearance of
being very cyanotic. His face, lips and hands were
a peculiar slate-blue color.
On examination, I found that Mr. Thomas R.,
was a Unitarian minister, aged sixty-one years. His
home was in Boston, Mass., but owing to chronic
bronchitis (?) he came to Atlantic City where he
felt much better and therefore decided to remain here.
He had influenza two years ago, scarlatina at
thirty-two, smallpox at eighteen. He also had ma-
laria. Nine years ago he had sore throat and wa*
advised by his physician to use Argyrol. He con-
tinued the use of Argyrol twice daily for a year. He
then noticed that he was turning "blue" — and has
remained so.
There is a faint murmur (systolic) heard, after
exercise, at the apex; otherwise general physical ex-
amination is entirely negative. Spleen was not pal-
pable. Systolic blood pressure 122, diastolic 80. He
"feels pretty good." Never had swelling of feet
and legs. There is no clubbing of the fingers, no
evidence of myocardial disease, of polycythemia, or
emphysema, or congenital heart lesions.
GottheU, November 21, 1909, reported before the
Medical Society of the County of New York a case
of argyria in a man, aged thirty-seven years, who had
syphilis. For seven years or more he was in the
habit of applying a 10 or 15 per cent, solution of
silver nitrate freely to his throat, several times a
day. Undoubtedly, large amounts of the drug were
gradually swallowed.
Crispin, of New York, in the Journal of the Amer-
ican Medical Association, May 2, 1914, page 1394,
reporte4 a case of argyrism in a young woman, who
was taking collargol internally. Hexamethylenamin
in ten-grain doses seemed to cause the dark color
to fade, her complexion becoming several shades
lighter.
Ballenger, of Atlanta, reported an unusual instance
of poisoning with argyrol injected into the deep
urethra and : bladder, in a man aged 35, and mentions
the fact that he has seen two patients with idiosyn-
crasies for argyrol when injected into the urethra.
Smith's case of argyria occurred in a man aged
55 — after taking silver nitrate in quarter-grain doses,
three times daily, for three months. The exposed sur-
faces, the skin of the hands and face, were chiefly
affected. In the case reported by Guillemot, Michaux
and Duval, silver nitrate pills were taken internally
for tabes, a daily dose of 0.01 gm. for ten years.
In Lochtefs case, argyria followed the use of in-
jections of silver arsphenamin in a young woman,
aged 21, who received seven (7) injections of neo-
arsphenamin, and later on was given injections of
silver arsphenamin, which made her skin (face and
body) a steel-gray color, also the eyes showed the
same discoloration.
REFERENCES
1.. Olson : Argyria localls due to organic silver prepara-
tions, J. A. M. A. 69; 87, July 14, 1917.
2. Stiger: Medicinal silver poisoning. Cor.-BL t.
Schwelz. Aerzte 47; 1192, Sept 15, 1917.
3. Savitz : Report of case of argyria. International
clinics 3; 59. 1920.
4. Smith : Report of case of Argyria. Illinois M. J. 38;
517, Dec., 1920. .
5. Lochte: Argyria following silver arsphenamin injec-
tions. Therap. Halbmonatsh, 34; 334, June 15, 1920.
6. Guillemot, Michaux & Duval : Argyria ; Bull, et mem.
Soc. Med. d. hop. de Paris, 44; 792, June 11, 1920.
7. Lancaster: Argyrol. Boston M. and S. J. 183; 565,
Nov. 11, 1920.
8. Ballenger : Atlanta Journal-Record of Medicine, July,
9.' Crispin : Jour. A. M. A., May 2, 1914, p. 1394.
10. Gottheil: Medical Record, Dec. 25, 1909, p. 1090.
11. Index Catalogue. 1918, vol. I, 3d series, u. 8. Army,
12. Weber, F. P.: Case of argyria. Proc. Roy. Soc.
726.
Med., London, 1909-1910, Dermat Sect, 111.
"RADIUM IN DERMATOLOGY"
C. J. Broeman, M.D., Cincinnati, 0.
Author's abstract from the December issue of the
Ohio State Medical Journal.
Radium is proving a most valuable addition to the
equipment of the dermatologist. The results upon
basal-celled epithelioma are especially good. The half-
strength ten milligram radium plaque is the best
apparatus for these cases. Radium is especially use-
( Continued one leaf over)
The American Physician] All HoTlCSt A/offrc/ PldCt 4f
When Mineral Oil Is Needed
too great care cannot be taken in selecting the particular oil to use, in order
not only to assure the beneficial results desired but to avoid the objectionable
effects that are invariably produced by oils of questionable purity and indifferent
quality.
In
INTEROL
painstaking practitioners have a mineral oil that presents in the highest degree, the purity,
quality and physical properties that give it maximum efficiency as an intestinal lubricant.
Especially is it free from tho lighter hydrocarbons and sulphur compounds liable to prove
irritating to the intestinal canal or the renal structures.
Therefore, whenever mineral oil is indicated or required,
Interol may be prescribed with the gratifying knowledge that
it will produce satisfactory intestinal lubrication with none of
the unpleasant or deleterious effects of oils of improper char-
acter or uncertain quality.
Stasis
Give one to two tablespoon-
fuls of Interol before meals,
three times a day, gradually
decreasing the dose as its
lubricating action becomes
apparent
Sample and brochure sent on request.
The Allied Drug & Chemical Corporation
2413 Third Ave, New York City
HERE'S NOTHING MYSTERIOUS ABOUT THE AC-
TION OF ANASARCIN TABLETS. NOR IS THERE
UNCERTAINTY IN THEIR USE TO BRING ABOUT
RESORPTION OF EFFUSED SERUM. ANASARCIN
INCREASES THE FORCE PUMP ACTION OF THE HEART,
OVERCOMES CIRCULATORY STASIS, INCREASES URINARY
OUTPUT OF SOLIDS AND FLUIDS, REGULATES AND CON-
TROLS CARDIAC RHYTHM. HENCE ANASARCIN TABLETS
ARE INDICATED IN ASCITES, ANASARCA, THE DROPSY
OF CHRONIC BRIGHTS, POST-SCARLATINAL NEPHRITIS,
ALBUMINURIA OF PREGNANCY, CARDIAC VALVULAR
LESIONS, AND IN EXOPHTHALMIC GOITRE AND CARDIAC
NEUROSES, TO REGULATE AND CONTROL HEART ACTION.
SAMPLE AND LITERATURE ON REQUEST
THE ANASARCIN CHEMICAL CO. WINCHESTER, TENN.
Mentioning The American Physician Insures Prompt, Careful Service
,'Vi'oN iv.Eo/c;
50
Pest CtnVent TOedical Thought
[Pbila., January, 1922
Best C/urrenTiMedical 1 bought
ful in working about the eyes and eye-lids. Endo-
thelioma of the face responds quickly to radium
therapy.
Epithelioma of the lip is especially adapted for
radium treatment and very brilliant results have been
obtained in cases where it has been employed.
The author has had satisfactory results in treating
such conditions as plantar warts, keloids, acne rosacea,
intractable pruritis, keratosis senilis, psoriasis, lichen
planus, lupus and tubercular skin conditions.
It is the treatment of choice in angioma, lymph-
angioma, leucoplakia, and eczema of the lips. Radium
cures cases of sycosis when all other usual methods
fail.
The author reports eight cases of lupus erythe-
matosis of the mucous membrane cured with radium.
He describes a different technique for the treat-
ment of extensive hypertrichosis with radium, and
reports his successful results in all cases, the cos-
metic result being superior to any other known
method.
He has treated successfully cases of epithelioma
and papilloma of the cornea, vernal catarrh and
other eye conditions which were referred by oculists.
Danger From Automobile Exhaust Cases
At the suggestion of the Surgeon General of the
United States Public Health Service, the State Com-
missioner of Health issued today a warning regarding
the danger to health and even life from the inhalation
of exhaust gases from automobiles. The effect of these
gases is produced very quickly, usually before the victim
realizes the danger.
The following precautions should be observed in all
garages :
1. Always open the garage door before starting the
engine.
2. Do not allow the engine to run for any length oi
rime in a closed garage.
3. Do not work near the exhaust of a running auto-
mobile engine.
4. Special precautions as to ventilation are necessary
when in garage pits. #
5. When the exhaust is used for heating a closed
car, the system must be free from leaks.
Persons overcome by exhaust gases from automobiles
and gasoline engines should be removed to fresh air,
and artificial respiration performed until a physician
arrives.
Sale W Horsehair Sharing Brushes Prohibited
Because it has been found that anthrax may be con-
tracted through the use of shaving brushes made from
horse hair, the Public Health Council of the State De-
partment of Health has passed a regulation effective
January 1, prohibiting the manufacture, sale or the offer-
ing for sale of such brushes in the State of New York.
Shall the Calories Be Forgotten?
During the World War, at a time when the food
supply of every nation presented many pressing problems
closely involving the welfare of its people, and when
it became quite customary to speak in terms of millions
of calories of foodstuffs as well as millions of rounds
of munitions, an American humorist said: "After aU,
we eat food and not calories!" This facetious remark
was widely quoted and doubtless provoked a variety of
trains of thought in the minds of the different persons
who heard it. The world was undergoing a great experi-
ment in nutrition on a scale never before witnessed.
While thrones were tottering and kingdoms were being
obliterated, millions of persons were being compelled to
change their customary diets and to subsist on a greatly
decreased food intake. The rations continued to be
reduced from month to month until the allotted daily
quota per person in Austria, for example, fell from 1800
calories to 1000 calories, and finally even to 800 food
fuel units. At this time supplementary food was pur-
chasable only with the greatest difficulty and at extreme
prices if at all— and yet people continued to live. There
were reports that some of the sick, notably diabetic
patients and victims of certain gastro-intestinal dis*
orders, were improving in health. Little wonder, then,
that thoughtful persons should ask whether the nutrition
standards of the physiologists since the days when Voit
preached the doctrine of 3000 calories a day for the
average man were false. Had the civilized world been
enjoying an orgy of food during the past generation?
Had peace and prosperity induced a "luxus consump-
tion" of nutriment? Was the headliner correct when
he announced that "calories have killed more persons
than has disease"?
The world-wide experiment has progressed to a stage
at which it is already possible to evaluate some of the
results and to determine whether .the slogan of a re-
turn to the simple life should include an appeal for a
reform of conventional standards of nutrition. A sur-
vey of the nutritional customs of the diverse nations of
the earth leads to the conclusion that, despite the wide
variations in climate and in economic and agricultural
conditions under which they exist, they, nevertheless,
manifest a surprising similarity in consumption of the
fundamental nutrients. It is difficult to escape the con-
viction that mankind seeks food in appropriate amounts
in response to a well-defined instinct which Rubner once
designated as "Nahrungstrieb." Statistics demonstrate
that, where some freedom of choice exists, the daily
intake of the "average" man, whether he be a native
of England, Japan, Russia, France, Germany, Italy or
America, approximates 2700 calories. Nutritional sur-
veys have demonstrated that in times of plenty, at least,
the data of food intake are almost identical in the case
of inhabitants of Rome and Helsingfors, of Boston and
Berlin.
Some one will naturally inquire: Does not enforced
decrease in food consumption increase the availability
of the less abundant ration? Numerous investigations
in the Central Empires have shown that this is not the
case. There is no evidence for an adjustment of the
alimentary tract of man to secure a better utilization of
war-time dietaries, many of which were uncomfortably
(Continued one leaf over)
The American PhytkUn]
An Honest Market Place
81
KELLOGCS BRAN
// t // 'v/
rdioves
many stubborn oases
of Constipation
rftVfntnry
""WBSCOMSnPMIOli
•MI3I
KRONBLED
**ADY TO EAT
Kellogg's Bran, cooked and krumblcd, is
coining into very general use as a natural
means of relieving constipation. While
the laxative properties of Bran have long
been recognized by physicians, there has
been very little information regarding it
in the books ordinarily in the hands of
medical practitioners. The evident reason
for this is that Bran is not a drug.
As of course you know, Kellogg's Bran,
cooked and krumblcd, adds to the indigestible residue in the bowel tract
Its bulk serves to distend the intestine, thereby inducing better peri-
staltic action.
Kellogg's Bran, cooked and krumbled, unlike
common Brans, is deliciously palatable, inviting,
appetizing. You will thoroughly enjoy it yourself.
It will benefit you greatly.
Please mail us a request card today. We will send
you — without the slightest obligation — a large pack-
age of Kellogg's Bran, cooked and krumbled. Eat
it as a cereal or on your cereal or have it used in
muffins, raisin bread or countless other ways that
appeal to your taste !
Results from eating Kellogg's Bran regularly will
be so gratifying that we feel sure you will prescribe
it with great confidence.
Try This Deli-
cious
Bran Recipe)!
1% cups Kellogg's
Bran
2 cups hot water
54 cup raisins
Boil for 10 mill-
utes. Place in but-
tered bread tin. Let
stand over nifht.
Slice and serve
same as Boston
Brown Bread.
tbe original BRAN
tx # •
d and krumbled
Mentioning The American Physician Insures Prompt, Careful Service
52
Best Current Medical Thought
[Phila., January , 1922
abundant in cellulose and similar indigestible com-
ponents. The war has not converted man into a suc-
cessful herbivorous animal; on the contrary, according
to many medical reports, the enforced intake of bulky
plant products caused much gastro-intestinal distress.
Nor did increased mastication enhance the availability
of the nutrients. The laws of the conservation of mat-
ter and energy have remained unchanged. A note-
worthy reduction in food intake has been followed by
a compensatory loss of body tissues and by reduction
in working efficiency. Ex nihilo nihil fit! Hence Pro-
fessor Durig has recently reminded an audience of
physicians in Vienna that the accepted standards of
nutrition should not be abandoned; for every experi-
ence of the last few years points to their wisdom. The
customary food habits of the world represent an opti-
mum which we must not juggle. The experiences of
the war, Durig said, have taught clearly that departure
from these norms leads to undernutrition and its con-
sequences, from which neither enhanced digestion nor
mastication nor any panacea can furnish protection. The
same story is echoed throughout Europe.
In these comments there is a lesson which looks to
the future. The nutritive needs — the caloric # require-
ments-^of children have not usually been appropriately
recognized in the past. It is now beyond dispute that
during adolescence the needs of children of both sexes
may exceed by nearly 1000 calories a day for each per-
son the requirements of the adult man or woman of
moderate activity. At the age of one year the average
caloric requirement approximates 100 calories per kilo-
gram (two and one-fifth pounds), falling to about
eiVhty calories at the age of six and continuing at this
value until the tenth year. There it remains until growth
is complete, when the adult standard of about forty-four
calories per kilogram suffices. Holt and Fales have
also found that the average amount of protein taken
in the usual mixed diet by more than 100 healthy chil-
dren ranged from 44 gm. (one and one-half ounces)
daily in the second year to 130 gm. (four and one-half
ounces) daily in the fifteenth year. The latter figure
exceeds the average adult need, and obviously should
do so, since adults require protein for maintenance only.
The amount of protein per kilogram of body weight
taken by these children averaged about 4 gm. (61^4
grains) at one year, diminished to about 2.6 gm. (40
grains) at six years, and remained at about this value
until the end of growth. So long as we preach the
doctrine of mens saaa in corpore sano, we must not
skimp the food allowance of the coming generation.
History now in the making is teaching what under-
feeding may result in. Editorial J. A. M. A.
The Effect* of Undernourishment
Graham Lusk1 has recently painted a vivid picture
of the effects of undernourishment on the people of the
central powers during the period of blockade. As he
says, most of the food difficulties occurred in middle
class families, among such persons as teachers, busi-
ness people and pensioners, who could not demand and
receive the enormous pay of common laborers. It is
to be recognized, however, that the laborers need more
food than those of sedentary occupation, and the first
result of insufficient diet, according to Rubner, is a
decrease in the efficiency of labor. Nevertheless, the
people of less vigorous occupation show also marked
effects^ and the usual muscular activity necessary to
maintain health is avoided because of a sensation of
fatigue. Those who have been in undernourished com-
munities recognize the situation especially by the fact
that the children do not care to play, but are as inac-
tive as elderly rheumatics; the chief reward of the
relief workers is the sight of the children resuming
their play after a few days of adequate diet Even
mental activity shows a corresponding depression. Lusk
says : 'The love of accomplishment, the power of per-
formance, the note of personal initiative are absent,
which impulses under ordinary conditions increase the
assimilation of food and favor muscular energy. As
the mind becomes depressed, muscular movements be-
come slow and listless. It is related that a distinguished
mathematician of Leipzig, in order to conserve his food
requirement, remained in bed most of the day, doing
his intellectual work while in bed. Zuntz and Loewy,
who for years have been among the leading German
students of nutrition, had the opportunity to follow
their own metabolism from its prewar figures through
the steps of emaciation until they had lost, respectively,
13 and 22 per cent, of their weight.
The recent hectic period of study of nutrition, with
particular reference to the vitamines, has not limited
itself to consideration of human beings, or even of ani-
mal organisms, but even unicellular forms have had their
nourishment needs carefully considered. It has been
found that yeasts and bacteria need their vitamines as
much as any one else; and although they may be able
to get along with simple food supplies of limited
variety, yet there are certain conditions that must be met,
or a famine district arises in the bacterial community.
It is interesting to learn that bacteria subjected to pro-
tracted undernourishment behave in quite the same
way as German professors or Russian children. Braun*
has studied this subject at length, and tells us that
proteus bacilli grown on a medium defective in nutrition
also show a disinclination to wander over the surface
of the medium, or to swim about in the hanging drop,
and shortly they are seen to have lost their organs of
locomotion, the flagella, as being the least vital part
of their structure. As new generations of bacilli grow
under famine conditions they are seen to be smaller
and smaller, stunted forms more like cocci than like
the well formed proteus bacillus. With the reduction
in the size of each organism the ratio of surface to
mass becomes increased, and so each individual be-
comes more capable of securing under competition ade-
quate food from the impoverished rations. This re-
calls the statement of Gibbon and Ferguson that the
children of Vienna between two and three years of
age were 26.5 per cent, under normal average weight
and 13.6 per cent, under the normal average height.
Braun found that his emaciated bacilli, if grown for
thirty generations on a starvation ration and then trans-
ferred to an adequate diet, continued for some time
to produce stunted forms without flagella, only gradu-
ally returning to the normal proteus structure. It is
fortunate that the war famine did not last for thirty
generations. Even the Thirty Years' War did not pro-
duce a race of dwarfs, and we may hope that the
effects of the three years of short rations in Europe
will not produce permanent changes in the stature of
the population. — Editorial. J. A. M. A.
"~TLusk, Graham: The Physiological Effects of Undernu-
trition. Phys. Rev. 1: 523, 1921.
*Brauns. H. : Neber die Wlrknng der Unternahrung auf
Bakteriens. Ztschr. f. allR. Phys. 19: 1, 1921.
The Path of Miction in Pncamococcic Invasion of the Lmngs
in Man
Since the publication in 1897 of the late Dr. Samuel
Gee's aphorism, "Pneumonia is nof a local but a univer-
sal disease ; and the brunt of it may fall upon any part
— lungs, endocardium, membranes of the brain, intes-
tines, kidneys," the path of infection in pneumonia,
whether by the blood vessels or the air passages, has
(Continued one leaf over)
The American Physician]
An Honest Market Place 53
niiiminimniiiiiM
IBtt«t«WH»M»WniHllffll«UHM^^
I Why this Grape -Nuts Advertisement is |
I Published in a Medical Journal and |
I Addressed to the Doctors of America |
S Doctors are men with little spare time — and no time at all to j|
5 waste on unimportant things. s
I Yet every manufacturer of foods realizes the inestimable value §|
I of the physician's endorsement of his product. And every phy- 5
I sician realizes the tremendous importance of properly selected 5
§ food. =
= With these mutual interests in mind, we desire to present a §
= few facts on Grape-Nuts to the doctors of America. S
s Grape-Nuts is a highly nourishing cereal food, made from a =
§ mixture of malted barley, whole wheat flour, salt and water. The 5
= mixture is raised by yeast, baked in loaves, then sliced, further §|
s baked and then crushed into granules. S
§ Probably no food in the world is so thoroughly baked as s
= Grape-Nuts. More than 20 hours is consumed in the various 5
I baking processes. S
5 As every doctor knows, this brings about a marked degree of §|
= conversion of the carbo-hydrate elements, resulting in the devel- =
S opment of dextrin, maltose and dextrose — readily utilized by =
s the animal economy to yield heat and energy. If
= The well balanced and high food value of Grape-Nuts is shown =
I by the fact that Grape-Nuts contains 95.25% of solids, including 5
s 1 1.88% of protein; 78.76% of carbo-hydrates (of which 48.24% 5
I is soluble, as dextrin, reducing sugars, etc.) and 2.27% of mineral g
1 salts. |§
§ These salts include =
2 Potassium chloride 4.55% Calcium phosphates 5.42% =
S Sodium chloride 34.33% Magnesium phosphates 24.20% =
s Calcium sulphate 1.96% Iron phosphate 0.62% S
s Potassium phosphates 22.87% Silica 2.02% 5
S You can now see why Grape-Nuts is about the best food you =
§ could recommend for building bone, tooth and nerve structure. =
| And why, when combined with cream or milk, it is admittedly a =
| complete food. =
1 Start a few of your malnutrition cases on Grape-Nuts, Doctor H
| — a liberal dish for breakfast and, occasionally, a Grape-Nuts pud- =
s ding for lunch or dinner — and note the difference in their condi- ||
| tion inside of a month. =
| Samples of Grape-Nuts, for individual and clinical test, will be sent on 1
| request to any physician who has not received them. s
| Postum Cereal Company, Inc. |
I Battle Creek, Michigan, U. S. A. §
i 1
Mentioning The American Physician Insures Prompt, Careful Service
54
Best Current Medical Thought
[Phila., January, 1922
been the subject of controversy. In the Lumleian lec-
ture for 1912, "On some moot points in the pathology
and clinical history of pneumonia/' Dr. Percy Kidd,
relying mainly on the early occurrence of septicaemia
before the appearance of local signs, summed up in
favor of the haemic route. Recently, in a paper giving
the results of a histological and experimental research,
Drs. R. R. Armstrong and J. F. Gaskell classify the
pneumococcic infections of the human lung as follows:
(1) Air-borne, (a) lobar pneumonia, (b) uroncho-pneu-
monia; (2) blood-borne, miliary pneumonia; and (3)
lymph-borne infection, relapsing pneumonia. In lobar
pneumonia the infection is seen to be first localized in
the bronchioles, all of which in the area of inflammed
lung are affected; their epithelium rapidly becomes
completely desquamated, and the infection then spreads
into the alveoli, reaching last those furthest from the
bronchioles. As compared with this histological evi-
dence, the occurrence of positive blood cultures is not
regarded as an argument of weight in deciding the path
of infection, for experiment shows that infection of
the extremely vascular lung easily leaks into the gen-
eral circulation, especially in the early stages before the
establishment of local protective reactions. The gen-
erally accepted opinion that lobar and bronchopneu-
monia are essentially the same process is confirmed and
extended; in both die pneumococcus reaches the lungs
by the air passages and settles in the terminal bronchi-
oles ; the factors determining whether the reaction is
lobar or bronchopneumonic are the virulence of the
organism and the resistance of the host; for children
and old persons react to less virulent infections than
adults, in whom greater vigor of the respiratory move-
ments may play a mechanical part by materially assist-
ing in the rapidity of infection of the alveoli, and so
in rendering lobar pneumonia the prevailing form in
adult life. There is an interesting suggestion as to the
mechanism of ithe crisis in lobar pneumonia; the
invading pneumococci are practically destroyed by the
fifth day of the disease, and then the liberation of
endotoxin, which is responsible for the general symp-
toms, comes to an end, and as soon as this endotoxin
is neutralized, a process apparently occupying about
forty-eight hours, the crisis follows, usually on the sev-
enth day. Miliary pneumonia, due to infection of the
alveoli by pneumococci reaching, the lungs by the blood
stream, is described and shown in a figure; this blood-
borne infection spreads from the capillaries directly
into the air vesicles, and the bronchioles either escape
or are affected only by secondary extension. An ab-
sence of polymorphonuclear exudate is characteristic of
this lesion, which is widely spread through the lungs,
is merely part of a general septicaemia, runs a very
rapid course, and is almost confined to young children;
it is analogous to generalized miliary tuberculosis, and
it is suggested that the pulmonary changes in pneu-
monic plague are also of this nature. The third method
by which pneumococcic infection is spread in the lung
is by way of the lymphatics, either from existing areas
of infected lung or from the bronchi; this process,
analogous to the spread of chronic pulmonary tuber-
culosis, is slow, and accounts for some cases of chronic
and relapsing pneumonia. — Editorial, British Med. Jour.
of vagotonia, their renal function, as measured by the
phenolsulphonephthalein test, being generally normal.
Although anaemic, nearly all have a normal haemo-
globin content, frequently an eosinophilia, and occasion-
ally leucocytosis. The amount of the precipitate on the
addition of acetic acid to the urine was found to
vary absolutely or relatively even in the same individual,
and the albumin , quotient of the proteins was equal to
that of the serum and of the cerebro-spinal fluid. Two
diagnostic methods most reliable for the provocation
of albuminuria are for the patient (1) to hold a rod
with both hands extended forwards at the level of the
shoulders for ten minutes, and (2) to kneel down for
ten minutes. Lordosis of the lumbar spine may be
a direct cause of the condition, though this is not
sufficient alone, vasomoter instability being a probable
factor.
OrtheiU&ic Albmmumria
Saito (Amer. Journ. Dis. of Children, October, 1921),
from a study of forty-four cases showing moderate or
severe degrees of orthostatic albuminuria, concludes that
such patients have an asthenic constitution. Lordosis of
the lumbar spine was present in about half the cases,
but tuberculosis and syphilis have no etiological bearing
on the condition. The large majority showed a state
Tkt Oxygen Treatment ofSlmgguk WemnmB
"A few years ago," said a well-known New York
practitioner of medicine the other day, "I was greatly
worried by my inability to heal a sluggish wound of
the forearm that refused to make any progress what-
soever.
"All manner of treatment had been employed, with
only indifferent results. Finally, one day in turning
over in my mind the measures that ought to be able
to stimulate cellular activity, I happened to think of
an article I had recently read in a scientific journal,
describing the effect that an atmosphere containing an
increased amount of oxygen had had on certain forms
of low plant life. While it is known that many plants
take up nitrogen and give off oxygen, it was shown in
the experiments I vaguely recalled, that certain varieties,
when kept in an atmosphere rich in oxygen, grew much
more rapidly and luxuriantly.
"If oxygen would do this to one form of cell life,
why would it not do likewise to the cells of the tissues
of a wound ?
"I immediately made an attempt to submit the wound
above referred to, to an atmosphere of oxygen, but
as can be easily imagined, the difficulties were so great
that I became discouraged. Suddenly I happened ■ to
think of peroxide of hydrogen. I had used this early
in cleansing the wound, and under its influence when
applied in the usual way, the infection and pus had
been cleared up promptly, leaving the tissue remark-
ably clean. The only trouble seemed to be an absence of
any tendency to cell growth and tissue repair.
"It seemed to me that if I would find a non-irritating
peroxide containing an unusually large volume of oxy-
gen, and could apply this to the tissues of the wound
in such a way that there would be a maximum liberation
of oxygen in the wound, I might be able to stimulate the
cell activity and growth to an effective degree.
"As for the peroxide of hydrogen, there was only one
that met my requirements — and this was Dioxogen. The
question of the method of use was more difficult. But
finally it came to me that ♦/ / sprayed the Dioxogen
onto the wound surfaces, I would thus bring the solution
into more complete or perfect contact with the tis-
sues, and thus liberate its oxygen more completely than
would be possible in any other way.
"I accordingly applied the Dioxogen by means of an
ordinary atomizer, taking pains to strike every part
of the wound, and cover its entire surface with a spray
of the solution. When this was done and gas libera-
tion well under way, I covered the whole wound for
a few minutes with a wet compress, to keep the oxygen
as much as possible from too rapid diffusion.
"When effervescence had stopped to a noticeable
(Continued one leaf over)
ican Physician]
An Honest Market Place
Meat vs. Cold
IN PNEUMONIA
The application of cold packs
to the thoracic wall at a reme-
dial agent in the treatment of
pneumonia is rapidly being dis-
carded by practitioners.
The application of heat is again in favor and physicians in every part
of the country are now convinced that the logical, safe, and sane
method of treating pneumonia includes the application of prolonged
moist heat over the entire thoracic wall.
not only offers the best known method of continuously applying moist
heat of equable temperature for a long period, together with the ad-
vantages attendant upon its physical properties, hygroscopy, ezomosis
and endosmosis, but it offers the pneumonic patient exactly what he
absolutely requires — EASE and KEST. When Antiphlogistine is
once applied it can advantageously remain in place for a long period,
usually from twelve to twenty-four hours, all the time perfoming its
soothing and effective service.
THE DENVER CHEMICAL li'FG. COMPANY, NEW YORK CITY
Has it ever occurred to you
that your rUIi-QOWll patients who are tired all the time,
whose oxidation and elimination are slow, temperature subnormal and
blood-pressure low, especially in cases following an attack of grippe,
pneumonia or even a bad cold,
are suffering from hypoadrenia?
You can modify these common symptoms by supporting the adrenals.
ADRENO-SPERMIN CO. (Harrower)
is a splendid remedy in such cases (Sig: 1, q.i.d. at meals and bedtime).
This pluriglandular formula is effective because it contains the missing
internal secretions from the thyroid and adrenals, plus sperm in (the
musculo-tonic principle from the gonads).
The excipient is calcium glycerophosphate — an accepted "nerve re-
constructant." It is a physiologic "pep-producer" and, figuratively speak-
ing, "h helps to burn up the carbon in the cylinders."
Try This, Doctor— It Works!
The booklet "Adrenal Support" eent to physicians on request.
THE HARROWER LABORATORY
HOME OFFICE: GLENDALE, CALIFORNIA
Now York, 31 Park Place. Baltimore, 4 E. Redwood St.
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Mentioning The American Physician Insures Prompt, Careful Service
56
Best Current Medical Thought
[Pfcila., January, 1922
extent, I again thoroughly sprayed the wound surfaces,
and covered as before. I did this several times, the
whole taking twenty or more minutes. Then I gently
irrigated the wound with normal salt solution, and
dressed as usual.
"This treatment was carried out each day. After the
third day, the effect on the healing and reparative pro-
cess was very striking. Two weeks and three days from
the first use of Dioxogen by spraying, the wound that
had worried me for over four months was entirely
healed.
"Since this case I have used Dioxogen many times
in the manner described, and the results I have uni-
formly obtained convince me that the method is one
of very great value for stimulating cell growth and
hastening the reparative process in slow-healing wounds.
"I usually dilute the Dioxogen, one part to two or
three of normal salt solution, but often use it as
above described in full strength."
Eneuresis
Eneuresis is more common in active, energetic
children, who by night time give evidence of neuro-
muscular fatigue. The cure of these cases depends
on detailed management, which includes rest, diet,
bladder control exercises, psychic impressions and,
in certain intractable cases, mechanical irritation of
the sphincter. Having removed possible physical
causes, such as phimosis or adenoids, the physician
must acquaint himself with the details of the child's
life, so that fatigue and excessive nerve stimulation
may be avoided. Meats, meat soups, tea, coffee,
pastry and all highly seasoned foods should be
avoided. A two-day rest cure is often beneficial,
requiring that the child have his breakfast in bed,
and "he is not allowed out of bed until lunch time.
Such a plan followed for two days each week, at the
beginning and the end of the week often helps a
great deal. The child should have a dry supper
with as little liquid as possible after 4 p. m., and
there should be no strenuous play in the afternoon.
He is put to bed one hour after his supper and is
taken up to urinate when the parents retire. During
the day the child is required to urinate and to stop
at the word of command. This teaches the higher
centers to control the act. These control exercises
are done at least three times a day in the presence
of an attendant. The patient is given a report card,
which is filled out every morning, indicating whether
the bed was wet or dry and the number of times the
control exercises were done.. Young children who
have not learned to write may affix a gold star for
a dry bed and a red star for a wet one. These
reports, which are mailed to the physician, make a*
deep impression and are extremely valuable adjuncts
in the cure. — Hill, in Amer. Jour, of Diseases of
Children.
Health Insurance
Mayor Wm. T. Ramsey is chairman of the com-
mission appointed by Governor Sproul to study com-
pulsory health insurance, and spent several months
in England as the official representative of that com-
mission. He found some good and some bad in the
law as operated there, and came to the conclusion
that the English law will not work in America. The
members of the commission have studied their task
carefully and seriously, and have interviewed all who
are interested in compulsory health insurance, includ-
ing the members of our profession. It is realized
that health insurance cannot be successful without
the co-operation of the physicians, and it is consid-
ered important to properly compensate them for their
services. The panel system in operation in England
could not be adopted here in justice to the physicians.
The latest scheme, embodied in a bill now before
the New York Legislature, provides that the sick
employee be allowed to select his own physician. The
State compensates the patient, who in turn pays the
physician at the rate charged patients in his private
practice. This would relieve the physician from the
humiliation of being compelled to do cheap work and
the resulting temptation to do this work in a hurried
and careless manner, a charge to which the English
panel physicians have frequently been subjected. Ac-
cording to Mayor Ramsey, there will be no compul-
sory health insurance in Pennsylvania for some time,
for he assured us that no bill will be presented to
the present Legislature. He believes that it will
eventually come, and this is probably true, so it is
necessary for us to be constantly alert in these days
of socialistic tendencies. We will not be caught
napping, as we were when the Workmen's Com-
pensation Law was enacted. — C. I. S., Berks Co, Med,
Society.
Information Wanted
This caption might also be written with a question
mark, that is, "Do you want information?"
It is a fact, admitted by most of us, that little can
be accomplished without organization and co-operation.
There was founded, some ten years ago, an association
of which we have heard very little but which has accom-
plished much for the doctor who, in the legitimate prac-
tice of his profession, has had to fight inimical legisla-
tion on the one hand, and the invasion of an army of
drugless healers on the other. In the face of countless
obstacles, the doctor has held his own, but he is still
fighting for the privileges and prestige to which he is
entitled.
The organization we refer to is not a medical society;
yet its interests are all* with the medical profession. We
refer to the American Pharmaceutical Manufacturers*
Association, founded ten years ago.
The medical profession can hardly realize the vast
amount of good this association has accomplished in
fighting legislation, both national and local, which was
unjust to physicians and destructive to the growth of
better pharmaceutical methods. In addition to the
effective legislative work in defense of the doctors'
rights, much has been accomplished in the way of labora-
tory efficiency, better manufacturing methods, and the
elimination of waste, all of which has indirectly bene-
fited the doctor in his combat against disease.
There are other larger organizations which have been
active in the medical field. The doctor is acquainted
with these and with their work, however, there is an
opportunity for the physician to become better ac-
quainted with the American Pharmaceutical Manufac-
turers' Association, and to make use of its various com-
mittees. In turn, the association wants information from
individual doctors as to the problems which confronts
them in their local fields, as well as from the medical
profession as a whole.
If you are cognizant of any legislation pending in
your state which, in your opinion, does not give the
doctor a square deal, it will pay you to pass the informa-
tion on to the American Pharmaceutical Manufacturers'
Association. If there is any information that you de-
sire in the field of manufacturing pharmacy, you will
be served efficiently on request. If you have any sug-
gestions to offer, they will be gladly received and
promptly attended to at the headquarters of the asso-
ciation, 32 Liberty St., New York City.
The American Physician]
An Honest Market Place
87
In Cases of
Delayed Convalescence
or
Malnutrition
DURING convalescence
from disease or surgical
operation and in cases of mal-
nutrition, the systemic vitality
is at a low ebb and rapid re-
covery depends to a large
% extent upon the quality and
character of the nutrition.
In the majority of cases, the
body is reduced in weight,
the appetite is poor and the
circulating blood shows a low
hemoglobin and red cell con-
tent.
In many such cases reported
to us, regular daily feeding
with YEAST VITAMINE-
HARRIS TABLETS has
shown a remarkably stimulat-
ing effect upon the appetite,
causing a greater daily intake
of common food, bv natural
desire. This was followed bv
a steady gain in weight, to-
gether with an improvement
in the content of the circulat-
ing blood and a very noticeable
gain in the general metabolic
activity.
NOTICE
A number of alleged Vitamine preparations containing drugs and
chemicals, with no guarantee of composition and exact contents,
are on the market. READ THE LABELS! Yeast Vitamine-Harris
contains no drugs and is intended only for use on physicians9
prescriptions.
THE HARRIS LABORATORIES
TUCKAHOE, N. Y.
Mentioning The American Physician Insures Prompt, Careful Service
58
Book Reviews
[Phil*., January, 1923
"Book cReMews
Traps cof Opktka&malogy
By Robert Henry Elliot, ScD., M.D., F.R.C.S.,
Lieut.-CoL I.M.S., Late Supt. Government Ophthal-
mic Hospital, Madras; Lecturer in Ophthalmology,
London School of Tropical Medicine, etc. Cloth, 525
pages, freely illustrated. Oxford University Press,
London. Price, $12.50.
This is the sixth work on ophthalmic subjects by
this talented observer and writer, who markedly pos-
sesses the rare gift of injecting human interest into
technical subjects. The present work is a charm-
ing one, alike for the scientific simplicity of the clini-
cal treatment of the subject and the intimate descrip-
tion of social, climatic, sanitary and pathologic con-
ditions met with in the tropics. Really the book is
a treatise on tropical medicine and sanitation as re-
lated to ophthalmology, most enlightening and a
worthy presentation primarily of interest to the phy-
sician in tropical environment, but possessed of great
value and interest to physicians in temperate regions.
So far as we know, this is the first work on tropical
ophthalmology; it is based on a long experience, and
we know of no other book so thoroughly stimulating
to the young physician who aspires to missionary or
other work in tropical lands, although it is not writ-
ten from the missionary's point of view. Technically,
the text is accurate and it presents conservative and
well digested views on ophthalmology. The reviewer
wishes especially to commend it to the favorable
attention of the American profession. — T. S. B.
Injmri** to Mate
By Col. Sir Robert Jones. Second Edition. Second
Impression. London: Oxford University Press, 1920.
Price, $2.00.
This very instructive little volume is one of the Ox-
ford War Primers. It is from the pen of Sir Robert
Jones, the eminent orthopedist It presents in small
compass a concise, yet thorough, presentation of the
diagnosis and treatment of injuries of joints, and is
intended primarily for the military surgeon. There
are a number of illustrations in the text which are quite
helpful. The manual is excellent and up-to-date.
Pkmnmactwtic<d B*t*my
By Heber W. Youngken, A.M., M.S., Ph.M., Ph.D.,
Professor of Botany and Pharmacognosy and Director
of the Microscopical Laboratories in the Philadelphia
College of Pharmacy and Science. Third edition,
cloth, 479 pages, 238 illustrations and a Glossary of
Botanical Terms. P. Blakiston's Son & Co., 1012
Walnut St., Phila. Price, $3.75 net.
(Book Reviews continued one leaf over)
MIIIIIIIIIIIIIIIIII1IIIM
COMPLETE LIST OF
PROTEOGENS
Prottoatn No. 1 — For inoperable malignant
and benign tumora, Including cancer,
enlarged prostate and fibroid tumors.
Prottoptn No. 2 — For rheumatic conditions,
not complicated with spedflc in-
fections, accompanying or prior to
the rheumatic symptoms.
Prottofftn No. 3 — For Tuberculosis.
Prottoatn No. 4 — For Hay Ferer and Bron-
chial Asthma.
Protooftn No. 5 — For Dermatoses, not due
to spedflc Infections.
Prottoptn No. fe— For Chlorosis.
Prottoatn No. 7 — For Secondary Anemia.
Prottoatn No. 8 — For Pernicious Anemia,
except the aplastic type.
Prottoatn No. 9— For 81mple Goitre.
Proteoptn No. 9-A — For Exophthalmic
Goitre.
Prottoatn No. 10— For Syphilis.
Prottoatn No. 11— For Gonorrhea.
Prottoatn No. 12 — For Pneumonia and In-
fluenza,
Prottoatn No. 13 — For Pyorrhea.
Prottoatn No. 14 — For Diabetes.
Ptoteogens Produce Results
NOT sporadic instances, but hundreds of
authentic reports of cases treated with
Proteogens received from reputable physi-
cians indicate the value of these remedies.
Proteogens are sterile liquids containing"
non-specific vegetable proteins, enzymes,
lipoids, vitamines, and other complex deriva-
tives obtained from selected plants.
Their use in the treatment of various
diseases is based on the fact that they have
the power of stimulating the cytogenic mech-
anism of the body. Such stimulation brings
about a correction of disturbed metabolism,
neutralizing and ridding the system of the
disease producing toxins or bacteria, and
thus removing the underlying cause of vari-
ous ailments.
General booklet on Proteogen Therapy and
special booklets on the use of Proteogens
for various diseases are available to the
medical profession. A card will
bring them to your desk.
Founded 1828
Nrvunaea awe
ERRELLcomunr
CKBtttJl U ft. A.
^iiiiiiiuiim^
You can buy with Confidence — See "Service Guarantee to Readers" on page 82
The American Pbytiehwl
An Honest Market Place
START THE NEW YEAR RIGHT
Lot 1922 See Yon Far on lb* Way to Outstanding Succau
Equipment is one of the "short-cuts." The equipment below b of
unquestioned merit and will greatly increase YOUR i
W1i.ii the foetal i
agalnet the Symphyal* lnitead of
octly toward tin birth
■d mar b* readily da-
fleeted toward the canal mud hour*
Worth Its Weight in Gold
"Shoe Horn" Makes Difficult
Obstetrical Cases Easy
Stricture Yields Readily
---. --- - Tho new Johnaon Kollman Dl-
slowly turn the thumb acrew back- Utor and catheter combined will
w«rdi until the blade* ere nearly do the work of the 130.00 Kollman
closed, then withdraw the dilator, instrument and coat* you only
Plenty of vaeeline ihould be uaed III. SO.
The New Huston Akouophone
(Jan. Patent)
Johnaon Kollman Dilator
Will Do the Work of the
$50.00 Kolbn
Co.t. You Only $12.50
Clinches your
Diagnosis
,.-> principle enablee yon to
**"»ft*et eubciepitant and aibllant rale*, feeble cardiac
■a^aton** Akoticphune give* you make* *ure of their
eathologlc character and cllnche* your diegmnli.
tve. the normal *ound. alao the accentuated eouiid.
alao graduate* all eound* ae you wi*b. Price, M.7J.
rVrihr tmdaj, Doctor, (iii tnaaeat cga-i* anai mill iam
, HlUton Bros. Co. Atlas American Bldg.
Price Only
$4.75
Chicago, HI.
Pond's Extract
r
POND'S EXTRACT CO.,
New York and London
Purity and Quality
One ba* only to coniidcr the purity, quality and
unvarying uniformity of Pond's Extract to under*
stand not only It* therapeutic efficiency, but also
the high regard In which it I* held by physicians
■a the (tandard preparation of hamatneH*. For
nearly aeventy-flve year* it haa been tervirur the
medical profession, faithfnlly and well, accom-
plishing result* not possible with ordinary ei-
You an buy with Confidence — See "
s Guarantee to Reader/' on page 8
60
Book Reviews
[Phila., January, 1922
Medical and pharmaceutical botany has been un-
duly neglected, partly because it was not on a very
scientific basis. This book is accurate and should
awaken an interest in the subject. The fundamental
principles of botany are well set forth, followed by
laboratory considerations, cytology, ecology and tax-
onomy. The description of the official botanic drugs
constitutes the bulk of the text. Physicians inter-
ested in this subject will find this book a valuable
text, though it is principally addressed to the phar-
maceutical profession.
Qimical Metkodi
A Guide to the Practical Study of Medicine. By
Robert Hutchison, M.D., F.R.C.P., London, and
Harry Rainy, M.D., F.R.C.P., F.R.S.E., Edinburgh.
With 16 color plates and 157 figures in the text.
Seventh edition, revised throughout. New York:
Paul B. Hoeber, 1921. Price, $4.50.
This excellent and practical manual is too well
known to require introduction. Since its appearance
in 1897 it has enjoyed a well-deserved* popularity
among students and practitioners alike. The present
edition has been thoroughly revised and alterations
made in keeping with the progress of knowledge. Ad-
ditions have been made to the chapters dealing with
the examination of the heart and of the urine. The
book should find a place on the desk of every prac-
titioner.
A Handbook for Physicians and Their Patients.
By Philip Horowitz, M.D. With twenty-seven text il-
lustrations and two colored plates. New York: Paul
B. Hoeber. Price, $2.00.
This little book is designed to enlighten the patient
so as to co-operate with his physician on a more in-
telligent basis. The keynote to success in the treatment
of diabetes, according to the author, lies in scientific
accuracy in the dietary and its adjustment to the
patient's idiosyncrasy. He advances the theory of
intestinal toxemia as the underlying cause of weak-
ened pancreatic function and outlines his treatment
on this supposition. The menus, recipes and tables
are from the author's own practice. Curiously no
mention is made of the Allen treatment.
Phy$icml DkfJtosis
By W. D. Rose, M.D., Lecturer on Physical Diagnosis
and Associate Professor of Medicine in the University
of Arknasas. Second Edition. Three hundred nine
illustrations. St. Louis: C. V. Mosby Company, 1921.
Price, $8.50.
Dr. Rose has carefully revised his successful book, in-
corporating all worth while advances in the subject.
The author informs us in his preface that "the clinical
anatomy of the various thoracic and abdominal organs
has been carried a step further in this edition, and
ANUSOL
(Trad* Mark)
Hemorrhoidal
SUPPOSITORIES
Hesitate to Operate
Until They've Had
Their Chance
>f
To be sure, there will always be Hemorrhoid cases that yield to the
knife only.
But their number is not by any means as great as is generally assumed.
At any rate, it is a fact that the verdict "Operation" is pronounced
much too readily and lightly in a great proportion of Hemorrhoid
Whenever possible, suspend sentence until Anusol Suppositories have
been given their chance.
Ample TtHal Quantity and Literature from
SCHERING & GLATZ, Inc., ISO Maiden Lane, New York
You can buy with Confidence— See "Service Guarantee to Readers" on page 82
The American Physician]
An Honest Market Place
^^S| The Management of an Infant's Diet ~| F^trJgSl^ij
Maltose and Dextrins
are the carbohydrates in
Mellin's Food
Protein
in a most available form is a part of the composition of
Mellin's Food
Potassium Bicarbonate
together with the salts in wheat and barley
are the inorganic constituents of
Mellin's Food
Mentioning The American Physician Insures Prompt, Careful Service
62
Helpful Points
[Phila., January, 1922
the intimate correlation of anatomy, pathology, and
physical signs has been emphasized throughout the text.
Additional space has likewise been allotted in the present
edition to the physical principles underlying the various
physical signs which are generated within the thorax
and abdomen in health and in disease." This excellent
book will receive from students and practitioners alike
the appreciation accorded the preceding edition.
Surgical Aspect* of Dysentery
Including Liver-Abscess. By Zachary Cope, B.A.,
M.D., M.S., F.R.C.S. London: Oxford University
Press, 1920. Price, $5.00.
This book deals with a subject which, outside of tropi-
cal countries, is not studied sufficiently in proportion to
its importance. Dysentery in epidemic form has from
time immemorial been an inseparable adjunct to every
big military campaign. Surgical complications are in-
frequent in dysentery, but when they do occur they are
apt to be acute and tax the surgeon's resources to the
utmost. The material contained in this monograph is.
based on the author's extensive experience in the Meso-
potamian campaign of the late war, together with in-
formation gathered from other sources. The text is
elucidated by several colored plates and a number of
diagrams and charts. A list of references is appended.
Salvarsan Adulterators Receioe Prisom Sentences
The Salvarsan adulterations in Germany and other
countries, which caused so much difficulty in the drug
markets during 1919 and 1920, were recently taken up by
the Criminal Court of the County of Hamburg. After
a trial lasting fourteen days, in which many experts
were examined, the manufacturer, Gerloff, and his su-
perintendent, Von der Heyde, were sentenced to three
m
CHLORYLEN
The New Anti-Neuralgicum
Original bottles of 25 grams each
NEUTRALON
For Gastric Afflictions
Original Boxes of 1 00 grams Powder each
VALAMIN
an Efficient and Prompt
SEDATIVE and Mild
HYPNOTIC
Original Boxes of 25 capsules each
Information and Literature on Request
KIRBACH, INC., General Agents
227-229 Fulton St., New York, N. Y.
Tel. Cortlandt 1268
iiiuiiiiiuiiiiiiiiitip
and one-half years in prison and to five years disen-
franchisement. Sixteen defendants received two-year
prison sentences each, and sixty-two others who had
conducted a flourishing business in adulterated Salvar-
san were fined 20,000 marks. Six persons were acquitted.
Those convicted of adulteration had manufactured and
sold a yellow powder from substances which were not
only worthless, but dangerous to health. It bore a
striking resemblance to the genuine Salvarsan, and
the labels and packing were so perfect an imitation of
the genuine Hoechst product that it could easily be
mistaken for the genuine even by physicians. The con-
victed men made a large amount of money by handling
these adulterated products, as they were selling this
stuff at a time when raw materials were scarce and
the entire world was crying for the genuine German
product, and it was easy to find purchasers.
The judge in his charge to the jury condemned the
unscrupulousness by which the defendants had endan-
gered the lives of their fellow-men for the sake of
greed, and he asserted that the good name of the Ger-
man industry had been injured. He felt that another
grievous factor in these adulterations was that the idea
had gotten abroad that German manufacturers were
attempting to sell poisonous medicines for ulterior pur-
poses and such charges had appeared in foreign news-
papers. The severe punishment inflicted upon those
convicted will, it is believed, put an end to further
adulterations of Salvarsan and will discourage possible
repetitions.
Conservation of Periodic Health
The conservation of periodic health means the nor-
malizing of menstruation from puberty to the menopause.
Dysmenorrhea, menorrhagia and other manifestations of
(Helpful Points continued one leaf over.)
A Trichlorethylene in its purest form. It
represents a volatile liquid of pleasant odor
which has a specific effect upon the sensitive
Trigeminus. It gives immediate relief and
the pain often disappears after a few inhala*
tions.
(Hyper- Acidity, Gastric and Duodenal
Ulcer, Hypersecretion, etc.) It is a Syn-
thetic Aluminum Silicate which neutralizes
the excessive acid in the stomach and pre-
vents by its astringent action on the stomach
lining the formation of additional acid. It
reacts gradually, is superior to Bismuth and
Silver Compounds and its effect is more per-
manent than that of the Alkalies and of
> Magnesia.
Combines all the valuable therapeutic
properties of Amylene-Hydrate and Iso-
Valerianic Acid. A valuable preparation
for Ordinary and Nervous Insomnia, Hys-
teria and other Neuroses (cardiac, vascular
or gastric). Palpitation of the Heart,
Flushes of Heat of the Climacteric, Relief
in Angina Pectoris and Asthma, for reducing
Excitement of the Patients before ahd after
operations.
1
You can buy with Confidence— See "Service Guarantee to Readers" on page 82
The American Physician]
An Honest Market Place
DOCTOR, we will make a Spinal
Appliance to order for any case
and allow a 30-day trial
Did any other orthopaedic institution ever make you a like offer?
Do you know of any other orthopedic institution that trill make you a
like offer? We offer to make you an appliance to special order for any
of your patients and let it prove its usefulness.
We have been doing business on that plan for more than nineteen
years. During this time more than 40,000 cases of spinal trouble have
been either wholly cured or greatly benefited by the Philo Bun Method,
consisting of a light comfortable appliance and special exercises.
If you have a case of spinal weakness or deformity now — no matter
whether it is an incipient case or one. seriously developed — write us at
once and we will send you full information about this wonderful method,
with incontrovertible proof of its efficiency.
Every Philo Burl Appliance it made to special measurement. It liftith* weight
of the head and shoulders off the spine, and corrects soy deflections in the
vertebrae. It does not chafe or irritate, weighs ounces where other supports
weigh pounds and is easily adjusted to meet improved condition!. The Philo Burt Appliance can be put
on and taken off in a moment's time. It ii easily removed for the bath, massage, relaxation or examination.
The price of the Philo Burt Appliance with the apeciat course of exercise ii within reach of all,
and each appliance i> fitted under our absolute guarantee of satisfaction or money back.
WriU for our tiliutrafd Am* and o«r plan of m optretion with Mntnou.
PHILO BURT MANUFACTURING CO., UB-isO.MPdbw.TMpl. JAMESTOWN, N. T.
Creo-Tussin in Whooping Cough
"When I ask a doctor if he has a satisfactory remedy
for whooping cough the answer is almost invariably and
emphatically NO. Hence I have no trouble to interest him
in Creo-Tussin which I know does afford relief in a large
percent of cases." So writes one of our detail men.
Physicians who are unfamiliar with Creo-Tussin are
requested to write us for sample and literature. Please
use attached coupon.
Creo-Tussin
The Maltbie Chemical Company, Newark, New Jersey
a.-- - — .Cut Here and Mail Today____
■
J THE MALTBIE CHEMICAL CO., Newark, N. J.
'*> a palatable solution of creosote,.
Kelsemium, passiflora, verba santa, . Please mail sample Creo-Tnssln to
**senthol and aromatics. Conveniently '
Pot up in 2 oe. bottles with blank la- J . . u n,
bela for directions, each bottle in!
Plain carton. '
>Pice— Dozen 2 os. $4.00, Pint, $240 ■
— i I a. p. n-ai __
Mentioning The American Physician Insures Prompt, Careful Service
64
Helpful Points
[Phila., January, 1922
painful and distressing menstrual abnormalities will be
benefited by the administration of Hayden's Viburnum
Compound.
In the light of years of clinical evidence, Hayden's
Viburnum Compound has proven a most effective and
dependable therapeutic aid. Samples and literature will
be sent to American Physician readers on request;
address: New York Pharmaceutical Co., Bedford
Springs, Bedford, Mass.
Yarn Will Want This
Many clinicians have found that Interol presents in
the highest degree the purity, quality and physical prop-
erties that give it maximum efficiency as an intestinal
lubricant. Especially is it free from the lighter hydro-
carbons and sulphur compounds liable to prove irri-
tating to the intestinal canal or the renal structures.
Interol may be prescribed with the gratifying knowl-
edge that it will produce satisfactory intestinal lubrica-
tion. Sample and brochure will be sent to you gladly
on request, address: The Allied Drug and Chemical
Corporation, 2413 Third Avenue, New York City.
A very special offer is being made by H. K. Mulford
Company mis month — a handsome white metal case,
holding twelve Mulford Hypo-Units — the ever-ready,
collapsible tube syringe. It is no larger than a cigarette
case, fits in the vest pocket.
Each Hypo-Unit is a complete syringe, with sterile
needle and contents — ready for immediate use. Turn
to page 17 and see if you want the regulation filling —
special fillings on request.
You will find this handy case the kind of efficient
equipment that will help you far toward outstanding
success. A Hypo-Unit is something that must be im-
mediately available, easy to use — always ready. That is
why this special offer — a very low price — is particularly
interesting to active physicians. Turn to page 17 and
send in the coupon.
Satisfactory Results
Too much care cannot be taken in selecting the particu-
lar mineral oil, in order to avoid the objectionable effect*
that are invariably produced by oils of questionable
purity and indifferent quality, as well as assure the
beneficial results that may be expected from the right
choice of mineral oil.
A Short Cat to Saectu
Some instruments that will greatly increase your effi-
ciency, and, therefore, your income, are advertised on
page 59 by Huston Bros. Co., Atlas American Building,
Chicago.
For example, any physician doing obstetrical work
should not be without the Obstetrical "Shoe Horn" — It
makes difficult obstetrical cases easy; where the foetal
head engages against the symphysis instead of emerging
directly toward the birth canal this instrument can
eliminate hours of suffering and danger. The price is
only $5.00, although you will find it worth its weight in
gold.
Or with the new Johnson-Kollman Dilator your stric-
ture cases will yield' readily to treatment. It will do
the work of the $50.00 Kollman instrument and costs
you only $12.50. Or the new Huston's Akonophone— -a
new stethoscopic principle — helps to clinch your diagnosis
and costs only $4.75.
Efficient equipment is one of the "short cuts" to suc-
cess. These and other Huston equipment will help you
toward great success during the coming year.
(Helpful Points continued one leaf over)
TESTOGAN
THELYGAN
For Men For Women
Formula of Dr. Iwon Block
After seven years' clinical experience these products stand as proven specifics.
INDICATED IN SEXUAL IMPOTENCE AND INSUFFICIENCY
OF THE SEXUAL HORMONES
They contain SEXUAL HORMONES, L e^ the hormones of
the reproductive glands and of the glands of internal secretion.
Special Indications for Testogan:
Sexual infantilism and eunuchoidism in the
male. Impotence and sexual weakness.
Climacterium virile. Neurasthenia, hypo-
chondria.
Special Indications for Thelygan:
Infantile sterility. Underdeveloped mam-
mae, etc. Frigidity. Sexual disturbances in
obesity and other metabolic disorders. Cli-
macteric symptoms, amenorrhea, neurasthe-
nia, hypochondria, dysmenorrhea.
Fmby la TABLETS for latent! m, ud la AMPOULES, for latraflateal Iaj«cti«.
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Don't Depend on Drugs
in the treatment of
STUBBORN SUBACUTE AND CHRONIC SINUS
INFECTIONS. MIDDLE EAR DISEASE, CHRONIC
TONSIUTIS, CHRONIC BRONCHITIS, ASTHMA
USE instead
Affixed Vaccine — Ear, Nose and Throat
(NATIONAL)
Begin with initial dose of 200 million bacteria.
Reaction slight, persisting not over 12 to 24 hours.
Subsequent doses at 5 to 7 day intervals until the full
treatment (4 doses) has been given.
Dosage: — 200, 500, 1 000 and 2000 million bacteria.
ALSO AN EFFICIENT PROPHYLACTIC
AGAINST COLDS, ETC.
We also supply Diphtheria Antitoxin (National) used
by many Health Boards throughout the country.
Send for iitsrafurs, prict-luUt etc.
National Vaccine and Antitoxin Institute
OkUst in America
WASHINGTON, D. C.
"THE REAL SIGNIFICANCE AND rj* r Dt J D
THE BEST TREATMENT OF tllgtl BlOOCL JrreSSUre
should be studied and understood by every doctor
Hypertension is alvtays a danger signal
Pulvoids Natrium Compound
(High Tension Dr. M. C. THRUSH)
h a scientific and clinically tested combination of safe, non-toxic, non-irritating agents, whose
action is prompt to appear, reliable and prolonged in effect
COMPOSITION
Potassium nitrate, sodium nitrite, sodium bicarbonate, nitroglycerin and Crataegus oxya-
cantha (tonic for heart muscle and to prevent shock). Special (green colored) sugar coat-
*n& to dissolve in intestinal tract, and avoid gastric disturbance.
Dosage: One pulvoid t.i.d. increased when necessary to twelve daily, until pressure
'caches normal, then reduce the dose.
Booklet on High Blood Pressure. How to take,
interpret and treat it, sent free on request.
If you Aspens*, ask for price list
SPECIAL OFFER TO PHYSICIANS AND HOSPITALS ONLY
200 Pulvoids for $1.00. One time only.
1000 Pulvoids for $5.00 on 60 days' trial; money back if not satisfied.
Either mailed free when cash accompanies order, or if sent C. O. D. mailing and
collection charges added.
?HE DRUG PRODUCTS CO., Inc., 150 Me*dow St, Long Island City, N. Y.
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
Crto-Taam AffarJi Relief
"When I ask a doctor if he has a satisfactory remedy
for whooping cough, the answer is almost invariably
and emphatically No. Hence, I have no trouble to inter-
est him in Creo-Tussin, which I know does afford
relief in a large per cent of cases," writes one of the
detail men of The Maltbie Chemical Company.
If you are not familiar with Creo-Tussin it is made
easy for you, this month, to receive liberal sample and
interesting literature free. Turn to page 63 and send
in the coupon today.
Am EMtttist mi Prompt StJatist .
Valamin is a dependable sedative and analeptic and
is an absolute essential to the medical practitioner.
Opportunities for the employment of such a drug are
countless. Valerian was for generations of physicians
a widely used galenical for the various conditions de-
manding sedative effect, but gradually it fell into dis-
use on account of its failure, through its apparent lack
of therapeutic merit, to give results.
Valamin, a recently discovered medicinal agent, is
likely to restore Valerian to popular favor with the
medical profession, for Valamin contains the necessary
elements lacking in Valerian itself.
The therapeutic action of Valamin is due to the com-
bined actions of Amylene Hydrate and Iso Valeric Acid.
The essential point, however, is the fact that much
less Valamin, and consequently much less Amylene
' Hydrate, is needed in this combination than when
Amylene is used alone.
Experiments with Valamin have demonstrated that
it produces specific effects, which are not produced by
its individual components — effects which do not belong
a priori to the therapy of Amylene Hydrate and Iso
Valeric Acid.
Interesting information and literature will be sent to
American Physician readers on request. Address:
Kirbach, Inc., 227-229 Fulton street, New York City.
Ntjcl to Combat /atatuuf Stmtu
Effectual elimination of toxic matter — a problem which
medical science has wrestled with since the days of
Hippocrates and Galen — appears in a fair way to be
disposed of with the discovery of such agencies as
liquid petrolatum. Many physicians of international re-
pute advise it extensively. Dr. J. H. Kellogg, in his
book, "Colon Hygiene," is an enthusiastic advocate of
its use for ridding the body of intestinal poisons. He
says: "The use of liquid petrolatum affords an effective
means of hindering the absorption of intestinal toxins
and conveying them out of the body."
The use of Nujol is widely advised because of its
established purity and correct viscosity. In determining
its viscosity many consistencies were tried, ranging from
a watery solution to a stiff jelly. Clinical test and re-
search proved the consistency now used in Nujol to
be the correct one.
The manufacturers of Nujol"' have adopted many
methods for insuring a continual maintenance of the
quality of their product. One of these is the final
chemical test. After all the processes of refining are
completed, the petrolatum is held in glass-lined tanks.
Here, as a last precaution, expert chemists take a sam-
ple for analysis. When the results of this test show
that the high standard set for Nujol is met, the order
for bottling is given.
Interesting booklets and sample will be sent to phy-
sicians on request; turn to page 71 and send in the
coupon.
(Helpful Points continued, i
e leaf o
■r)
You can buy with Confidence — See "Service Guarantee to Reader^' on page 8
The American Physician]
An Honest Market Place
67
as
Benzylets
in gall-stone and other colics:
in spasmodic dysmenorrhea:
in true asthma, neuritis, whooping cough
in short, in most pathologic conditions
where opium was formerly used.
BENZYLETS
the non-narcotic analgetic-*iitispaaiiiodic
pharmacies in boxes of 24 gelatin globules, each
of S mm. medicinally pone benxyl-benxoate.
Sharp & Dohme
Soto Makers
"The Wonder Remedy of the Age "
Radium Capsules
For Internal Administration
The physicians who have employed radio-activity in the form of our RADIUM
CAPSULES are enthusiastic over the remarkable results secured through their use.
There are ample proofs for knowing that the radium emanations are incorporated in
these Capsules. The photographic plate and electroscope, as well as the highly favor-
able clinical results, prove it. Convenient and accurate for internal administration. No
Possible harm can come from over-dosage.
Therapeutic Indications. — Gout, Rheumatism, Neuralgia, Eczema, Acne, Pruritus,
Psoriasis, Glandular Enlargements, Chronic Ulcers, Arterio-Sclerosis, Nephritis, Diabetes,
Menstrual Disorders, Neurasthenia, Impotence, Pre-Senility.
^ EXPERIENCED CLINICIANS have demonstrated the following therapeutic facts by administering
^-•«lium internally: Elimination of Carbon Dioxide and Uric Acid — marked increase of the red blood
COrpuscles and hemoglobin — Constant improvement of metabolic changes — -Arthritis, Gout, Sciatica, Myalgia,
Promptly relieved — Pain in general yields quickly — Increases the quantity of urine — Regulates all glandular
*c*ivity — It has proved a powerful aphrodisiac: — It is a remarkably effective and harmless TONIC for the
??e<i and infirm — In chronic skin affections its results are often but little short of wonderful — It lowers
"*o©d pressure, through its influence on the vasomotor nerves.
RADIUM CAPSULES are supplied at $2 per hundred or $15 for one thousand.
Guaranteed radio-activity. Containers protected by heavy X-Ray Lead Foil.
SO YOU MAY CONVINCE YOURSELF by a thorough clinical test, Doctor,
a^cept our INTRODUCTORY OFFER of $10 worth of these Capsules for only $5.
Regent Drug Company, Detroit1
MAIL THIS COUPON TODAY
jygmt Drug Company,
***«t Station, Detroit, Mich.
For the enclosed $5, send me at once, postpaid, insured, five hundred RADIUM CAPSULES, with
Co*Hplete directions, as per your special introductory offer in Th« American Physician.
**AME
•M^DRESS
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
IPhila., J«ou»ry, 1922
FIRST ON YOUR LIST OF
WINTER TONICS
Prunes do not possess or profess any mirao
ulous "pick-me-up" qualities. At the same
time they offer one of the best body-building
"tonics" you can prescribe for any case —
convalescent or chronic.
You have always known, in a general way,
that prunes belong to the "iron group." But
have you ever realized j ust how much iron
and mineral matter this fruit-food furnishes?
Nor is this all! Suns wee t Prunes not only
are rich in assimilable iron— but their nat-
ural fruit sugars offer the invalid a quick
source of energy. There is no tax on the
digestion. No elaborate process of sugar-
conversion is necessary.
Then, too, there is the traditional laxative
quality of prunes— a quality made doubly
effective in Sunsweet Prunes. Arid, on top
of this, are the experiments of Osborne and
Mendel which prove prunes to be a source
of water-soluble vitamine. Frankly, doctor,
can you find a better, ready-to-put -up tonic
than this in all of Nature s Materia Medica?
TotnypF,y,ieia...di«rtian, or mint we will gUdly lend
«irhriWbnxliui«''Forihtg<»d<li>i'iinthtin."
Also our iww Recipe P«J.n— "Suniwm Surpriw
fofi022.''Both«f.w! aliform PmiwcVAprirM
Grown Int!, lflOMsritrf Slrerl.Swi JwcCaJifbmi*
SUNSWEET
CALIFORN1AS NATURE-FLAVORED
F~di*g Pperfy tkmitktd Mat,
In extreme emaciation, which is a characteristic symp-
tom of conditions commonly known as malnutrition,
marasmus or atrophy, it is difficult to give fat in suffi-
cient amounts to satisfy the nutritive needs. It is,
therefore, necessary to meet this emergency by sub-
stituting some other energy-giving food element.
Carbohydrates in the form of maltose and dextrins
in the proportion that is found in Mellin's Food are
especially adapted to the requirements, for such carbo-
hydrates are readily assimilated and at once furnish
heat and energy so greatly needed by these poorly
nourished infants.
The method of preparing the diet and suggestions for
meeting individual conditions will be sent to American
Physician readers, gladly, on request; address: Mellin's
Food Company, Boston, Mass.
If at* m Ptmaal Tat of Thit
You can prescribe Kellogg's Bran with confident
expectations of results. Kellogg's Bran, cooked and
crumbled, is nature's health food; you not only get the
regulatory benefits, but also an actually delicious food.
The best way to prove this is to make a personal test
of Kellogg's Bran — you will find it entirely different
from common brans. Just drop a card to Kellogg
Toasted Corn Flake Co., Battle Creek, Mich., and large
package will be sent to you.
Amotker Light o.
When the lumen of the alimentary canal is contracted
by adherent fecal material, it is interesting to note that
the patient, while having a daily movement of the bowels,
yet suffers from constipation, auto- intoxication and in-
testinal absorption. The entire thirty-six feet of bowel
surface may be coated with dried and hardened feces
and toxins constantly taken up by the system.
In treating such cases, McKesson & Robbins Liquid
Albolene (genuine Russian oil) is used to lubricate the
mass and loosen it from its point of contact.
A particularly helpful and instructive booklet, "Be-
low the Equator," will be sent to American Physician
readers on request, address : McKesson & Robbins, Inc.,
New York City.
DOCTOR: Write Us-
Hip. Thigh or I** Set. Splint* Rented Ready
patient! pay *».<» for > month* or less. Your
with the AMBOXATORT PNEUMATIC SPLINT, in ._
of bed. secure* good bone union, comfort strength
health In tlie leut poaalble time. To order: State ac
patient; fracture; which limb; length perineum
to heel; circumference of cheat; hips; and thigh |
at perineum. Wire and mail ordera B
on receipt, adjusted to fit, with compli
" r application. Specify our Splir"
tedirec-
AMBUMATIC WASHABLE ABDOMINAL I
EUutlc Hosiery. TnWM, Braces. ArtlncUlfc
Hands, Aims. Leas. Extension Shoes, Surgical*
ent Blank* and 111 nitrated
.. ._ -e Service. Highest Quality
ind Right Price*. GUARANTEED.
You can buy with Confidence— See "Service Guarantee to Readers" on page 82
The Americas PhyiicUnl
An Honest Market Place
Endocrine Derangements
Functional Unbalance
of the Ductless Glands
Endocrine products have largely replaced other medication in the many conditions now
known to be due to functional impairment and unbalance of the ductless glands.
Attention is particularly called to the following perfected pluriglandular formula.
Prmto-Orchoid Compound (Mayson) is the most successful pluriglandular remedy
for the treatment of Impotence, Sexual Neurasthenia, Prostatic Disorders, Hypertrophied
Prostate, with Bladder Irritation, and Prostatorrhca.
Prosto-Orcbotd Compound (Mayson) contains prostate, orchic extract, lymph
glands, with nuclein in suitable proportions. The synegistic relations of the prostate and
orchic glands are perhaps more pronounced than those of any other two glands in the
body, and physicians are obtaining the most gratifying clinical results by the use of this
remedy. Cases are reported in which the need of catheterization with its attendant danger
of infection was avoided by the persistent use of this formula..
Prorto-Orcboid Compound (Mayson) is indicated and has been*used with success in
Chronic Prostatitis, Senility, and after Prostatectomy. It it a most valuable Genito-Urinary
Try it in your stubborn c— —
Pukift of 100 tablat* is suiUry «■■» vUti, t3M
Booklet containing list of per-
fected pluriglandular formulas,
therapeutic uses, etc., free. 5 S. Wahaah An
The Mayson Laboratory
highly therapeutic formula com*
pounded of the best drugs known
to Medical Science for the treatment
of Tonsillitis.
Beam mint la antiseptic and antipyretic.
It acts both locally and syaterolcally In
reducing Inflammation and congestion. In
rebuilding strength and quickly relieving
all constitutional symptoms.
Benzomint &
An Internal Remedy
For TONSILLITIS
Compound of Sodium Bensoate With
Alkaloids of Calisaya Ben.on.tnt ba. . Clinical History cotm-
tiig many years of consistently incceMful
treatment*.
f*\ YaOafsF^lM An Effioacious astringent and antiseptic gargle of
VXL I VV/JJlll great value in the treatment of Tonsillitis.
Put up for Dispensing use in Pint, 6 Pint and Gallon containers
Stn d for SampUl and littrotwi
Throat Specialties Laboratories
(Mils urn Phaiuacal Company, Inc.)
BALDWIN, L. I. NEW YORK
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
[Phila., Juntry, 1M2
idU of RHEUME OLUM
Swelling*
nti. and u
celpt
^roo P
RHEUMEOLUM CHEMICAL CO., be
SEATTLE, WASH.
TltJ ProJatt Rawlti
Not sporadic instances, but hundreds of authentic re-
ports of cases treated with Proteogcns received from
reputable physicians prove the value of these remedies.
Their use in the treatment of various diseases is based
on the fact that they have the power of stimulating
cytogenic mechanism of the body. Such stimulation
brings about a correction of disturbed metabolism, neu-
tralising and ridding the system of the disease -producing
toxins or bacteria, and thus removing the underlying
Address a card today to The Wm. S. Merrell Co..
Cincinnati, Ohio, and they will mail American Phy-
sician readers two booklets, "General Booklet on Pro-
teogen Therapy" and a "Special Booklet on the Use of
Proteogens in Various Diseases."
A Pirnnj—iilar Pro,
Orcho-Lymph Compound (Mayson) c
ual hormones with adrenal (total), lymph glands, leci-
thin (from brain and spinal cord), glycerophosphates
and ext. nux vomica, gr. 1/10 to the dose. This has been
found to be a powerful physiologic tonic and recon-
structant for the treatment of asthenia, neurasthenia,
senility and presenility. In impotence many physicians
consider Orcho-Lymph Compound a specific. Box of
100 tablets (in five sealed glass tubes of twenty each),
$2.50.
Reference booklet containing formulas, etc., will be
sent to American Physician readers free. Address:
The Mayson Laboratory, S South Wabash Avenue, Chi-
TitrapraHc Powtr of Prmctratict Ugkt
The Sterling Therapeutic Lamp has been found of
distinct value in the microbic skin diseases, such as acne,
furunculosis, erysipelas, tinea sycosis and similar infec-
Heat waves bring pure arterial blood to the part and
take away the venous blood by dilating the smaller
vessels in the periphery. The main action of the lamp,
however, in germ or microbic diseases, is, that the germs
cannot live in light. The penetrating effect of tho
2000 c. p. lamp is fatal to most germs in ten minutes
Illustrated booklet and interesting literature will be
sent to American Physician readers, address: Sterling
Therapeutic Lamp Co., 546 Garfield Avenue, Desk 203,
Chicago, III.
ADattrSifwJ
The real significance and treatment of high Wood pres-
sure should be studied and understood by every physi-
cian Hypertension is alwavs a danger signal. You will
be interested in the booklet: "High Blood Pressure:
How to Interpret and Treat It," which will be sent free
on request to : The Drug Products Co., Inc., 150 Meadow
Street, Long Island City, N. Y. ,
This company is making a special offer to physicians
this month of Pulvoids Natrium Compound (High Ten-
sion Dr. M. C. Thrush)— one time only: 200 Pulvoids
for $1.00 or 1000 Pulvoids for $S.00, on sixty days trial;
money back if not satisfied. _
A special feature of Pulvoids Natrium Compound
(High Tension Dr. M. C. Thrush)— the composition is
given in this month's advertisement, page 65— is the
special (green colored) sugar coating, to dissolve in
intestinal tract and avoid gastric disturbance. Write for
booklet and special offer quantity today.
(Helpful Points continued one leaf over)
You can buy with Confidence— See "Service Guarantee to Readers" on page 8
An Honest Market Place
Intestinal Stasis and Lubrication
" Liquid petrol alum in a large number of sails gilts most
excellent mutts, and it far as -we h™, may be used
indefinitely and in large amounts. Its results art par-
ticularly gratifying in tie drj er rectal types ef stasis. "
Harold Barclay, M. D. , Attending Physician, Knicker-
bocker Hospital, Nrtu York, and C. A. McUillianu,
M. D., Presbyterian Hospital, New Tori.
NUJOL, the quality liquid petrolatum, is highly effective in the
majority of cases of intestinal stasis. It thoroughly permeates and
lubricates the faeces, assisting normal peristalsis.
Nujol is scientifically adapted by both viscosity and specific gravity to
the physiology of the human intestines. In determining a viscosity best
adapted to general requirements, the makers of Nujol tried consisten-
cies ranging from a water-like fluid to a jelly. The viscosity of Nujol
was fixed upon after exhaustive clinical test and research and is in accord
with the highest medical opinion.
Sample and authoritative literature dealing with the general and special
uses of Nujol will be sent gratis. See coupon below.
mm
A Lubricant, not a Laxative
Nujol Laboratories, Standard Oil Co. (New
Room 765, 44 Beaver Street, New York.
Jertey),
Please lend booklets marked:
D "In General Practice"
D "A Surgical Assistant
D
D
'In
Also
Vomen
and Children' '
Name
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
[Phil... j«
MEDICAL KEYBOARD
._ . n par t*M ■ month and an one. Think of
a 1100.00 HaoUne far tU.lt. Oath print 1*4.00, Jnat
• than halt 1th orirlnal prloe.
) MEDICAL KEYBOARD
return It to the
nachlne, We Mil par the B_ ...
oachlue li guaranteed Juit >i If job paid t
thla prioe li limited. I
i million people ,.._ .,,._
be beat erer mann facta red. The tupplr a
< prioe will probably he rnieed when boot
ilmplj "ao'denlood that wa retain title to the marhlne until foil
I5B.85 la paid. Tod cannot lots, ton win pertiap. nerer ham
a (renter typewriter opportunity. So not land ni one oent. Oat
tin coupon In the malli to-day — aure.
SMITH TYPEWRITER SALES CO.
Dapt. ISO. 21S N. Walla St, Chiofo
A FtwU Food «W niraan^^
Prunes oiler one of the best body -build ins "tonics''
that you can prescribe for any case — convalescent or
chronic.
Sunsweet Prunes are not only very rich in assimilable
iron — but their natural fruit sugars offer the invalid a
quick source of energy. Then, too, there is the tradi-
tional laxative quality of prunes — a quality made doubly
effective in Sunsweet Prunes. Add to this the vitamine
content and you have a fruit food and therapeutic aid
that should not be overlooked.
You will be interested in the health -brochure, "For
the Good That's In Them"— It will be sent free. Address
California Prune and Apricot Growers, Inc., 180 Market
Street, San Jose, California.
Ware*'. New Rtg-t OtmUg nna? ftita tint
Merck & Co. are distributing a new edition of their
booklet, "Blue Label Reagents and Other Laboratory
Chemicals." Merck's Blue Label Reagents, familiarly
known as M.B.L., are made according to the require-
ments in "Standards and Tests for Reagent Chemicals,''
published in 1920 by D. Van Nostrand & Co., of New
York, and a special feature of the new catalog is the
concise summary under each reagent showing its
standard of purity, methods of testing, and other data
taken from that textbook with the author's permission.
Such of Merck's "White Label" chemicals of H.P,
"C.P.", and other grades as are of particular interest to
laboratory workers are also listed and current prices are
given throughout. The booklet, therefore, should be of
chemists generally as a manual and price list
American Physician readers may obtain copies by ad-
dressing Merck & Co., 45 Park Place, New York City.
* lmafina the parfeaUon of thla beautiful i
typewriter until ran have Hen it. Wa have uld theuauda of thaie
perfect lata atria meohlaea at thla buijain prloa and *v*ry on* of
tfceao thoaauda of eeUeflad onetwnan had thla beautiful, <trtctly
up-to-date manhlno an Be* dare' fm trial bafor* deotdlnc to buy it.
We will eend It to jou P. O. B. Chicago for Ire daye" tree trial
It will Mil ltulf, but If too are not aatlifled that thla la the
The sedative action of bromine, while unquestioned,
is seriously militated against by certain collateral effects
when given in the form of its inorganic alkaline salts,
the bromides. They do not carry the halogen well. Such
derivatives as Bromural are advisedly to be used in
their stead, affording as they do the straight hypnotic
and sedative effects wanted.
Bromural is one of the best of these organic bromine
compounds and appears to be very satisfactory in cases
of nervous insomnia and general nervousness. It is said
to produce sleep without markedly affecting the circula-
tion or respiration. In nervous and hysteric cases, espe-
cially affecting women, it brings calm and rest. But,
like other hypnotics, it may fail where there is pain
or cough ; these symptoms must be subdued by other
measures or adjuncts. The dose is five to ten grains.
The advantage is claimed for it that, while quickly
and decisively impressing the central nervous system,
it does not stuptfy to the degree that other agents of
this class are wont to do, nor leave that feeling of
heaviness which after some hypnotics is quite distressing.
Samples and literature will be sent to American Phy-
sician readers on request. Address : E. Bilhuber, Inc.,
45 John street, New York.
Smith Typewriter Salea Co., Itept ISO. SIS K. Walla St.. C
Ship idf the L. C, Smith Typewriter. P. O. B, Chicane. » w>
^^^^^iSS^a^bJme^&'^'up^fftSa. It Must Be Hade Right from the Start
that ith.™e™daWV»hrphttDft'117 liM*aa*t thatontwrffi? For a centtlTY OT more- cod-liver oil has been recog-
ir I ehooae nut to keep it i wiu'nreraiir reptTr. it and"retarri nized as a dependable and easily absorbed nutrient, and
it to the eipreu eneDt. It la nndentood that you fire the itand- more recent investigations reveal that it is an exceedingly
ard raarantee. fruitful source of the anti-rachitic vitamines. Cod-liver
*"• • oil to be utilized to fullest extent by the system should
st-eat Addraaa be pure and sweet and free from admixture with infer-
oity Btat* (Helpful Points continued one leaf over)
You can buy with Confidence— See "Ser
a Guarantee to Readers" o
The American Physician
•toadlly and inc
■•aingly prMcriblni It
•■t by jomr.
proporlr «djait«i atav-
or add imparlttoa, no bloom or flnorM-
TW nimTfflniT
of opinion of aifht bad'
orod Imported Rihud
SS (bn A. M."
■W rJniraJ »«*, ■
* «. httU mf USOUHS
JflHt OIL PRODUCTS CO.. Inc.
■B M> Unloa Sqwn, N*w York, N.Y.
To ALLEVIATE PAIN, to PROMOTE DIURESIS
and to PROTECT the membrane of the urethra, especially
THE POSTERIOR PORTION— these are the important
object! of the treatment of acute cases of Gonorrhea.
The entire nrinary tract should be influenced by means
of proper internal medication. Local injections alone will
not be sufficient
This is the rationale of GONOSAN.
RIEDEL & CO., Inc.
526 Broadway Now York
PETTEY & WALLACE SANITARIUM £$££%£.
FOR THE TREATMENT
OF
Drag Addiction, Alcholism,
Mental and Nervous Diseases
■tote ogataa—*. Bo.
Dm pattern* iroatod br Dr. P«*W»
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
[Phila., Janiuir. 1*23
Pluto Water
has been successfully employed
and endorsed by the Medical
Profession as a uric acid sol'
vent and eliminating agent in
renal disorders; prompt, safe
and efficient and well retained
by the most delicate stomach.
Many practitioners direct con-
valescent patients to the spring
for rest and complete treat-
French Lkk Sprint Holi1 C*.
French Licit, IncL
Jr
mmm
*%
TAUROCOL COMPOUND TABLETS
\=
THE PAUL PLESSNER CO.
It Matt be Made Rigkt— cont'd
ior non-cod oils, and also free from admixture with
blood and gall — due to careless and unscientific handling
of the livers. Cod-liver oil is as delicate as butter and
in the selection and processing of the livers should re-
ceive as much care as science has thrown around the
production of pure milk. It must be made right from
the start
For nearly half a century the producers of the "S &
B Process" Clear Norwegian Cod Liver Oil have con-
centrated their endeavors and specialized upon the
product of livers of the true gadus morrhuae. Never
satisfied with the quality of oils offered on the market,
several years ago Scott & Bowne established their own
cod-liver oil plants in Balstad (Lofoten), Norway, where
under most exacting, modern scientific and hygienic con-
ditions the **S & B Process" is produced. This high-
grade oil is then brought overseas in special containers
to be refined in the unique S & B laboratories in
America. The "S & B Process" is the only cod-liver
oil made in Norway and refined in America. This oil
is guaranteed a 100 per cent, product of the livers of
the true gadus morrhuae and absolutely free from ad-
mixture with other oils or impurities.
Physicians may prescribe the "S & B Process" with
an assurance that his patient will always receive the
nutrient and vitamic virtues of cod-liver oil in truest
form. We are reliablv informed that liberal samples
of this high-grade medicinal cod-liver oil will be sent
to American Physician readers on request. Address,
Scott & Bowne, Bloomiield, N. J.
J>
The Host Effective Way
It is a very significant fact that nature has pro-
vided the most efficient and antiseptic means for tak-
ing care of mucous membranes by supplying the lat-
ter with secreting cells which furnish a solution which
is in every way able to take care of ordinary and
sometimes extraordinary conditions, provided such
solution is of normal content. •
Unfortunately, however, no provision could be
made against over-stimulation of such cells which
leads to their hyper- sec ret ion, and as a necessary re-
sult, to modification in such secretions.
To attempt to substitute an artificial solution that
exerts antiseptic action and effect in the test-tube is
not the most rational or most effective way to over-
come the difficulty. On the other hand, it is axio-
matic that to feed exhausted cells and thus enable
them to regain normal secretory ability, to over-
come congestion, to avoid adding to the disturb-
ances of osmotic balance is the best and the most
natural way to overcome the difficulty
This is why Alkalol is so successful when used
upon mucous membranes. It is composed of physi-
ological salts which have been very carefully se-
lected with a view to meeting the needs of mucous
membranes cells. Its salinity and alkalinity have
been carefully worked out. Its tonicity is impor-
tant. Alkalol is soothing and healing to a degree, and
even a superficial trial of this preparation would con-
vince the most skeptical medical man or specialist that
it is worthy of a place in his armamentarium.
The number of alkalol users is great, but any
physician who has not yet become acquainted with it
may do so by writing for sample and literature to
the Alkalol Company, Taunton, Mass.
(Helpful Points continued one leaf over.)
You can buy with Confidence— See "Service Guarantee to Readers" on page 8
An Honest Market Place
When A Baby Must Be Weaned
there is no food that can be used to replace its mother's milk, with
greater convenience and benefit, or less trouble and danger, than
Nestle's Milk Food
Made from pure cows' milk, malt, cane sugar and
wheaten biscuit, Nestle's Milk Food enables the
painstaking physician to provide the infants under his
care with a digestible and nourishing food that assures
every advantage of properly modified milk, with
gratifying avoidance of inconvenience or danger.
There is a constantly increasing number of phy-
sicians, therefore, who are finding in Nestle's Milk
Food, not only modified milk at its best, but a food
that means "in weaning the baby," a new era of
improved health and progressive bodily growth.
NESTLfe'S FOOD COMPANY
tn Market Street Nestle Bulldinf
San Francisco New York
The Peculiar Advantage
•ttta
Marvel "Whirling Spray" Syringe
x centrif-
l flushes
a volume
smoothes
S the In-
a contact
irface.
Cut:
JLVBLS
rata, Vagini
«uc It all
TWHarval
S.CUUD-H
AU Vrugji
MARVEL COMPANY, 25 W.4Sth Street, New York
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
[Phila., January, 1922
A Campaign of Education No. 2
Government Inspection
Discounted
If teeth are allowed to
decay
THE United
States Govern-
ment spends huge
sums every year to in-
sure pure food prod-
ucts. This money is
wasted if decayed or
unclean teeth are al-
lowed to contaminate
the food.
Joseph Head, M.D.,
D.D.S., says: "Many
fatal diseases will be
reduced by 50% if
the teeth are fcept
properly clean."
ANTI-PY-0
Dental Cream
Is antiaeptle. It nmedlea
binding and receding
funis; check* pyorrhea.
:« germicidal quail Has
reduce activity of dan-
li prevented. Your pa-
tient* need the neutral-
izing effect* of
ANTI-PY-O.
The Antidolor
1 Mfg. Co.
ANTIDOLOR MFC CO..
32 Main St., Springvllle. N. Y.
Chi receipt of your ]
. including
Y— Cam EmUj Omm nil
You can rent a Tyros, the new 1922 blood pressure
apparatus, for nine months and then it is yours by
means of the easy-payment plan of A. S. Aloe Co., 551
Olive Street, St Louis, Mo. The price is $25.00. En-
close $2.50 with order for first month's rent and the
instrument will be sent to you immediately, then $2.50
each month until the cash price, $25.00, is paid. The
price is the same— $25.00 — if all cash is sent with order.
Money back if you are not entirely satisfied. Turn to
page and send in the coupon. You will find this
sphygmomanometer a great help in your practice.
Vitamineg for the Sick
Why prescribe vitamines? an inquirer said the other
day. The vegetable kingdom affords us an abundant
supply. Why cannot we direct our patients to eat vege-
tables, butter or milk containing these all-important
essential principles? To completely reply to those in-
quiries would involve the writing of a lengthy thesis.
A few words will suffice to make a practical statement
of the situation.
The majority of our population live in towns and
cities, in institutions, on shipboard, and some in remote
regions away from civilization. The dietary of these
people during a great part of the year consists largely
of canned and dried vegetables, bread, artificial butter,
sterilized milk, etc All of these products have been
subjected to heating or other processes that impair or
destroy the vitamines they may have contained origin-
ally.
Even in regions where fresh vegetables and fruits are
obtainable it would not be practical to feed sick people
on them. As the editor of a well-known medical
periodical recently said : "It is frequently undesirable to
(Helpful Points continued one leaf over)
A Stand-By in
Uterine Troubles
VIBURNO
(BEACH)
The best evidence of this it the
repeat orders received from physi-
cians and druggists.
Nervine-Tonic and Anticongest-
ive, with calmative and corrective
action on the bladder. Employed
with much satisfaction in ovarian
congestion and congestive dysmenor-
rhea; weak pregnancy and deficient
lactation; menopause and its phe-
nomena, including hallucinations, hot
flushes, etc.; nervous and menstrual
derangements after "flu," and the
troubles of adolescent girls. Sterility
often responds after 2 or 3 bottles if
no lesion exists.
Unlike similar product*, VIBURNO
i* palatable and pleasant to take.
Doao: 2 tna*p. (undiluted) ti.d.
before meal*.
Pot up in U or. bottle*
Sample and Formula an Reqaeit
THE VIBURNO COMPANY
116 Maiden Lane, Now York
You can buy with Confidence — See "Service Guarantee to Readers" on page 8
The American Physician]
An Honest Market Place
77
ALKALOL AIDS DISARMAMENT, BECAUSE INSTEAD OF DEPEND-
ENCE UPON A QUESTIONABLE POWER TO DESTROY PATHO-
GENIC ORGANISMS. ALKALOL FEEDS THE CELLS WITH PHYSIO-
LOGICALLY NECESSARY SALTS, AND THUS HELPS THEM TO
RECOVER NORMAL SECRETORY ACTIVITY AND SUPPLY THE
BEST OF ALL ANTISEPTICS— W HICH IS THE NORMAL SECRE-
TION OF THE NATURAL CELLS. MUCOUS MEMBRANE OR SKIN
IRRITATION OR INFLAMMATION YIELD PROMPTLY TO ALKA-
LOL. IT IS A STERLING PRODUCT OF MANY USES. NOT TO
KNOW OR USE ALKALOL IS TO HANDICAP PROFESSIONAL EF-
FORT AND PREJUDICE THE PATIENT'S INTERESTS. TO KNOW
ALKALOI — SEND FOR SAMPLE AND LITERATURE.
THE ALKALOL COMPANY
TAUNTON, MASS.
RHINOL
in All Affections of the Nose and Throat
Thm Rhinol Company, Inc.,
Dear Sirs:
Permit me to state that we have used Rhinol
at the Quality Hill Sanatorium with several of
our patients that were suffering from Hayfever.
The results were indeed good and pleasing.
Will be glad to have you publish this state-
ment for the benefit of the medical profession.
(Signed) J. S. MASSEY. M.D..
Physician and Surgeon.
Quality Hill Sanatorium.
Monroe, N. C
Company, Inc.,
July 6. 1921.
Tha Rhinol Company, Inc.,
Gentlemen:
I want to inform you that during the last year
I have treated a large number of patients suffer-
ing from Coryza, Chronic Rhinitis, Pharyngitis,
Laryngitis and Hayfever with your Rhinol, and it
gives me great pleasure to state that the results
have been very satisfactory in each instance.
Rhinol is one of my standby* in my practice
and now that I have realised its great therapeu-
tic value in the treatment of the above named
conditions, I could not do without it. You may
make any use of this letter in any way you may
desire.
Sincerely yours,
(Signed) CHAS. B. GRAF, M.D..
Physician and Surgeon.
230 E. 15th St.. New York City.
Tha
Gentlemen:
Enclosed please find check for three dollars for which send me one complete Rhinol outfit. You
nave a very superior preparation, and I was astounded at the quick result* produced.
1 am very much disappointed that you cannot or will not supply my druggist, Theo. Metcalf
t* *a! iJ"0?]? ?*• *? P"*"** your outfit for some of my patients. I cleared up my own acute
2?n^Lf£u*i,i£s t? * l#w *"*•/ t^a? *ave ** *° a hayfever patient who has been more relieved than
by anything she has ever used. 1 dread being without the outfit for fear 1 may have another attack
of sinusitis. Hoping for an outfit by return mail, I am, gratefully yours,
«*9 n i » «. «, . w (Signed) JACOB D. SNYDER. M.D.
542 Boylston St., Boston, Mass.
Price Complete, $3.00— Refilled Packages, $2.50
RHINOL COMPANY. Inc. 1416 Broadwav. New York
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
GRIFFITH'S CSMPOUND MIXTURE
_ t Alto-
other well known reaw-
...inner tint It it tolerated
from Rbenmatum, Gont,
of Guainc, StillinrU, ate.
A Powerful Altcratire — Compoaed u _..
Still ingia. Prickly Aah, Turkey Cam, Colchicum,
Black Cohoih, Sareaparilla, Sallq " '
lies. Iodide of Potaasa and "
diet, combined in Mich * i
by all patient! aufferinf
Lumbago, Neuralgia, Scut..-, >iw
Prucriba ft for That Stubborn Caaa"
Ta Phyiiciant only — we will upon requeit, aenal ■
rerular eight ounce bottle ($1.25 aize), for trial, ana*
receipt of ?l centa for cxprcaa chargee.
Griffith's Rheumatic Remedy Company
Nawborgb, Nrw York
UR-LIHED OVERCOATS
lack wool keney eloth. lined with
eautiful dark brown marmot fur.
[andaome marmot fur collar, double-
re«sted. full length, aiiea 16 Is M
eady for immediate delivery. Your
pportunity to accurc a handiome gnr-
Pr'rMcwP'»«.BO
Faually retailed at $75.00. Direct from
lanufaeturer. You save all niiddle-
len profit and take no riak.
SENT FOR EXAMINATION
jramrae and try on before paying,
Vrite at once, statins cheat measure,
eight and weight Encloee $1.00 for
apreaa chargea only and coat will be
™ * IThART, For Dent,
SIB West 134th St.. New York
MORPHINE
NEW HOME TREATMENT
Far all Drag aati AJkohofle AJfioaBBj-goclon Mat I
awiaaal 1,Trz hernial Eadosa oamp hi fnl ggssa
-"*"" DR. QUAYLE'S SANITARIUM
MADISON. OHIO __
Woodlawn
Maternity Home
nancy and confinement,
care, nuraing and protect!
for the infant by adopt!
v*OODuWn"oWEGO, Tio»a Co, N. Y.
best medical
A home found
desired. AH
(Vitan
\ued from page 76)
give the kind and quantity of food which would be
necessary to yield a sufficient amount of a desired vita-
mine. One rarely prescribes a mess of spinach for a
patient acutely ill or for a convalescent with impaired
digestion, just because the vitamins that is present in
spinach is desirable."
To meet the evident need, Parke, Davis & Co. have
developed and perfected Metagen, a product containing
the three known vitamines. These are fat-soluble A.
water-soluble B, and water-soluble C, Apart from its
unquestioned utility in the treatment of the so-called
"deficiency" diseases, Metagen should prove of immense
value in the treatment of poorly nourished infants and
children, in all cases of subnutrition and reduced bodily
tone, and in convalescence from febrile, infectious and
wasting diseases, wherein failure to improve may not
be due so much to a lack of a properly balanced diet as
to failure of assimilation. Here the vitamines play an
important part in stimulating anabolism in adults and
healthy growth in children. As a supplement to a highly
concentrated diet in tuberculosis, Metagen should be
tried for its immediate effect on nutrition. The same
might be said of anemia and chlorosis.
In view of the radical change that has come over
the accepted methods of, preparing and supplying the
food of the nation, it seems that the discovery of the
vitamines and the elaboration of Metagen, the most
available preparation of vitamines for the use of the
physician, are not only timely but of the greatest im-
portance in their bearing upon the health and well-
being of the population.
Interesting literature will be sent to American Physi-
cian readers on request. Address Parke, Davis & Co.,
Detroit, Mich.
The Fat-Solable Vlttvnln "A"
and Alkaloid's
or active principles of Cod Uver Oil
are presented in a palatable form in
M0RRHU0L and
M0RRHU0L CREOSOTE
Prescribed for over thirty years
with gratifying results in the
so-called "deficiency diseases"
Recent studies on the Vitamine have con-
firmed previous clinical evidence and have
definitely established the therapeutic value
of these Chapoteaut preparations in the
routine treatment of —
T. B., tUckctJ «and Bronchial
Catarrh
Prescribe in original vials
Literature and samples on request to
£. FOUGERA & CO., Inc.
You c
i buy with Confidence— See "Service Guarantee to Readtrs" on page 8
The American Physician]
An Honest Market Place
79
* S'/fi yv\ S'(y/K7/;\;///
(SILVER-ARSPHENAMINE^METZ)
Tho sodimun salt of aflTac-diamino-dihydroxy-araa noWmtnt
|3 ELATIVE infrequency of reaction, rapid disappearance of contagious
lesions, and general therapeutic effectiveness seem to indicate that Silver-
Salvarsan is a drug of real value in the treatment of syphilis.
Silver-Salvarsan requires no alkalinization and its ease of admin-
istration commends it to many practitioners.
UB
Trade Mark
Reg. U. S. Pat. Off.
More than two million injections of Silver-Salvarsan have been
given in the United States and abroad.
IfAMETZ lABOMPORIES.Im,
One-Tit>enty<1ii)o Hudson Str—t,Nn0lforL
PHYSICIANS-
Try these Prescriptions on your next case and note the result The hypodermic
administration of Campho-Pheniqu* Liquid in Boils, Carbuncles ana Hemor-
rhoids is a well known fact Tried ana tested by many Physicians with excellent results.
SUGGESTIONS.
Felon.
Hemorrhoids.
Bt Inject three to seven drops into each
Hemorrhoid.
Boils C to abort)
IJt Gampho-Phenique Liquid. M J *v*
Sig. Apply to point threatened; keep the
part constantly moistened.
9 Campho-Phenicrae Liquid. „ 5 "•
Sig. After splitting use freely.
Eczema (Gangrenous)
flt Campho-Phenique Liquid.. ..J iv.
Sig. Apply on compresses, and keep the
compresses wet with OP.
CAMPHO-PHENIQUE LIQUID, Small Sum 25c, Large Sum $1.20
CAMPHO-PHENIQUE POWDER, Small Six* 25c, Urge Sum 75c
Pkyician'* Samtpl&t mmd LUmrmtmrm mm rmmmni.
CAMPHO-PHENIQUE COMPANY
ST. LOUIS, MO. - - U.S.A.
Mentioning The America* Physician Insures Prompt, Careful Service
Helpful Points
[Fhihu, January, 1922
For Determination of the
Basal Metabolic Rate
BORN
landy
etabolism
Apparatus
THE full clinical accuracy, sim-
ple technic and reasonable
price of the Handy apparatus make
it the instrument of choice for the
busy practitioner who, to obtain the
greatest service value, must have
apparatus of day-in-and-day-out
availability.
LittratmTt mmd complttt informaiittm ml fnt
Sanborn Company
Cheapness in lubricating oil is not
measured in cost of oil, but in saving
of repair bills. Buy a high grade
oil regardless of its price and you will
find it the cheapest.
Emco Oils, refined from Bradford
Penna., Crude, are among the really
cheap oils as they are pure, have least
possible free carbon content and are
backed by a most liberal guarantee.
Emery Manufacturing Co.
Bradford, Pennsylvania
These Advertising Pages art m
Honest Market -Puce
A CimuiatrUm Whm Tm Cm Bail WW CwHurt mi§*k*
frr— «■ c— — d>l «<-itfe, — mI-WWM t»ym**i ,k*U
«MKdirpdUii^iH Wi awl to t«M« mi nW
Onr Advertising Standards
Advertisements must give honest service to our read-
ers and their patients— is the basic principle for these
standards and for the conduct of Thi A-iebicam
Physician's advertising pages.
Our attitude in applying these standards is not one
of narrow technicality but of practical service-
Advertisements must give honest service to our read-
ers and their patients.
Advertisements of the following classes are nut
acceptable for the pages of Tee American Physician:
Fraudulent pharmaceuticals; those making dishonest
Pharmaceuticals charging excessive price; price not
warranted by content and by trade conditions.
Pharmaceuticals and other mixtures containing nar-
cotics or other habit -inducing drugs in quantities suffi-
cient to promote their repetition on prescription
(chloral-bearing proprietaries, etc.).
Potent pharmaceuticals which justly merit profes-
sional disapproval because of their lay advertising or
manifestly unethical exploitation.
Financial advertisements that claim returns not com-
patible with conservative investment. Only conserva-
tive investments are advertised.
Further
subject to revision
by the
Advertising copy
editorial staff.
The American Physician- agrees heartily with the
principles of the Council on Pharmacy and Chemistry
of the American Medical Association and we exclude
from our advertising pages such pharmaceutical prod-
ucts as they have definitely shown to be unworthy of
professional confidence and the manufacturers of which
have not removed the cause of objection; but we do
not accept such findings as are based on academic data
without due recognition of general clinical experience.
Concerning formula;. The American Physician is
urging pharmaceutical manufacturers to give full thera-
peutic data regarding formula;, stating quantitatively
active medicinal content, in order that physicians may
intelligently prescribe. We do not accept advertising
of secret pharmacuettcals.
But We do not Decline - - -
Advertising of original drugs, compounds or preparation! imi-
«»j (- -....—. .a;.T... _t .ue v s. Pharmacopeia or Nut ion*!
cing preparation!) ; new prodttcta
■Inkle, but which bit not been
n br the C™
You can buy with Confidence — See "Service Guarantee to Readers" on page 8
An Honest Market Place
FORMULA
PNEUMO-PHTHYStNE
In Analysis
Pneumo-Phthysine
The best remedy (Pneumo-Phthysin
misapplied, may defeat the combined
skill of all who have contributed tc
success. More especially in the treatment
of pneumonia, the u neon que red foe of
medical science.
If PNEUMO-PHTHYSINE has failed
you, there is a reason.
How to Apply in PNEUMONIA
Apply a thin layer, thickntsa of lilver dollar
Syretie. Heat plaster Co detired temperatur
rat applying Id cheesecloth and then holdi:
through the ahtorptiye property of the akin. The
Pneumo-Phthysine Chemical Co.
Chicago, HI.
Mentioning The American Physician Insures Prompt, Careful Service
The American Physician
THE MERZ CAPSULE CO.
DETROIT, MICH.
Our Advertising Standards
uougc. pro
Weed iigaiiut them.
Minor antiieptic*, *oap* and
to both phyiician* ud laymen ■
stent; honestly advertised m'-
food product*, malt tonici
tiding ( *«*]
i preKription written by a
e proprietary form decani
lie remediei in ndequit*
si place in medical ktenv
■pile pharmacologic data
rtlcle* honestly adTertiaed
advertised mineral v
New Prices on
Merz Santal Comp.
Capsules
DISPENSING PHYSICIANS CAN BUY
OF US DIRECT
10 Minim Elastic Capsules, box of 100
' Alas ttoxa* *l 12 and bona* *f 2*
5 Minim Per.es bottleof 36
S " " bottleof 500
8 " " bottleof 1000
Unsurpassed for happy effect in Urethritis,
Cystitis, Prostatic Troubles, difficult mic-
turition, etc.
PRICES AND SAMPLES UPON APPLICATION
Service Guarantee to Readers
IP YOU HAVE ANY UNSATISFACTORY
DEALING WITH AN ADVERTISER IN THE
AMERICAN PHYSICIAN, WRITE US TUB
PARTICULARS AT ONCE.
WE WILL IMMEDIATELY TAKE THE MAT-
TER UP WITH THE ADVERTISER AND SEE
THAT THE ADVERTISER EITHER MAKES
GOOD, OR HIS ADVERTISEMENT IS ELIMI-
NATED PROM THE AMERICAN PHYSICIAN'S
PAGES.
THE STORM BINDER
AND ABDOMINAL SUPPORTER
THE STORM BINDER la *™^tableJi "*»
THE STOBM BINDER 13 FOR GENERAL
SUPPORT in hernia, floatiu* kidney, descent ot
""THE- STORM BINDER IS FOR POST-
OPERATIVE SUPPORT of lutdrion* in upper,
middle and loafer abdomen.
"*..£„ ^nou mvnH let POR MATERNIT
. and discomfort*
■CATHERINE L_ STORM, BLD.
17*1 DU*a«**d Stnct
You can buy with Confidence— See "Service Guarantee to Readers" at top of page.
The American Physician]
An Honest Market Place
83
Fair Questions
TRADE
Is there a better or safer antiseptic, or germicide,
for all-round surgical, medical or hygienic use than
peroxide of hydrogen?
Is there a purer, more stable or better peroxide of
hydrogen than
Dioxogen?
Is there any antiseptic more widely or generally
employed in clinics, hospitals, offices, factories,
schools and homes by physicians themselves, or
on their recommendation, than
Dioxogen?
Need more be said?
THE
OAKLAND
CHEMICAL
59 Fourth Ave.
New York City
In purity and oxygen*tiberating power,
Dioxogen exceeds U. S. Phar. standards for
Hs Oi by 25*.
Dioxogen is odorless, almost tasteless,
and entirely free from acids and acetanilkL
It is also colorless and does not stain the skin.
Absolutely noivpoisonous and non^nitat^
ing, Dioxogen is not only the most potent,
but the safest and most harmless of antiseptics*
Applied to wounds, Dioxogen promptly
destroys bacteria and stimulates the reparative
processes of the tissues.
Dioxogen is the one powerful germicide
at the physician's command that can be freely
used anywhere and anytime without the
slightest danger.
r~ 1
Mentioning The American Physician Insures Prompt, Careful Service
LIBERAL DOSAGE-MINIMUM EXPENSE
Id ipecULuunf i
raMaate of Pnrfei*
? benefit, e<eu
THE BIG THREE
(ACTUAL SIZE)
'•PINEAPPLE CULTURE. METCH-
NIKOtP." A two-ounce lw of
fot ill cam of HMinimiHfiM
Even
■Indicted. Price
BULGARICUS. UBTCBNIKorr."
BtLGARICUS
ilKTCHNIKIlh'F.'
All the above products can be obtained at the leading druggists or will be delivered at
patients address without extra charge.
Literature and Samptea on Requeat
FRANCO-AMERICAN FERMENT COMPANY
225-7 SIXTH AVENUE, NEW YORK
The American Physician
[Ptaila.. Februaiy, 1922
Has finally dem
atrated the falla.
;complishes a
the so-called uri
nite, scientifically
solvent therapy
clinically estab-
etc), and made
phyaiologic stim-
aary the emplo'
Colchicum with
to be feared
effects on hear
by dosage and
blood tests.
Information. Ltttrc
~,..M«.,» Jl GLATZ, INC
Ample Trvd Quantify from
GOUT
ISO Maiden Lum, Naw York
AN IDEAL ARSENICAL
SODIUM DIARSENOL
SODIUM ARSPHENAMINE
Sodium Diarsenol marks a distinct advance in syphilology. It dissolves
very quickly in water, giving a solution ready for immediate injection. No
addition of sodium hydroxide is necessary. It has the therapeutic advantage
of arsphenamine with the solubility and convenience of neoarsphenamine,
and gives clinical results equal to or better than either of the two latter com-
pounds. Neutralization with alkali being obviated, there is no undue hand-
ling and consequent decomposition of the highly reactive solution.
SODIUM DIARSENOL has been accepted by the Council on Pharmacy and
Chemistry of the American Medical Associaiion for inclusion in "New and Non-
official Remedies."
Manufactured by Din
i The Chemical
DIARSENOL COMPANY, Inc.
BUFFALO BOSTON ATLANTA
Tbc American Ph J»ci*n]
An Honest Market Place
Tyj ORE people die from pneumonia than
any other disease.
Approximately 25 out of every 100 cases end
fatally. Dr. Gustav Goldman has demon-
strated that at least twenty of these twenty-
five deaths may be prevented by employing
Bacterial Vaccines.
Why delay and chance a fatal termination?
Dr. C.'iulflU Coliinmii article appcartJ in American Medhine, March, 1921
UiclerUUiicil Liborilor 1*1 of
G. H. SHERMAN, M. D.
DETROIT, U. 8. A.
„ j_ „ Mo. *. Fi*M*li«j moxihty—Tht Taylors; C. C. Taylor, Pttblishtr; Mrt. I. J. Taylor, Ed. Ugr. Enttrtd at tecead-clau mttttrr Fab. 13, itotf, 1 tka tot
vw*" ** oBici at Philadelphia, Pa., under Act of March 3, 1S79.
* FVnirin, "Most Widely Circulated Medical Monthly," continuing the quarter century of dietinctioa service of
Copyrighl 1922, by Tie Taylor*. Puhliikw.; 420 Walnut St, Philadelphia, U. S. A.
88
The American Physician
[Phil*., February, 1922
GOOD WINTER REMEDIES
EVERY ONE A PRACTICE BUILDER
Acetylsalicylic Acid, Aromatic Pituitary Solution (Abbott)
(Abbott) Both for oral and hypodermic use*,
fLiat No 1140) *n amPu^°* ana" bulk container. A re-
_ , .11* . i i i liable preparation; made from fresh
In 5-grain tablet*, with color and gland.; sterile; precise,
flavor. A new idea. The reason is ob- Net pr|ca> per box of 6 ampules,
vious. Besides these tablets contain the fan strength $1.88
genuine drug, acetylsaUcylic acid. Net pricef pw 20.mil bulk* Von-
Net price, 500 $1.20 tainer $4.13
Net price, 1000 $2.14 Net price, per box of 6 ampules,
half strength $1.38
Abbott'a Dosimetric Trinity Net pric- ~ H^ *"*** $15°
(List No. 243) Buckley'* Uterine Tonic
An aconitine combination for the (Abbott)
treatment of fever. Better and safer {. . N 9oa\
than coal-tar antipyretic, especially for ^u»* o. o99)
asthenic patients or in late stages. Aletroid, gr. 1/12; bryonin, gr. 1/500;
Net price. 800 $1.35 caulophylloid, gr. 1/6; macrotoid, gr.
N«» Z*l*m IMA *2 4Jt l/o; belenoid, gr. 1/6; hyoscyamine
Net price, 1000 $2.48 al?lphate, gr. |/2000. For tha pelvic
distresses of women where is its equal?
Abbott'a Laxative Cold Net price, 100 4ic
/t • » m *mm\ Net price, 800 $1.43
(List No. 685) Net price, 1000 $2.83
The formula speaks for itself. It's
a winner. Quinin. hydrobromid., gr. Antineundgfc (Abbott)
I; acetamhd, gr. I; gelsemoid, gr. 1/50; ~ v
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A palatable laxative tablet contain- AnticOttatipation (Abbott)
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Pleases the most finicky. Segmented Originated by us. A formula many
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Special bulk prices quoted on any of the items listed
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LOESER'S INTRAVENOUS SOLUTIONS
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91
THE REMEDY FOR HEMORRHAGES
STYPTYSATE
Not Subject to Narcotic Law
Two Cases of Interest Where Styptysate Was Used
Mrs. E. M., age 30. Menorrhagia of five years, with menses
of ten days' duration, at times more profuse than at others, some
dysmenorrhea which caused her to go to bed.
January 10, 1921, 8 a. m. — Patient unable to sit up. Pre-
scribed Styptysate in dose 15 gtts., t. i. d 9 p. m. — Better,
less pain, less discharge. January 11, 1921 — Improving.
January 12, 1921 — Feeling O. K. Menses four days in-
stead of ten as heretofore. Expect to see less trouble next
time, as action in this case was remarkable in the light of
previous experience.
Mrs. A. S., age 39. Uterine hemorrhage following miscar-
riage at five months.
Called January 11, 1921, 2 a. m. Administered Styptysate
as indicated hemostatic. Reult very satisfactory.
I believe from clinical observation thus far made you have
in Styptysate a meritorious hemostatic, etc.
B. H. M., M.D., Kansas City, Mo.
Dose: gtts. x-xv or more by mouth, or in ampules for
intra-muscular injections. Prescribe in 10 ex. bottles.
Samples and literature on request
®
INTRODUCTORY OFFER
One Dozen Bottles of STYPTYSATE for $5.00
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ERNST BISCHOFF CO., Inc
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For $5 remittance enclosed
..••'" send 1 dozen bottles of Styp-
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Mentioning The American Physician Insures Prompt, Careful Service
92
Contents
Copyright, 1920, by The Taylors, Publishers. All Bights Reserved.
Editorials
One Good Reason Why Some General Practitioners Are
Losing Ground Unscientific Practice; the "Pill Doctor."
By John U. Fauster, M. D V'JP
Dr. Fauster says that while he has due respect for the
responsible pharmaceutical producers, and realises
that the refinements in therapy are In a large meas-
ure their handiwork and that the development of the
blologicals Is an epoch which could be realized only
with their co-operation, yet on the other hand, the
nostrum vender, whether he solicits patronage from
the medical profession or from the laity, cannot be
too strongly condemned; nor the physician so lack-
ing In scientific pride and professional self-respect
as to allow himself to patronise such houses.
Health Conditions In the South Much Misrepresented.. 106
Original Articles
Surgery of the Thymus Gland. . m
By Albert J. Ochsner, M. D., LL.D., and Francis T.
CTDoubler. M. D.f Ph. D .....107
The function of the thymus gland has long been in
dispute, and rather fantastic claims made as to its
endocrine activity. This paper clears up many dis-
puted points, sets forth what is defcnitely known,
and gives clinical points of real value in the diagnosis
and treatment of the thymus gland and associated
structures.
Danger of Incorrect Diagnosis In Ovarian Hemorrhage,
Not Due to New-Growths or Pregnancy.
By J. L. Bubls, M. D., F. A. C S 1 13
Abdominal hemorrhage is a grave condition and re-
quires serious and prompt attention. To know clearly
where the bleeding is from, and consequently to know
how to proceed, is always a pressing question— a
question of life and death. Dr. Bubls differentiates
ovarian hemorrhage from the usual entities It is often
confused with. It goes without saying this short and
practical paper is well worthy of consideration and
should not be overlooked.
An Interesting Case of Acromegaly and Lymphatic
Leukemia, Observed Over a Period of Eleven Years.
By Hyman L Goldstein, M. D 115
Few diseases are as pussllng as acromegalia la For
some obscure reason the pituitary body "goes wrong,"
becoming disturbed, appears to overfunction, and the
skeletal tissues, like wild weeds, begin to thicken,
enlarge* grow and overgrow. Both body anatomy and
body physiology become perverted, controlless, and
helpless and hopeless. Dr. Goldstein's case of
acromegalia, complicated by lymphatic leukemia,
studied thoroughly and presented in detail, Is illus-
trative, interesting and instructive. It Is one of the
diseases rarely met, and the paper should attract
unusual attention.
A Case Illustrating a Method For the Radical Cure of
Varicose Veins.
By A. Mackensie Forbes, M. D 124
Treatment of Two Cases of Empyema, Substantiating Dr.
Mackenzie Forbes' Fourteenth Clinic
By George E. Nour, M. D 12s
Importance of the Internal 8ecretlons In the Treatment
of Asthma.
By R. O. Brown, M. D 12*
Some Common Forms of Nasal Obstruction In the Adult
By L. F. Long, M. D 180
A deviated septum does not call for operation unless
ventilation and drainage are interfered with. Also
it is important to carefully examine these cases and
institute proper treatment since nasal obstruction
causes great discomfort and produces many diseased
conditions.
(Cofifenfs cofinfMieof on page 04)
Chinosol
"A POWERFUL ANTISEPTIC. SOMEWHAT STRONGER IN
THIS RESPECT THAN MERCURIC CHLORIDE AND CONSID-
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(COUNCIL ON PHARM. AND CHEM. A. M. A.)
ASEPTIKONS (supVpAo%NtAoLr,es)
producing complete antisepsis
But
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Indicated in cervicitis, leucorrhea,
specific and non-specific vulvo-vaginitis, in all cases
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93
When the plane of metabolism
must first be raised
HUNDREDS of experiments in
animal nutrition have proved
the great value of yeast in the
growth-producing dietary. One
of the most striking descriptions
of its importance is given by a
man pre-eminent in the field of
physiological chemistry:
"A scrawny, lethargic animal,
rapidly dwindling in size, with
unsleek coat and evident malnu-
trition, will completely change its
appearance and responses in a few
days at most on a diet unchanged
except for a tiny bit of yeast."
It has been found that not only
the brewers' yeast usually util-
ized in laboratory experiments,
but also the ordinary baker's yeast
has extremely important prop-
erties. One of the outstanding
qualities of this yeast is that its
unusually high vitamine content
renders it especially valuable in
dietetic troubles where the plane
of metabolism must first be raised
before the patient can safely in-
gest a larger quantity of food
without suffering from overeat-
ing, and where it is unwise to
stimulate the patient's metabolism
by exercise.
"In such cases," says a leading
physiological chemist, "yeast ap-
pears to offer the best means for
furnishing a relatively large quan-
tity of the water-soluble vitamine
together with a comparatively
small proportion cf calories."
In the American Journal of
Physiology for March, 1 9 1 9, will
be found a full account of the ex-
periments made with Fleisch-
mann's Yeast as a food for the
growing organism. The experi-
ments were carried on in the
Laboratory of Physiological
Chemistry at Jefferson Medical
College, and they bear out the
statement that yeast, by furnish-
ing the water-soluble vitamine,
raises the plane of metabolism
rapidly.
In administering Fleisch-
mann's Yeast the usual dosage is
one cake t.i.d., plain or dissolved
in water, mi Ik, fruit-juices or beef-
tea. As whole milk is the most
important source of the fat-solu-
ble A vitamine a combination of
yeast and milk offers a rich sup-
ply of both vitamines. If the pa-
tient is troubled with gas it is
advisable to treat the yeast first
with boiling water.
Physicians can secure fresh
supplies of Fleischmann's Yeast
from the local grocer, but if they
prefer they may write direct to
The Fleischmann Company in the
nearest large city and a supply
will be mailed on the days wanted.
The Fleischmann Company, Dept. S-2, 701 Washington St., New York.
Mentioning The American Physician Insures Prompt, Careful Service
The American Physician
[Phfla.. February, 1922
A campaign of education — No. 3
How Good Teeth
Increase Food Value
Malnutrition is all
too frequently directly
traceable to your teeth.
It is one of die greatest
factors in all diseases.
Broken down, decayed
teeth prevent thorough
mastication ; lead to
malnutrition.
Impress this upon
your patients; teach
them the value of clean
teeth as general health
ANT1-FY-0
Dental (
Keep* teeth strong and
healthy: free from dan-
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ready and able to thor-
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Watte'* ANTI-PY-O Dental Cream, including a
\~OfltCfllS rx>nlinVtdfr>nnp0ge92
Therapeutic Essentials in Acne.
By Edward J. Lorenze. M. D 131
SO. often (lose the treatment of acne spell failure that
ne Klarll.r publish the short paper or Dr. L»renie,
giving the therapeutic essentials of this dlsaa.se— a
disease as troublesome to the physician as It Is to the
An Efficient Furore for Medical l'ractica
Co-ordinating tha Work of the Family physician and the
Hospital 132
Proposed Reorganization of the United States Public
Health Servica 138
Best Currant Medical Thought
A Thorough History An Important Factor In Syphilis. 123
Cyatoceie and Prolapse 134
The Relationship of Carcinoma to Infection 134
De Capsulation of the Kidneys In Bright'* Disease, .. .138
Tha Etiology of Rickets 13a
Duodenal Ulcer 140
The Determination of Dental Focal Infection* by Means
of the Radiogram 140
Book Review*
Infection* of the Hand 140
A Physical Interpretation of Shock, Exhaustion and Res-
toration. An Extension of the Kinetic Theory 140
Roentgen Interpretation 142
The AlBSssment of Physical Fitness 142
A Manual of Physics For Medical Student* 142
The New Pocket Medical Formulary 142
Modern Italian Surgery and Old Unlver*ltles of Italy.. 142
Studies in Neurology 142
Feeblene** of Growth and Congenital Dwarfism 142
Diseases of tha Nervous System 142
A Practical Treatise on Diseases of tha Skin 144
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service of a needed practical character In the problems of
everyday practice.
If any subscriber feels that The American Physician Is not
giving him full measure of such service sad U dissatisfied, If
be will write us we will cheerfully refund the money b* paid
for subscription, without question.
Tbe American Physician seeks only satlsQed, Interested
readers.
Sabacriptioa Continoonea
Prsctlcslly all of our subscribers want their subscriptions
continual so they will not miss any Issues If they should
neglect to remit before expiration.
Where this Is not tbe subscriber's wish It Is carefully noted.
Subscribers sre expected to notify us with reasonable
promptness to atop the Journal if it is no longer required.
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The American Physician]
An Honest Market Place 95
r
In POST- FEBRILE ANEMIA and Convalescence from
Acute Illness, where kematinic reconstructive treatment u indicated
iifmaMotdo-
is especially adapted. It u bland, palatable and easily acceptable to tke
irritable gastric mucous membrane, for it is axiomatic tbat organic iron is
assimilable iron and free from all barsb or constipating effects.
^ HBMABOLOIDS is fundamentally a iood iron— baaed on the concentration of iron-
bearing vegetable nucleo-protein*. Its blood building and rertoratire propertiee are
increased and assured by tke accompanying ingredients bone-marrow and nuclein.
•J WKen tke iron action ljL^^e*riJls5^i!lJK "*** ^ tt**^— eve11 **
muft be enkanced NThR^ ^Nlfl ffexS «•■•• V Militated
byadjuTanta If IP MjVl digeetiTe power*
CONTAINS fa gr. Areenioue Acid and fa gr. Strychnia to tablespoon
Sumylm and Ljfiatmt) on RsjsjnesC
The Palisade Manufacturing Companj
YONKERS, N. Y.
When You Prescribe Salicylates
Qive your patients the benefit of the difference between
the synthetic, coal tar product, and the natural salicy-
lates made from the pure natural oil. Write
Your Druggist can fill this prescription.
The natural salicylates produce less irritation of the
gastric tract, are more rapidly eliminated than the syn-
thetic coal tar products and are tolerated in larger doses
over longer periods of time.
Give your patients the best.
M FOUNDED 182S
ERREllC0MI*,iY
CINCINNATI.US.A.
M
Mentioning The American Physician Insures Prompt, Careful Service
The American Physician
[Phils., February, 1922
INi.ifli
Cnlci
.• of the respiratory apparatus, especially in bronchitis,
won a place in the therapeutic armamentarium of the
physician. It in of value in the treatment of bronchitis auociated with
pulmonary tuberculosis, became it hat creoiote effect without untoward
action on the stomach, much aa nausea, disagreeable eructations and
BRONCHITIS and TUBERCULOSIS
CALCREOSF. can be given in comparatively large doses for long
periods of time without any objection on the part of the patient. The
indications for CALCREOSE are the same aa those for creosote.
Price:— Powder, lb., $3.00. (Prepared by adding I lb. to
I gallon of water.) Tablets: 4 gr., 1000, $3.00;
500, $1.60; 100. 40c
Sample* (tablets) and literature free
THE MALTBIE CHEMICAL CO. Nomk, N. J.
The Prevention of Weak, Tender Feet
is one of the notable bene6ts that
logically result from wearing
O'Sullivan's Heels
It is a well known fact that abnormal conditions of the foot structures
are often brought about by shoes with hard, rigid heels, and lacking
in flexibility. Free movement of the muscles is prevented, muscular
tone is lost, and sagging of the arch naturally tends to follow.
O'Sullivan's Heels, however, by reason of their elasticity and
springiness assure a greater latitude of muscular action. The foot
muscles (hus receive more exercise, the local circulation is increased
and die foot structures are kept in a nearer normal condition.
The use of O'Sullivan's Heels, therefore, is a simple bi
exceedingly effective means of promoting the health and
strength of the feet.
O'SULLIVAN RUBBER CO., Inc.
New York City
4
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The Neutral Salicylic
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SANTYL
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for the INTERNAL TREATMENT of
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Dose: 3 espsules 3 or 4 times dail
Liliruurt sad ttmpltt from
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Digital! (Digipuratum)
Physiologically Standardized Digilanttoid*
as Digipuramin, la manufactured ander license from the
accurately standardized according to the original teats.
RAPID AND RELIABLE IN ACTION
UNIFORM IN STRENGTH
Powder: In vials of S <"■-
Tablets: l1^ grains, lubes of II
Oral Solution: Vials of 12 Cc
Information on request
MERCK & CO., New York
g(gUrUg)l
What the Surgeon Could Tell
About Russian Mineral Oil
WHEN Sir Arbuthnot Lane &r.t definitely established the
value of Russian mineral oil as an intestinal cleansing
agent and as a preperatur in surgery, medical science took a
definite step forward-
Surgeons and medical men everywhere have since learned
to depend upon this form of laxative to insure thorough
cleansing of the intestinal walls.
This it Especially true where there has been a history of consti-
pation, with the Inevitable adhering • ' ' . , .
i with chro
This
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alls foi
n Mi.
nltely establish
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McKESSON & ROBBINS
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Mentioning The American Physician Insures Prompt, Careful Service
The American Physician
[Phil... February, 1922
Mercurosal
A Remarkable Antisyphilitic
MERCUROSAL, a new synthetic: chemical, is unquestionably the molt
noteworthy addition to the list of available antiluetic mercurials.
It is the answer of our research chemists to the quest for a mercury
Compound that would combine the convenience of the soluble salts of mer-
cury with the therapeutic virtues of some of those that are insoluble, such, for
example, as the salicylate of mercury.
Although Mercurosal has just been announced to the profession there is
already an impressive bibliography on the subject. The authors of these
papers give unstinted approval of the new product. And their opinions are
based on hundreds of cases of syphilis in which Mercurosal was the mainstay
of the treatment.
The reports of all investigators show that Mercurosal has low toxicity— only
one seventh that of bichloride of mercury. Moreover, there is abundant clin-
ical evidence that Mercurosal possesses high spirocheticidal value, and that its
administration, cither intramuscular or intravenous, is not attended by untoward
symptoms.
Parke, Davis & Company
BIBLIOGRAPHY
SMITH: Mercury in the Treatment of Syphilis; Illinois Medical Journal,
May, 1920.
BREMERMANand McKELLAR: Mercurosal in the Treatment of Syphilis;
The Medical Standard, January, 1921.
MARCHAND: Mercurosal; New Orleans Medical and Surgical Jour-
nal, May 1921.
ROBINSON: Report of a New Mercury Compound for Intravenous Use;
Southern Midical and Surgical Journal, October, 1921.
KEANE: A Preliminary Report and Study of the Value of Mercurosal in the
Treatment of 60 Cases of Syphilis; abstracted in Bulletin of Ike Wayne
County (Mich.) Medical Society, October 31, 1921.
INTRAVENOUS
INTRAMUSCULAR
Infection! ibould be allenufed with
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ENDOFERARSAN
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ENDOMETHYLENAMIN
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Send for catalogue giving
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ENDOOLOBIN fc
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Menlioning The American Physician Insures Prompt, Careful Service
100
The American Physician
[Phila., February, 1922
Facts Would Not Justify
Such a Decision
A PATIENT developed a rash
* ** after an injection of diph-
theria antitoxin. But have you
stopped using antitoxin in diph-
theria? Hardly, because you know
— you realize — that that patient
is, perhaps one in a hundred; and
to cut antitoxin from your list of
therapeutic agents because of an
occasional anaphylaxis would be a
decision without justification.
Is there any more logic — is there
any more justification in taking
the joy out of your patient's break-
fast, as you do when you pronounce
"Cut out coffee !" without the his-
tory, the etiology, the symptoma-
tology, the diagnosis of each par-
ticular case pointing conclusively,
or even possibly, to coffee as a
pathologic irritant?
Here is what Professor Samuel
C. Prescott, head of the Depart-
ment of Biology and Public Health,
Massachusetts Institute of Tech-
nology, says of caffein : —
"For the great majority of nor-
mal individuals it is a mild stimu-
lant of the heart, increases
power to do muscular work, in-
creases concentration of mental
effort and therefore the power to
do more brain work. It is not fol-
lowed, except in excessive doses,
by undesirable after-effects. Our
studies lead us to entire agreement
with the results stated by Holling-
worth that when taken with food
in moderate amount, caffein is not
in the least deleterious."
That case management which
gives relief with the least derange-
ment of the patient's normal habits
certainly is to be preferred over
that which upsets his daily routine
of living. Taking coffee from the
breakfast of the vast majority of
•patients is adding hardship to
illness.
Is it necessary? In how few
cases is it really necessary? Turn
to any work on dietetics.
Copyright 1922 by the Joint Coffee Trade Publicity Committee of the United States.
You can buy with Confidence — See "Service Guarantee to Readers" on page 166
An Honest Martlet Place
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On a handsome, white metal case, holding 12 Mutford
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MENSTRUAL DISORDERS
A large proportion of the patients treated in a physician's prac-
tice are women suffering with some derangement of menstrual or
generative function. These disorders are due in large measure to
diminished or disturbed function of the glands of internal secre-
tion. Owing to the reciprocal relationship that exists between
these glands, a functional disorder of them is, in its last analysis,
always a pluriglandular disturbance — never a monoglandular
malady. It is now recognized that pluriglandular combinations
give better results than sin-
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In those cases that have a
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Hormotone Without
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Literature on request
G. W. CARNWCK CO.
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You can buy with Confidence — See "Service Guarantee to Reader/' on page 166
The Am
encan
Phys
ician
Vol 27
February, 1922
No. 2
SPONTANEOUS BDITOHJALS; An American Pkpslemn mmhpmmnt *f joamolbtk «n*»; m» JooinoU.
One Good Reason Why Some General Practitioners
Are Losing Ground
Unscientific Practice; the "Pill Doctor"
By John U. Faustor, M J)., Defiance, Ohio.
Proper Use of Reputable Medical Journal Advertising
tha Efficient Way to Stop an Irritating Amrnyamco
Dr. Fauster says that while he
has due respect for the responsible
pharmaceutical producers, and real'
he* that the refinements in therapy
are in a large measure their handi-
work and that the development of
the biological* is an epoch which
could be realized only with their
co-operation, yet on the other hand,
the nostrum vender, whether he so-
licits patronage from the medical
profession or from the laity, cannot
be too strongly condemned; nor the
physician so lacking in scientific
pride and professional self-respect
as to allow himself to patronize
such houses.
Of course, it hardly needs to be
said very few readers of The
American Physician will be found
among the users of such product*.
Men of that type would find very
little in The American Physician to
appeal to them.
For our readers the problem is
how to avoid the irritating annoy-
ance and waste of time Dr. F ouster
so graphically describe*; and also
most eieciwely to assist in jnmn-
taining the professional public opin-
ion that slowly, but surely, is
remedying this problem.
What is needed is something
practical; something the individual
practitioner can use effectively.
Have you thought. Doctor, of the
use YOU can make of reputable
medical journal advertising in
checkmating the nostrum vender?
Statements the pharmaceutical
manufacturer makes in advertising
in reputable medical journals (those
who properly censor advertising
pages in the interest of service to
readers) are public statements made
before the whole profession for
which the manufacturer is publicly
responsible. Contrast this with the
irresponsibility so often the case
with the word of mouth statements
of some personal representatives
("Detail Men*) and so forcefully
portrayed here by Dr. Fauster.
Make it your standard procedure
to refuse to give time to the repre-
sentative of any house mat ha* not
first properly gained your confidence
for its scientific integrity and de-
pendability in public statement in
the public forum properly available
for that purpose — the advertising
pages of medical journals in which
you have confidence.
The reputable pharmaceutical
houses whose products and service
are thoroughly scientific and to be
depended upon, we know would be
mote than glad to co-operate with
the profession in developing this
guarantee of responsibility in pro-
motion methods if practitioners
would make it a practice to de-
mand it
We cant take space to further
develop this idea here, but shall do
so in subsequent issues. After
reading this forceful paper of Dr.
Funster's— think it over. — The
Editors.
SOME TIME AGO a zealous and energetic repre-
sentative of a pharmaceutical house, of which I
had never heard, that is located in one of the smaller
cities of this state, called on me and directed my
attention to the preparations which he classed as "very
elegant," manufactured by the concern he traveled
for. He had concoctions of various colors and con-
sistencies, each having its own definite virtue — they
never disappointed and were infallible and could be
used to cure certain diseased conditions. He seemed
considerably surprised when I did not embrace the
opportunity to supply myself with these "goods," as
he called them, and being loath to leave me entirely
without the aid of his extremely valuable remedies
he finished his solicitations by saying: "Doe, don't
you want a good kidney pill V9 I used both the spoken
and sign language to inform him that neither he nor
his wares were indispensable to my continuance in
Advancing Standard* — "A Urrice •! TnA, hem Cm t» Covet"— page 166
104
Unscientific Practice — Fauster
[The American Physician
the practice of medicine, whereupon he retired.
This experience is not at all novel and rare; many
of you have had similar ones, no doubt. There is a
reason for such experiences or they would not occur.
"What is the reason?'' you ask. Manifestly that lies
with the physician. If this class of salesmen could
find no sales they would be engaged in other lines,
which means that if we physicians did not buy their
junk it would not be offered to us.
The question then follows: "Why do physicians
buy these ready-to-use remedies that have the ad-
vantage over Aunt Jemima's Pan Cake Flour in that
they do not need to have water added to them to make
them ready to 'serve'?" That can be answered in one
word — INDOLENCE, an indifference to apply oneself
to treat a case scientifically.
Perhmctty Exmtamtwm emi Smappy Oiof»Mtt
We have forgone the task incident to the situation
in the treatment of disease that would require any
energy in a therapeutic way and are looking forward
to the happy day when diagnosis will be made for
us. With this later achievement realized, cases that
are not ambulatory can send their symptoms by letter
or messenger when, with a diagnosis and treatment
"all ready-to-use," the office girl can supply the patient
with what he needs and we can continue our game of
pinochle quite undisturbed.
Is this overdrawn? Perhaps so, and possibly not
so much even if so. I have a physician in mind who
buys acetanalid tablets and sodium bicarbonate tab-
lets in large quantities. He has these tablets in pack-
ages ready to dispense, and that is about all he does
dispense. I should add, however, that he has them
in different colors so that the patient may have a
change in medicine should this become advisable.
We rail at the cults and examine chests — when we
care to go to that trouble — through the clothing;
which of these two evils is the lesser? If a patient
complains of a discomfort in the upper abdomen we
look at his tongue and diagnose his case as "indiges-
tion," whatever that means, and give him a "digestive"
of what we happen to have the most.
Several years ago I was testing a gastric filtrate
and in the process used a bit of coagulated egg albu-
men. While I was engaged, a detail man represent-
ing the manufacturers of a widely known elixir lac-
tated pepsin called. He assured me that their product
SPONTANEOUS EDITORIALS
The editorial form has a journalistic value all its own — a quality
of concisely illuminating a subject like a searchlight playing over
a landscape.
Unfortunately, however, the editorial is subject to the limita-
tion of being to largely occasional writing — forced expression for
the occasion.
Frequently we receive short pithy contributions that have the
natural qualities of the editorial plus the vigor of spontaneous
expression; are in fact spontaneous editorials. It has occurred
to us to give them a particular attention they merit. — The Pub-
lishers.
digests an inordinate amount of albumen. I put a bit
of the coagulated egg-white in a test-tube and covered
it completely with pepsin elixir; the tube was kept
at body temperature for a period of twenty-four hours
at which time there was no change in the contents
of the tube. Those of you who have followed the
procedure of adding coagulated egg-white to the gas-
tric filtrate will recall how quickly the filtrate disin-
tegrates the specimen.
Cases of headache are attribute to ''biliousness,"
with no attention to any existing pathology. Rheu-
matism and grip cover a multitude of ills, while "heart
trouble" fits in very well when nothing else is handy ;
and so the story goes except in those cases wherein the
patient has made his own diagnosis and directs us to
prescribe accordingly. When we prescribe without
having a definite reason to use the remedy we employ
in the particular case in hand, we are in the same class
with the long-haired individual who sells corn cure
and worm medicine on the street corner— the quack.
To the public there is more or less mysteriousness
in the practice of medicine. The laity has not gotten
away entirely from the savage's idea of the medicine
man. With the other professions this condition does
not prevail. The lawyer while trying a case has an
opposing council ready to snap him up should he
chance to present statements that are not founded on
facts in the case. Thought from the pulpit is an open
page, but who knows about the physician and his
work — none but himself. What a change it would
make in the practice of medicine if the physician's
work could be lined up for inspection as the soldier
is lined up to be criticised by those who are qualified
to make such criticisms. The slothful and slovenly
manner in which we pursue our professional duties is
accountable in no small way for the existence of the
cults. Legislation controlling these nuisances is valu-
able. However, if we mend our ways a larger part
of their clientele will be kept from them, and with-
out sufficient patronage they cannot endure.
Systemuiic mad ScUatiic Thtomglmeu Imtptrotwe
Having brought to your attention a few facts which
you have already recognized, clearly indicating that
a fuller appreciation of a sense of duty to the public
is justifiable, the next thing to be considered is what
should be done to remedy this evil. Some one has
said that a large percent of a physician's success
depends on his securing the confidence of his patients.
This may be true; the psychology is plausible. The
way to secure the confidence of your patients is in an
honest endeavor to give them such service as they
seek and require. Give them the best that is in you
and their confidence is secured.
We should do less work but should do it better
than is our habit, should see fewer patients, but should
give them competent service. A physician may be
Phila., February, 1922]
Unscientific Practice— Fauster
105
tempted to hurry about his work if he has several
patients waiting to consult him, yet such a procedure
is a mistaken one. Our aim should be to do our task
well, not how many patients we can prescribe for in
a given time; for we are not doing "piece work.'1
Every physician should have at least a small labora-
tory, not that we are expected to go into laboratory
work extensively, but that we may obtain such infor-
mation that many times cannot be realized in any
other manner, and which may be absolutely essential
that our treatment may be properly directed. Should
the advice of an expert technician be necessary this
is easily available. In the great majority of in-
stances as much information as is required to aid
in making a proper diagnosis can be obtained in the
physician's own laboratory.
One should keep case records and not be embar-
rassed by being forced to inquire of the patient whiu
bis trouble was when he last consulted us and what
we gave him. There is a further advantage in keep-
ing case records in that in following out the printed
blank one is less liable to miss certain parts of the
examination that might be very helpful in arriving
at a proper conclusion. We should use care and be
concerned in making a physical examination. The
ease may seem trivial to the physician, and indeed it
may really be so, yet it is not so to the patient, else
he would not have consulted us. Diagnosis should be
based on what we have observed in the examination
and the treatment directed accordingly.
With a proper diagnosis established the process of
prescribing is simplified. We cannot prescribe satis-
factorily without first having found a definite condi-
tion at which to direct our therapy. One cannot take
a journey unless he first knows his destination and the
way to proceed to it; thus with the treatment of dis-
eased conditions we must first know what we have
to do before we can set about to do it.
Our therapy should be selected with the same care
that is followed in making a diagnosis. There are
useful and dependable drugs which may be selected
from a known and tried pharmacopea; we should re-
frain from using nostrums whose only virtue is in
the propaganda the commercial concern producing
them exploits them with.
I have due respect for the responsible pharmaceu-
tical producers. The refinements in therapy are in a
large measure their handiwork; the development of
the biologicals is an epoch which could be realized only
with their co-operation. On the other hand, the nos-
trum vendor, whether he solicits patronage from the
medical profession or from the laity, cannot be too
strongly condemned. I know of but one practice that
is more deplorable, and that is the habit of disregard-
ing proper diagnosis and treatment by accepting the
extravagant statements and prescribing the products
of these irresponsible drug concerns.
Health Conditions in the South
Much Misrepresented
IT IS UNFORTUNATE that so little of the South
is included in the United States "registration
area," for 'if vital statistics of official character were
available from this section of the country it would
be impossible for false impressions regarding health
conditions there to gain such wide currency, to the
injury of one of the fairest sections of the nation.
Some time since we commented on the claims of
Goldberger that pellagra was rampant and under-
feeding common throughout wide sections of the
South, aiid the sensational newspaper sob stuff over
the r.llcged poverty and threatened starvation in Dixie
Land that followed the issuance of certain govern-
ment bulletins. Since then we have been aided by
friends in ascertaining actual conditions on the spot,
and knowing the South somewhat ourselves and hav-
ing a son who is doing commercial publicity work
there over a wide area, we feel justified in attempt-
ing to correct some false impressions.
As nearly as can be ascertained by Southern health
officers, there are, on the authority of Southern Med-
ical Journal, whose estimates were very carefully col-
lected, less than 10,000 cases of pellagra among the
35,000,000 people living in an area of over 1,000,000
square miles; that is, one person in 3500, inclusive of
mild cases, has the disease, or one case in 100 square
miles. This makes it apparent that pellagra is merely
one of the endemic diseases of some sections of the
South and that it is not an epidemic condition.
The etiology of pellagra, despite many claims, has
not been definitely ascertained. That it is a deficiency
disease is probable; but with our modern understand-
ing of vitamines the North has been shown to have
quite as many cases of deficiency disease as has the
South.
Other Dssmms
We remember very vividly the terrible epidemics
of yellow fever that, years ago, were a Southern
menace; but yellow fever is now unknown down
there. We are also conversant with the hook-worm
menace; but if you go South today in search of
hook-worm cases you will have quite a hunt to
locate any notable number of characteristic cases ex-
cept in certain isolated sections where people will
not wear shoes or co-operate with the health officers.
Malaria still exists to too great a degree, though it is
being eradicated fast. Cholera no longer exists in
the South.
When Philadelphia was a place of 10,000 people,
cholera, yellow fever and malaria were so great a
health menace that it was seriously proposed to
abandon the place except as a port. We have per-
sonally seen, years ago, as serious and widespread
malaria in Michigan as the South ever encountered.
106
Announceaieata
[The American Phyadaa
To this day the North has not made the headway it
ought to make in eradicating tuberculosis. Perhaps
comparisons are odious, especially between various
sections of the nation; but it must be remembered
that even the North is what it is today because it is so
well populated that it has been financially profitable
to drain the swamps, open great markets for produce,
develop the dairy industry and remove insanitary
menaces. The lower half of New Jersey has,
naturally, no better soil than has Georgia; but look
at New Jersey farming now and you will see what
Georgia can become. Really, the problem of South-
ern health conditions is an economic one, for there
is no natural reason why the South may not become
as sanitary as is any section of the North. It is
asserted by Southern authorities in position to know
that the death rates of the whites in the South are
lower than the white death rates in the North. Ram-
pant industrialism is creating new health menaces
in the North even faster than it is in the South.
Gw* ike Smtk m Chnct
Climate is not a mere matter of latitude. The
summer is just as hot in St. Louis and other parts
of the Mississippi valley as it is in New Orleans. Los
Angeles is in about the same latitude as is Charles-
ton, S. C, the sun beating down as vividly in one
place as in the other. Southern Florida is in the
latitude of Arabia; but a Floridian would perish of
heat in Arabia. Don't be afraid of a southern lati-
tude in the United States, for Philadelphia has as
much sunstroke and heat prostration as has Savan-
nah. One of the most glorious climates in the world
is that of the Carolinas. There is plenty of fine
scenery in the South, and a wealth of fine people. We
have thousands of farmers going to Canada who
would far better go South, where nature is kinder.
The South is a comer: give her a chance! She has
had too much bad advertising and she is lied about,
just as "the great American desert" used to be. Yet
the South is the greatest refuge for the ambitious
man with little money that the United States has
today to offer to her people. If a man goes South
and is willing to work, he is less apt to starve than
if he settled in Chicago.
We want to ask the Southern doctors to "pep
up" and help boost their section;* making it healthy
and rich is no more of a job than it formerly was
in Ohio. Economic conditions need a little pushing
up grade in the South, it is true; and in some places
there rather primitive conditions exist. There is no
real reason, however, why a pull-together movement
among Southern and Northern people should not
make of the South a glorious heritage for the com-
ing generation. Fundamentally there is no reason
for the South being unhealthy, and conditions there
at present are vastly better than they are commonly
represented to be. Doctor, go and see for yourself.
Coming In Next issue
Complications Following Gastric Operations, by A.
Wiese Hammer, M.D.
Complications and sequalae of gastric surgery are
frequent and important To know the probabilities
and possibilities of the procedure under considera-
tion is to know what to tell the suffering patient in
quest of vital advice. The paper of Dr. Hammer
is excellently presented and covers its ground ad-
mirably well. We hope our readers will benefit
by it.
Some Pediatric Reminders, by H. Brooker Mills.
M.D.
From his wide experience, the author gives prac-
tical points which will help the physician both in
diagnosis and treatment, with his small patients;
interestingly written in the shape of brief, pertinent
reminders, on the more frequently met pediatric
problems.
Symptoms and Diagnosing of a Rectal Fistula, by
Charles J. Drueck. M.D.
The general practitioner knows little of rectal fistu-
lae and usually "bothers with it" as much. That it
is real, obstinate, and worthy of serious attention,
those who have suffered with it will tell you in no
uncertain terms. Dr. Drueck's paper presents this
rather neglected but important subject in clear,
concise and practical form. He discusses all the
phases of this disease in a way that will interest
and help the reader. Don't miss it.
Rectal Etiology of Gastroenteroptosis, by E. Jay
demons. M.D.
The paper of Dr. Clemons is well written and well
compiled. It is based on excellent logic of cause
and effect It, furthermore, reviews briefly but
clearly a series of embryologic, anatomic and physio-
logic facts which the general physician has a ten-
dency to forget They are all subjects of importance
and are well worth reviewing.
Hydrotherapy in General Practice — A Few Examples,
by O. M. Hayward, M.D.
The effect of hydrotherapy is often remarkable, even
in its most humble form. The washing of the face
with cold water removes "sleepy feeling" and sensa-
tion of fatigue, as if by magic. The exhilarating or
soothing action of the cold or hot bath, as the case
may be, and its beneficial influences in both health
and disease, cannot be denied by even the so-called
opponents of this form of treatment. Combine these
simple truths with the facts elucidated in the paper
so non-pretentious but so clear as it is presented
by Dr. Hayward, and you will enrich your thera-
peutic armamentarium with a series of "simple pro-
cedures which will serve any physician well if he
will only make use of them."
Syphilitic Leg Ulcer, With Report of a Case, by C.
J. Broeman, M.D.
The genesis of leg ulcers is as uncertain as repel-
lant, as it is indeed unyielding to corrective meas-
ures. Here the best efforts of the best brains often
fail. Verily, how are you going to treat the
obstinate sore unless you know that the causative
factor is varicose veins, tuberculosis, diabetes,
phlebitis, trauma or syphilis — influenced additionally
perhaps by elements such as age, sex, occupation,
constitutional or social environments? This multi-
phased subject is admirably discussed in Dr. B roe-
man's paper.
The following Papers
are contributed exclu-
sively to this journal.
Republication is per-
misted if credited as
follows: AMERICAS
PHYSICIAN, Phila-
delphia.
Original Articles
SutnttL Hi MfcHBi tan dNptst itai utt MMmii
We ore not respon-
sible for the views ex-
pressed by contribu-
tors; but every efort
is mode to eliminate
errors by careful edit-
ing, thus helping the
reader.
Surgery of the Thymus Gland
Many Disputed Points Illuminated for the General ^Practitioner
By Albert J. Ochsner, M.D., LL.D.,
and Francis T. H'Doubler, M.D., Ph.D.,
2106 Sedgwick St.,
Chicago, Illinois
The function of the thymus gland has
long been in dispute, and rather fantastic
claims made as to its endocrine activity.
This paper clears up many disputed points,
sets forth what is definitely known, and
gives clinical points of real value in the
diagnosis and treatment of the thymus gland
and associated structures. — The Editors.
IT SEEMS LIKELY that within a short period
of time the thymus gland will be entirely elim-
inated from the field of surgery. This is interesting
because it is but a very short time since this organ
was first looked upon as coming legitimately within
the domain of surgery.
It has been protected against surgical attack (a)
because of its inaccessibility, (b) because of its
tendency toward self -elimination, (c) because sur-
geons are less likely to attack pathologic conditions in
children than in adults and the thymus gland is
usually eliminated before adult life.
It seems quite worth while at this point to review
the physiology of this organ before proceeding to
the surgical consideration.
The Physiology of the thymus has for the
most part remained a mystery — though a number
of interesting observations have been made. A
further knowledge is of greatest importance, for we
should know the full effect upon a patient in whose
case thymectomy is indicated and should also know
whether there is any form of specific treatment for
conditions arising due to thymus disturbances.
No one doubts that the thymus belongs to the so-
called group of glands of internal secretion. It does
not seem amiss at this point to review briefly the
literature as to observations on thymus function
and physiology. In so doing only the more important
and well established results are mentioned, and the
numerous disputed ones are omitted.
1. The sexual organs and the thymus work antago-
nistically. In man and other animals a double
castration is followed by hyperplasia of the thymus
and prolonged atrophy of the same. In young ani-
mals during breeding the thymus undergoes very
rapid atrophy. Removal of the thymus is followed
by increase of the sexual organs and cases of hypo-
plasia of the testicle accompanied by hyperplasia of
the thymus have been reported. The general results
seem to hold equally true in case of either sex.
Still further of interest in this connection are the
respective effects of absence of the sexual organs
and the thymus on the skeletal system; castration
in the young leads to skeletal growth while
thymectomy is followed by a decreased growth. The
same antagonism is further borne out by the fact that
involution of the thymus occurs at the time of sexual
development and the latter probably is instigated
by the former. The observations so far cited are,
mainly, to be credited to Schredde, Hamma, Calzo-
lori, Hart, Nordman, Henderson, Soli, Lucien,
Parisot, Klose and Tandler.
Decreased active and passive immunity have been
observed in thymectomized animals.
The researches of Matte, Basch, Klose, Vogt and
others have shown that thymectomy when performed
on young animals leads to marked changes in the
osseous system and its development. The skeleton
shows underdevelopment in length; the epiphyses
are abnormal, are soft and deformed and contain
about half the normal amount of calcium. It is
difficult to say whether these changes are rachitic.
Fracture healing occurs with little callus formation,
as in rickets.
Symptoms em Removal
Klose and Vogt made a careful study of thymec-
tomized dogs and describe first a period of increased
weight, due to the fat, followed by cachexia thymo-
priva, and they describe, further, coma thymicum
and idiotra thymica.
Removal of the thymus is also followed by an in-
creased electric irrritability of the nerves (Klose,
Basch, Vogt). The similarity has been pointed out
108
Surgery of the Thymus Gland— Ochsner & H'Doubler
[The American Physician
between the symptomatology of tetany in man and the
symptomatology observed in thymectomized animals.
In both cases there is a calcium deficiency and tetany
in children occurs at any age when there is a varia-
tion in the thymus gland. It is interesting to note
that complete thyroidectomy leads to disturbance
of calcium metabolism and tetany and to disturbance
m the skeleton and that the thyroid, parathyroids
and thymus all are branchial in their origin.
Thymectomy also leads to degenerative processes
in the brain and ganglion cells and to a general
acidosis. It is claimed by some that the thymus
normally acts as a detoxifier.
The thyroid and thymus are related; a removal
of either one leads to a hyperplasia of the other.
Further, an exactly similar relationship between
thymus and spleen has been observed (Matte), and
splenectomy hastens the death of thymectomized
animals. The question arises, does the thymus in
man compensate for the spleen in splenectomy t
Thymectomized animals show marked degenerative
processes in the muscles, but in contradistinction to
this is the thymic hyperplasia in myasthenia gravis.
Ckemicd RttafomtMi?*
Recent chemical studies of the thymus have pointed
to a possible relationship of thymus to phosphorous
metabolism, similar to the relationship between the
thyroid and iodine metabolism.
Thymus gland extracts have shown little physio-
logical effect. Some investigators have described a
lowering of blood-pressure by injection of thymus
gland extract and on this basis attribute the phe-
nomenon of status lymphaticus to hyperthymism.
Ascher and his pupils, Miller and del Campo, showed
the thymus extract to have a specific property of
restoring muscle from fatigue and of preventing the
muscle from fatiguing for a considerable time. They
obtained similar results by intravenous injections of
thymus extract into either fatigued animals or animals
about to be fatigued. Ascher was unable to find any
effect of thymus extract on the blood-pressure.
It is interesting to follow the embryologic develop-
ment and the histologic structure of the thymus gland.
Embryology and Histology. The thymus is
first noted in the 5-months' embryo as an entodermal
evagination from the third branchial cleft on each
side. Early these outgrowths are hollow and com-
municate with the pharyngeal cavity showing charac-
teristics very similar to the early stages of the thyroid
gland. Later they become solid and lose their con-
nection with the .parental epithelium. Sometimes,
however, the communication persists as a duct, and
we have a fistula which begins behind the tonsils and
runs diagonally down the neck and ends at the ster-
num. The thymus grows caudally until the caudal
ends of the lobes lie ventral to the carotid arteries. If
the cephalic end does not disappear completely there
occurs an accessory thymus lobe. As the gland con-
tinues to increase the caudal ends lie upon the cephalic
surface of the pericardium, a fact which must be
borne in mind when operating, and the cephalic ends
reach to the thyroid. With separation of the thymus
from the thyroid, the former leaves fragments on the
lower poles of the latter. These give rise to parathy-
roids III, and are from the third-oleft-portion of the
thymus. Groschuf has demonstrated in animals, in
addition to the thymus from the third cleft, a second
or inner one from the fourth ; and Grosser and Bettle,
with serial sections of thyroids of children up to two
years of age, demonstrated a thymus metamer IV.
This portion gives rise to the parathyroids IV. All
this is of importance because it is evident that only
by complete intrathoracic thymectomy and complete
removal of thyroid and parathyroids is all thymus
tissue removed.
The fibrous capsule of the gland sends down proc-
esses into the gland substance and divides it into
lobules .5 to 1 cm. in diameter. Each of these is further
subdivided. The whole gland is made up of adenoid
tissue. The small lobules are especially rich in blood-
vessels and in lymphocytes at their peripheries, while
the center is not so dense. Thus we distinguish be-
tween medulla and cortex. The medulla contains the
Bassals' corpuscles, which may be remains of epit-
helium (His, Steider, etc). These corpuscles consist at
the periphery of concentrically arranged semilunar
cells, while at the center are nuclear and cell detritus.
Nucleated erythrocytes and mitosis are frequently
seen in the gland. Fine nerve plexuses are seen in the
septum and medullary portion.
Croat Amdomy
The thymus may occupy the entire area bounded
from above downward between the lower border of
the thyroid and the diaphragm, the so-called thymic
area. In shape the thymic area is quadrilateral and
it is divided by the upper border of the manubrium
sterni into upper surgical and lower non-surgical re-
gions. The thymus is formed by two lobes enclosed in
a capsule and in close anatomical relation to each
other but without an isthmus. According to Hammar,
the weight at birth is 13.26 grammes; between the
11th and 15th years it increases in size and reaches
its maximum, 37.52 grammes, after which it decreases
with age, (6 grammes at 65 yrs.).
In front the thymus is in contact with the middle
cervical aponeurosis, behind with the anterior aspect
of the trachea and laterally with the common carotids.
The two thyro-thymic ligaments which extend from
the lower poles of thyroid to the upper pole of the
thymus each contain a branch from the inferior thy-
roid arteries to the thymus. The external part of the
Philip February, 1922]
Surgery of the Thymus Glaad— Ochsner £ H'Doubler
109
capsule is directly continuous with the connective tis-
sue of the region; through the capsule the gland is
closely related in the mediastinum to the arteries and
nerves and veins — in succession the ascending aorta,
aortic arch, right brachio-eephalic arterial trunk, left
common carotid and left subclavian are in relation to
the thymus. The right inferior cardiac nerve, left
braehio-cephalic trunk, phrenic nerve and the peri-
cardial and diaphragmatic vessels are also in contact
with the gland.
In young children the upper pole as a rule extends
1 to 2 cm. above the episternal notch, but in adults the
thymus, even when hypertrophied, does not usually
extend any distance above the episternal notch.
Involution of the thyroid occurs in a number of
conditions, physiologically after puberty, during star-
vation, etc Involution is very marked in young
animals that are allowed to breed.
These anatomic facts are of the greatest importance
when this gland is considered surgically because their
study, together with the embryology, will show that
having grown down from above, the blood supply can
be readily controlled and the gland enucleated from
the space into which it has insinuated itself with re-
lative safety.
Status lymphaticus designates a condition of hyper-
plasia of the entire lymphatic system, in which the
spleen participates. Hyperplasia of the thymus as-
sociated with status lymphaticus is called status thy-
molymphaticus. It is believed by many that thymic
hyperplasia is always associated with status lymph-
aticus, and conversely, though in varying relative de-
grees, while others recognize three conditions, namely,
status lymphaticus, status thymo-lymphaticus, and
status thymicus. Closely related conditions are the
hypoplastic constitution described by Bartel, as Com-
by's "infantile arthrismus" and Czerny's "exudative
diathesis," etc
Status thymo-lymphaticus is associated with hypo-
plasia of the cardio- vascular system, seen as narrowed
calibers of the heart, aorta and large arteries, often
with very long intestines and anomalies of the kid-
neys, sometimes with hypoplasia of the adrenals, oc-
casionally with anomalies of the sex organs, and
hyperplasia of the brain. Children with this condi-
tion show a damaged physical condition, the extent
of which is not always proportional to the degree
of thymic hyperplasia. They* are under-resistant to
infection, pale, though well nourished, and have im-
paired nervous systems and frequently die from
heart failure They bear anesthesia badly.
The most remarkable feature of thymic hyperplasia
is dyspnea, which may vary all the way from slight
to most intense, which may be constant or intermit-
tent, and which may be accompanied by inspiratory
stridor, also sometimes expiratory in extreme attacks.
The length of attacks varies from a few minutes to
several days. We are dealing here with pressure on
the trachea, the clinical picture being termed thymic
tracheostenosis. We differentiate between the acute
and chronic forms of the same The former com-
prises certain cases of asphyxia of the newborn and
children, who either previously are well or after a
few slight attacks of dyspnea develop sudden in-
tense choking spells and die in suffocation. The
chronic type comprises cases of repeated frank at-
tacks and certain cases of chronic ill-defined respira-
tory disturbance, due to thymic hyperplasia.
Chronic cases are, of course, liable to acute at-
tacks, with death. Attacks may be precipitated by
dorsal lordosis, hyper-extension of the neck, cough-
ing, anesthetics, etc., or may occur without any recog-
nizable cause whatever.
The mechanism of thymic tracheo-stenosis is as
follows: In the newborn the antero-posterior diam-
eter of the thoracic outlet is relatively small (2 to 3
can.) and the hyperplastic thymus wedging in this
"critical space" constricts the trachea. This happens
in coughing and swallowing as the thymus is at-
tached to and moves with the thyroid, and in hyper-
extension of the neck or in dorsal lordosis. In the
young, the trachea lies relatively high and its lower
and less firm portion is near the critical space; also
the trachea is inelastic and therefore easily displaced.
The trachea, in the region between the innominate
and left carotid, lies between the thymus and spine
where sudden swelling of the thymus can exert
intra-thoracic pressure After two years the thymus
decreases in relative size and the upper thoracic open-
ing becomes altered toward the adult form, hence
the rarity of thymic tracheo-stenosis after two years
of age Further, children with thymic hyperplasia
are sickly and disposed to circulatory disturbances
and hemorrhage into the thymus. Edema of the
glottis may play some role at times.
In contradistinction to the cases with mechanical
cause, are cases of sudden death in which hyper-
plastic thymic glands are found but without any
possible sign of tracheal compression. Such deaths
occur more commonly in older children and adults.
The attacks may be brought on by coitus, punish-
ment or other extreme excitement or may occur out
of a clear sky. Explanations of this type vary.
Paltauf claims these and all thymic deaths are due
to a condition of which the thymic hyperplasia is
an effect. Others attribute the phenomenon to heart
failure, due either to pressure on the base of the
heart or on the cardiac ganglia, or due to an in-
hibiting shock of an instable nervous system. Then,
too, there is the possibility of deranged internal se-
no
Surgery of the Thymus Gland — Ochsner & H'Doubler
[The American Physician
cretion, possibly hyper-thymic function or a dys-
function. Wiesel points out the hypoplasia of the
adrenals seen in thymic hyperplasia and suggests
that there may be an insufficient adrenal function,
as a result of which disturbances that ordinarily cause
temporary fall of blood-pressure lead to vascular
paralysis and heart failure.
The differential diagnosis of thymic tracheo-sten-
osis, according to Klose, includes malformations of
the larynx and epiglottis, intra-laryngeal obstruction,
foreign bodies, polypi, adenoid hypertrophy, retro-
pharyngial abscess, acute pharyngitis, croup,, diph-
theria, fracture of trachea, foreign bodies with
edema of glottis, enlarged mediastinal and bronchial
glands, spasm of the glottis (which is difficult to
exclude), and laryngismus stridulus.
Careful examination rules out a number of these
conditions. In spasm of the glottis a sudden re-
lease of the spasm with inspiratory stridor allows
free breathing, while in thymic tracheo-stenosis the
stridor and cyanosis remain fairly constant; in laryn-
gismus stridulus there are signs of tetany. Klose
further points out two important points indicative of
respiratory obstruction below the level of the thyroid
cartilage, stridor and sucking-in of the lower thorax
without hoarseness and very little up and down mo-
tion of the thyroid cartilage. Little emphasis can
be placed on the inspiratory as versus expiratory
nature of the stridor.
Dwgmw
In making the diagnosis it is important to thor-
oughly try to feel the thymus. This is sometimes
possible. Percussion helps; the thymic area of abso-
lute dullness reaches from the upper end of the
sternum to, and fuses with, the area of cardiac
dullness. Unfortunately, it is not always present.
Aneurism and substernal goiter which could cause
confusion are practically absent in children. The
X-ray is also a help but is likewise fallible. In
typical roentgenograms the thymic shadow is seen
as a thin, soft shadow with sharp margins over-
lapping the mediastinal shadow. Its shape and
location vary. When all physical signs fail a posi-
tive diagnosis can be made from tne history of
chronic dyspnea with acute exacerbations and with
an expiratory tumor showing in the jugulum.
An enlarged thymus can also compress the gullet,
the vagus nerves, the large vessels and the heart —
all with symptoms. From the sixth to the sixteenth
month of life thymic tracheo-stenosis is most fre-
quently encountered. It is more common in males
than in females.
Formerly the treatment of hyperplastic thymi in
children by the X-ray has been condemned because
of the danger that it may precipitate attacks of
tracheo-stenosis. Intubation and tracheotomy are
only palliative. • Thymus extract feeding is yet ex-
perimental. Phosphorous and calcium given in-
ternally improve certain phases of thymic disturb-
ances, but of course have no effect upon the tracheal
stenosis. Thus the only treatment to be advanced,
in case the enlargement does not subside under careful
X-ray treatment, is surgical, which will be described
under its proper heading.
ApUuia mmd Hypoplasia %k the Thywmu
These conditions are known to exist. As yet the
symptomatology resulting has not been systematically
worked out. Klose points out that in disturbances
of internal secretion we see principally psychic
changes, skin changes and bone changes, the latter
being very analogous to those observed in thymecto-
mized dogs consisting of disturbances of growth and
ossification, shortening and deformities. Then, too,
some cases of idiots show at autopsy thymic hypo-
or a-plasia. There are good clinical reasons for
assuming the existence of an "idiotic thymicades."
The thyroid and thymus stand in close anatomical
and physiologic relationship and there is a tendency
to consider certain conditions, hitherto believed to
be due to thyroid disturbances, as due primarily to
thymic disturbances.
The question as to whether there is possibly a
pure cachexia thymopriva, or thymic, is still open,
though there are reasons for believing such condi-
tions to exist.
As to treatment, until recently little could be done
and the prognosis was unfavorable. Vegetable diet
and calcium carbonate help. Adrenalin is to be
tried. Thymus transplants in animals become partly
absorbed and partly cystic after ten months, though
at first they exert a therapeutic effect. Heredity,
alcoholism, inbreeding and syphilis are apparently
causes that play a role in these conditions of the
thymus.
Pmtkology W ike Thymm
Thymus blood cysts occur as sudden hemorrhage
into congenital cysts of the thymus. These cysts are
due to lues. The bleeding is usually due to a torn
vessel in the cyst wall. The condition is diagnosed
by visible bulging of the thymus into the jugulum
and by signs of compression. See paragraph on
surgical treatment.
In pulmonary stasis swelling with resultant hemor-
rhagic infarction of the thymus sometimes occurs,
calling for immediate surgical intervention.
Acute thymitis as a primary process is unknown,
but metastatic abscesses are possible, with swelling
of the gland and compression signs. The diagnosis
is made so late that surgical treatment (which is the
only treatment to be recommended) gives little hope.
Phila., February. 1922]
Surgery of the Thymus Gland — Ochsner & H'Doubler
HI
Pathologists describe a chronic thymitis. Syphilis
affects the thymus sometimes by cyst formations
and sometimes by causing epithelial proliferation!
both of which conditions may cause sufficient swelling
to demand surgical relief. Miliary tuberculosis in-
volves the thymus, but otherwise tuberculosis is
rarely seen. Even in the presence of tuberculosis
of the mediastinal lymph nodes, it may or may not
show involvement. Leukaemias, Hodgkin's disease
and chloroma practically never occasion changes in
the thymus.
Injuries are so rare that they need not be con-
sidered.
JVc*-Grwrtat
Tumors of the thymus are very rare indeed. It
is interesting to note the marked relationship be-
tween neoplasms of the thymus and myasthenia
gravis. Space does not permit of theorizing on this
point, but the reader is referred to Ascher's experi-
ments with muscle fatigue in the paragraph on
physiology. The thymic tumors are classified as
follows :
(A) Benign — lipoma, myxoma, dermoid and cystic
tumors.
(B) — Malignant — sarcoma, carcinoma, metastases
from elsewhere.
The tumors grow so slowly that they rarely cause
traeheo-stenosis. They do press on neighboring veins
and nerves and sometimes give rise to toxic symp-
toms which may lead to false diagnosis, such as
Graves' disease.
The relationship to myasthenia gravis is men-
tioned above.
HemutUlogy mad Thymic Chmmget
Klose, in his excellent work, (Chirurgie der Thy-
mus Druse, Neue Deutsche Chirurgie, Vol. 3) re-
views the literature as to the role of the thymus as
a blood-forming organ and comes to the conclusion
that it plays no active part in producing any of the
blood cells. He cites experiments by himself and
others where thymectomized dogs showed a progres-
sive fall in the lymphocyte count, which was fol-
lowed, however, by an increasing lymphocyte count
after either intravenous injection of thymus extract
or after implantation of the gland. He calls further
attention- to the low lymphocyte count reaching
as low as 9% sometimes in cases with thymic
aplasia, and to the high count of 80 to 86% in
eases of hyperplasia. Also during childhood, the
period of thymic activity, the lymphocyte count is
higher than in normal adults. From this Klose con-
eludes that the thymus and lymph systems are in close
relationship, the thymus secretion stimulating the
latter to production. He points out the possibility of
using these findings in diagnosis and prognosis and
also for a post-operative criterium as to whether
sufficient or too much thymus gland was removed
at operation.
It should be added that thyroid disturbances are
associated with similar blood changes.
fat Thymms mm\ the Tkynii
It has been mentioned above that the thymus and
thyroid stand in close relationship. Removal of one
causes hypertrophy of the other, and hypertrophy
of one is often associated with a similar condition
of the other one.
Even in the majority of thyroidectomies for sim-
ple goiter performed by Klose an enlarged thymus
was found, and the same investigator believes all
cases of Basedow struma are accompanied at some
time by enlarged thymus glands, the thymic hyper-
trophy in long standing and severe cases having
given way to aplasia. The differential diagnosis be-
tween thymus hyperplasias in simple goiters and in
Basedow goiters lies in part, according to Klose, in
the lymphocyte count, which is high in the latter
condition and low in the former one. Hart believed
all cases of Basedow disease to be primarily due to
the thymus, which is assuming too much, though un-
doubtedly the thymus participates actively in the
clinical picture of Graves' disease.
Capelle and Bayer removed only the thymus from
a severe case of Graves' disease, in which also an
hypertrophied thyroid had been demonstrated. The
lymphocyte count sank to normal, likewise the pulse-
rate, and the palpitation of the heart ceased.
The same investigators produced an increased
lymphocyte count by injecting dogs with thymus
extract. Klose injected dogs with thymus extract
from a severe case of Graves' disease. The ovaries
had already been removed and after the injection
the lymphocytes rose from 32% to 64.5% and se-
vere Basedow intoxication also developed. From
this Klose concludes that the abnormal thyroid se-
cretion injures the ovaries and the resulting decrease
in the internal secretion allows a hyperplasia of the
thymus, which is antagonistic to the ovaries, and
that the increased or abnormal thymus function
brings about an increased production of lymphocytes
and toxic symptoms. After thyroidectomy the
dysthymism ceases only when the ovaries recover in
the absence of the harmful thyroid action. Much
quicker disappearance of the Basedow symptoms
and return to normal lymphocyte count occur with
thyroidectomy and thymectomy. According to Klose,
we may draw only the following certain conclusions:
the size of the lymphocyte count in Basedow cases
indicates the extent to which dysthymism enters, and
thereby indicates a primary thymectomy, in case the
thyroid is relatively little enlarged and the heart-
symptoms are severe. In this connection should be
112
Surgery of the Thymus Gland — Ochsner & H'Doubler
[The American Physician
added the demonstration of vagotomy with a strong
pilocarpine reaction or absent adrenalin action.
Since the introduction of deep X-ray therapy with
the use of aluminum niters of 10 m.m. thickness, it
has been possible to produce a marked decrease in
the size of hypertrophied thymus glands without
much danger from burns.
The difficulty in former times came from the
fact that in order to apply a sufficient dosage to
effect the enlarged gland it was necessary to give
a sufficient amount to endanger the skin. The thick
filter now in use has the power to prevent the pas-
sage of the actinic rays, even when a sufficient dos-
age is applied, for the required time to have the
desired effect upon the enlarged gland.
Smrgtry of Am Thymuu
(A) In cases of hyperplastic thymus which can-
not be relieved by the above treatment, whether in
the young or adult, thymectomy is indicated if
there have been grave signs or symptoms of tracheal
stenosis or if there is ground for fearing the same.
The operation must accomplish several effects, namely,
mechanical relief, decreased secretion and stimula-
tion to subsequent normal tissue regeneration. It has
been observed that after thyroidectomy for Base-
dow's disease normal thyroid tissue may regenerate.
In adults it is better to use local anesthesia, and
in children general anesthesia is preferable in case
the anesthetic does not increase the dyspnea.
The technic is as follows: the head is put in the
reclining position and a 6 cm. transverse skin in-
cision made at the level of the incisura of the
jugulum. The fascia is divided longitudinally and
the stemo-hyoid and stemo-clydo mastoid muscles
are retracted on both sides from the median line.
Then the deep neck fascia lying behind the sterno-
hyoid is divided longitudinally, great care being
exercised not to injure the veins in this fascia. This
brings us to the pre-tracheal space into which
either both lobes or just the left lobe of the thymus
can be pulled by traction on the capsule.
Some surgeons complete the operation extra-cap-
sularly by clamping the gland at its base and ligating.
The gland should be cut far enough away from the
ligature to prevent slipping, as it is almost impos-
sible to arrest the resulting hemorrhage save by
packing.
Klose condemns the extra-capsular method because
of the relations of the capsule to large vessels and
in some cases to the pericardium, and after exposing
and delivering the thymus by the above method he
opens the capsule and removes the gland from within
the same. He then fixes the anterior capsule to the
sternal fascia with silk sutures to prevent future
compression on the trachea, packs the lower pole
of the wound with gauze, which is left in for two
days, and closes the various layers divided and the
skin. He believes the drainage referred to has a
marked effect in reducing the post-operative fever
and reaction indicated by a rapid sometimes irregu-
lar pulse, nervousness, anxiety and sometimes in-
testinal disturbances. Other surgeons do not drain.
The prognosis of thymectomy for hyperplasia is
good and the results are very satisfactory. The size
of the resected portion varies accordingly to the
increase in size of the gland and the symptoms pro-
duced. If in addition to tracheal compression there
is esophageal compression, a large amount must be
taken. Again if after removal of part of the gland
dyspnea is observed to be persistent, more must be
taken. According to Klose, the weight of the ex-
cised portion varies from 6 to 60 grammes. In
extreme cases, Horse-Murphy, D'Olsnitz and Prat
have combined excision with resection of the sternum
and dislocation.
(B) Tumors of the thymus, if benign, should be
removed by the above technic, if possible. Benign
tumors resisting this method, and malignant tumors,
are difficult and require splitting or resection of the
sternum. The reader is referred to Sauerbrueh's re-
ports, who has had success with these cases.
(C) Thymus blood cysts require exposure of the
gland and packing of the cyst. A puncture is of
only temporary value.
(D) In case of hemorrhagic infarction, immediate
dislocation of the gland is imperative. The technic
described under (A) suffices.
(E) Abscesses of the thymus offer little hope, the
process usually having gone too far, causing supura-
tion in the mediastinal space by the time the diag-
nosis is made. The procedure indicated varies from
resection of a lobe to resection of the sternum.
(F) The swelling sometimes found due to
syphilis may require surgery, the technic of which
is like that described under (A). This should, how-
ever, be employed only after carefully conducted
antiluetic treatment.
(G) Thymus neck fistula) can be treated success-
fully only by surgery, for injections, etc., are likely to
inflame rather than cure. The indications for opera-
tion are relative. The operation, to accomplish re-
sults, must remove radically the whole tract involved,
a difficult procedure when we consider that the tract
extends from the sternum through to the tonsillar
region. The common carotid and vagus are in the
field; the tonsils must be removed, and even partial
resection of the sternum and hyoid bone may be
necessary. The procedure is a serious one and
should not be attempted except for sufficient reasons,
for instance, the presence of cysts associated with
the fistula.
PkOm^ February, 1922]
Ovarian Hemorrhag e — Bubis
113
Danger of Incorrect Diagnosis
0i
Ovarian Hemorrhage, not due to New-Growths or Pregnancy
With Report of Two Cases
By J. L. Bubis, M.D., FJLC.S.
1725 E. 82nd Street, Cleveland, 0.
A SUrt md Prmdkd Fqpcr
Abdominal hemorrhage is a grave condi-
tion and requires serious and prompt atten-
tion. To know clearly where the bleeding is
from, and consequently to know how to pro-
ceed, is always a pressing question — a ques-
tion of life and death. Dr. Bubis differen-
tiates ovarian hemorrhage from the usual en-
tities it is often confused with. It goes with-
out saying this short and practical paper is
well worthy of consideration and should not
be overlooked. — Editors.
ALTHOUGH OVARIAN hemorrhage ii not a
condition rarely found, it is one which is only
too often incorrectly diagnosed. Very often it simu-
lates a ruptured extra-uterine pregnancy or a fulmi-
nating appendicitis as the following case would
suggest:
Miss M. J., aet. 22 years, engaged to be married,
was admitted to Mt Sinai Hospital complaining of
general abdominal pain especially marked in the
lower right abdomen. Previous history was negative,
except that a toxic goitre had been successfully re-
moved two years before the present admission. The
patient suffered from occasional attacks of indiges-
tion and frequent constipation. No urinary disturb-
ances were present Menstruation, which had begun
at 13 years, was of the 28-day type, normal amount,
lasting from four to five days, often accompanied by
slight pains, and preceded for three or four days by a
marked leucorrhea. During the last three periods,
however, the patient had suffered severe pains in the
lower right quadrant of the abdomen, which radiated
to the epigastrium.
The present illness began at 7.30 P. M., after she
had been menstruating about two days. The flow had
been less than usual. While entering an automobile,
she was suddenly seized with a severe cramp in the
lower right abdomen, felt nauseated and chilled, fol-
lowed by a severe tremor. A physician was immedi-
ately called and an attack of acute appendicitis was
considered. The symptoms gradually became worse,
and the temperature rose to 101° F, at 9 P. M., when
she was sent to the hospital. A blood test showed
4,500,000 red cells, and 22,000 white blood corpuscles.
The urinary and physical examinations were negative,
except for the severe muscle spasm and rigidity in the
lower right abdomen. The hymen was intact and the
rectal examination was unsatisfactory on account of
the excessive pain and rigidity.
She was immediately prepared for operation. Un-
der nitrous-oxide-oxygen and anoci anesthesia, a Mo-
Burney incision was made and a slightly congested
appendix was removed. A small amount of chocolate
colored fluid appeared on the tape as it was removed
from the abdomen. Further investigation showed a
cystic, adherent mass about the size of an egg lying
to the right of the uterus. The mass was liberated
and proved to be an enlarged eystic ovary, filled
with chocolate colored fluid, which was escaping
through a rent. The ovary was removed, and the
peritoneal cavity was sponged dry. The left adnexia
were examined and were found to be normal The
abdomen was closed without drainage. Recovery was
uneventful, the temperature dropping to normal on
the fourth day.
The pathological report by Dr. C. E. Swanbeek
showed a mild exacerbation of chronic catarrhal ap-
pendix. The ovary showed an increase of fibrous tis-
sue with slight thickening of the blood vessels as is
found in a chronic oophoritis.
Occmrremce
Ovarian hemorrhage may occur at any time from
birth until menopause, but rarely after, unless due to
some growth. Sampson (1), states that this condition
is most common between the ages of 30 years and the
menopause. Schumann (2), had three unoperated
cases in adolescent girls in their early menstrual
period. The following history is fairly typical of
such a condition.
"A normal, healthy girl, at the expected date of her
fourth menstrual period, suddenly developed a severe
pain in the lower right quadrant of the abdomen ac-
companied by signs of rapid, mild shock and faint-
ing. She rallied in a few hours. The pain, however,
became worse and the rigidity, tenderness and dis-
tention of the abdomen increased. Her temperature
114
Ovarian Hemorrhage — Bubis
[The American Physkiaa
was 101° F. He was consulted 24 hours after a
diagnosis of appendicitis had been made. Rectal ex-
amination demonstrated a tender doughy mass in the
right cul-de-dac, which in view of the patient's age
and history, induced him to make a diagnosis of
ovarian hemorrhage. Under expectant treatment she
made a complete recovery, and several months later
no pathology could be palpated.1'
Eti^Ugy
Willson (4) states that the sudden cessation of
menstruation from a "cold," accompanied by severe
pain, so common in young girls, is a cause of ova-
rian hemorrhage, chronic oophoritis following infec-
tions, sexual excitement, traumatism, hot douches or
baths at the menstrual period might be predisposing
factors.
PcdUfofy
Bovee" (3) states that there is no other organ in
the body which is so frequently the seat of hem-
orrhage as the ovary.
Increased connective tissue, which occurs in chronic
oophoritis following infection of the ovary, frequently
prevents the rupture of a Graafin follicle and
retains it as a cyst. This is illustrated by the follow-
ing case:
Mrs. 0., aet. 31 years, 1 para 2 years old, appeared
at the Out-patient Department of Mt. Sinai Hospital,
complaining of pains in the lower left abdomen for
the past three months, which was worse during the
menstrual period. She also suffered from constipation,
leucorrhea and sacral backache. General physical ex-
amination was negative. On bimanual examination the
cervix was found to be lacerated with the cervical
lips everted. This caused an endocervicitds with the
resultant leucorrhea and slight thickening of the
bases of the broad ligaments. The uterus was slightly
enlarged, in good position and freely movable. The
left ovary was about twice the normal size, tender,
prolapsed and adherent. The other adnexa seemed
negative. The operation consisted of a dilatation and
curettage, trachelorrhaphy, appendectomy for a
chronic appendicitis, and left oophorectomy for an
adherent enlarged ovary.
At the distal end of the ovary, a ruptured corpus
luteum was present; the cortex was thickened and
covered with adhesions. In the center of the ovary was
a thick-walled cyst, the size of a hickory nut, which
was filled with a dark brown blood clot."
Undoubtedly there is some intra-peritoneal bleed-
ing whenever the corpus luteum ruptures, but it is not
excessive, because the process is slow and not violent.
Nature, moreover, has time to prevent and protect the
excessive flow by sealing or covering the corpus lu-
teum with the fimbria of the tube. The increased
coagulability and exudation of peritoneal fluid may
also help to seal the torn capillaries.
Schumann (2) calls ovarian hemorrhage a func-
tional error, i. e., an excess of bleeding from the wall
of the mature Graafian follicle.
Wolf (5) divides ovarian hemorrhage into three
types (1), interstitial; (2), follicular; (3), intra-fol-
licular, in various combinations; while Savage (7),
states that the hemorrhage is either from the Graafian
follicle or from the corpus luteum.
Novak (7), states that primarily it begins as a
perifollicular type and that it then breaks into the
follicle. Microscopically, a proliferation of the nor-
mal perifollicular vessels with marked degenerative
arteritis was found by Schumann in his cases.
Schumann tersely sums up the symptoms and clini-
cal picture by stating that they are simply character-
istic of a sudden intraperitoneal hemorrhage, more or
less in amount, usually associated with acute pain in
one or both iliac fossae, although in a few cases, the
initial pain may be entirely absent Distress becomes
* apparent when the irritating effect of the free, blood
into the peritoneal cavity produces a dull, generalized
abdominal ache. There usually follows some abdom-
inal distention, elevation of temperature, moderate
leucocystosis, rectus rigidity, and, in the general, the
syndrome of the "acute abdomen." Recto- or vagino-
abdominal examination will show an enlarged tender
ovary or a tender doughy mass, due to the presence
of blood, adhesions and inflammatory reaction.
DmgmttM
Appendicitis, ruptured extra-uterine pregnancy,
acute salpingitis, ulcer of the intestine and ingestion
of poisons must be differentiated. Especially in the
case of a virgin, or a widow, or in a medico-legal case,
extra-uterine pregnancy must be ruled out by micros-
scopical examination. Bovee* found microscopical evi-
dence of pregnancy in 17 cases out of 29 examined,
while Caturani (8), found 85 in 100 cases. A correct
diagnosis is seldom made before operation or post
mortem. A thorough, pains-taking history, blood
count, recto- or vaginoabdominal examination will aid
in the diagnosis.
This depends on the early recognition of an "acuta
abdomen," and treating it as such. The patient, how-
ever, must be carefully watched, preferably in a hos-
pital where blood counts, etc., can be repeatedly done,
and if the condition does not materially improve with-
in a reasonable time, a laparotomy should be done.
If indicated, a blood transfusion will help to tide the
patient over the acute anemia and strengthen her
resistance to shock and infection.
Owe fiiii— i
1. Ovarian hemorrhages per sc are more
mon than is generally believed.
com-
Phila., February, 1922]
Acromegalia with Lymphatic Leukemia— Goldstein
115
2. This condition may occur at any time between
birth and the menopause, often at the early men-
strual periods.
3. An acute appendicitis or a raptured extra-uter-
ine pregnancy often simulates this accident.
4. A positive diagnosis cannot be made without a
microscopical examination.
5. Expectant treatment in a young girl, operative
interference in older ones and married women! will
probably give the best results.
Bibliography
L Sampson, J. A.: Arch, of Surg., iii; pg. 245,
September, 192L
2. Schumann, E. A. : J. A. M. A., pg. 692, August
27, 192L
3. Bovee\ J. W. : Surg. G yn. & Obst., xxviii, pg. 117,
February, 1919.
4. Willson, quoted by Bovee*.
5. Wolf, quoted by Schumann.
6. Novak, quoted by Schumann.
7. Savage, quoted by Schumann.
8. Caturani, quoted by Bovee\
An Interesting Case of Acromegaly and Lymphatic Leukemia
Observed over Period of Eleven Years
By Hyman L Goldstein, M.D.,
1425 Broadway, Camden, N. J.
Assistant Visiting Physician and Chief of the Medical
Clinic, Northwestern General Hospital, Philadel-
phia ; Assistant in Medicine, Graduate School
of Medicine, University of Pennsylvania,
Philadelphia
Simdied ThorwmgUy mi fr«t— f«W ta Jfctaif
Few diseases are as puzzling as acro-
megalia is. For some obscure reason, the
pituitary body S(goes wrong," becomes dis-
turbed, appears to overfunction, and the
skeletal tissues, like wild weeds, begin to
thicken, enlarge, grow and overgrow. Both
body anatomy and body physiology become
perverted, controUess, helpless and hopeless.
Dr. Goldstein's case of acromegalia, com-
plicated by lymphatic leukemia, studied
thoroughly and presented in detail, is illus-
trative, interesting and instructive. It is
one of the diseases rarely met and the paper
should attract unusual attention. — Thi
Editors.
MR. JACOB R. S., white adult male, aged (at
present) 43 years. Married. Wife and one
child living and well. Wife's first pregnancy resulted
in miscarriage. First saw this patient in 1911.
At that time he was an active barber and apparently
in good health with the exception of very slight
disturbances in vision and occasional headache. Past
history unimportant. Family history negative.
Father living and well. Now aged sixty-six years.
Mother just died (1921) from strangulated hernia.
Four brothers living and well — none dead. Two
sisters living and well. One little infant sister dead.
Patient has been married about sixteen years. His
only child, a girl of twelve, living and well, except that
for many years she has had frequent attacks of
epistaxis. Patient has weighed in the past few years
as much as 200 pounds. His present weight is 188
pounds. In 1900 he was a fairly tall, slender, nor-
mal man. Photograph at this age is here presented.
In 1911 his chief complaints were as above men-
tioned, those of slight disturbance in vision and slight
headaches. The history of the case during the next
few years was more or less that of progressing
acromegaly.
The first evidence of trouble that the patient noticed
was the fact that a ring worn* on the little finger
of the right hand became so tight that it had to be
cut off. Then he found that the cutting scissors he
was using in his work in the barber shop became
too small for his thumb and fingers. He then noticed
that he had to wear a larger hat, collar and shoes.
During 1913, 1914, and 1915 he had developed into
a typical acromegalic. His nose became large, his
lips became thick and prominent, his tongue became
broad and thick, his speech altered, the forehead
became prominent, especially above the eyes, the
lower jaw became very large, and his skin became
thick and slightly of a sub-icteroid tint. His hand
became spadelike and the fingers took on the shape
of sausages. At present his left wrist measures 7%
inches, his right wrist 7% inches in circumference;
from the right wrist to the tip of the middle finger,
8 inches. The right middle finger measures 4 inches
from the metacarpal head to the tip. The circum-
ference of the middle finger at the middle joint is
3% inches. The circumference of the hand around
the middle of the palm and back of the hand is 9
inches. And 8% inches around the middle joints of
116
Acromegalia with Lymphatic Leukemia — Goldstein
[The ^
ji Ph^Hdj
the four fingers kept close together represent a typical
large spade-like hand. The circumference of the
head over the posterior occipital protuberance and
above the superciliary ridges is 24% inches plus, size
of the collar, 16%. The chest across the nipples at rest
is 41% inches; circumference at the base of the
chest, 42% inches; circumference of the abdomen
over the umbilicus, 40% inches; circumference of
the trunk over the right shoulder and under the
right buttock, between the thighs, 64% inches. His
height is 69% inches. Inside leg measurement is
31% inches. Measurement from the vertex of his
head to the symphisis pubis is 38% inches; from the
symphisis pubis to the floor, 34% inches. In other
words, his torso is about 4 inches longer than his
leg measurement. The length of the foot is 11%
inches; circumference of left ankle, 10% inches;
width of the tongue, 2% inches; nose from the
bridge to the tip, 2% inches long. Measurement
from the tip of the third finger of the right hand
to the tip of the third finger of the left hand with
arms outstretched, is 71% inches. Length of right
arm is 30% inches; circumference of ear, S inches.
Mr. S. was admitted to Dr. Fraziera service at
the University Hospital on April 6, 1015. He was
there about a week. At this time urine analysis
showed 1.012 specific gravity, a few hyaline casts
present. No. R.B.C.'s, occasional W.B.C., acid re-
action, no sugar, no albumen, cylindroids present,
amount 1600 c.c. This specimen of urine was ex-
amined after the ingestion of 100 grams, no glucose.
Sugar tolerance test — after 100 grams, no glycosuria,
after 200 grams, specific gravity 1.012, no sugar,
amount 1.000 c.c. X-Ray examination by Dr. H. K.
Pancoast showed slight enlargement of the sella
turcica.
Blood— E.B.C. 4,780,000, W.B.C. 20,400. Hb.
85%. Polys. 67%. Lymphocytes 27%. Large monos,
4%, Eosinos. 2%. T. B. Holloway (April 18, 1916)
reported the eyes as negative.
On the 12th of April, 1915, he was discharged
from the University Hospital. This time I was
giving him thyroid extract tablets, one grain t.i.d.
May 4 1915— complains of increasing weakness in
the limbs, dizziness, and very giddy on "bending
over," and headache. May 17, 1915, complains of
a knocking noise in the head and back of the neck,
numbness of the fingers, slight cough. May 26, 1915,
fingers become blanched and cold "like a dead man's
ringers." Pain in the nape of the neck still com-
plained of. June 26, 1915, headache, tires quickly,
dizzy on bending over, pain across the eyes.
January, 1917, right turbinate congested and
swollen, septal deflection; except for a slight cold
in the bead, be feels pretty good. During 1916 and
1917, he complains of disturbances of vision, noises
in the ear, particularly on lying down, and pains in
the knees. He also has an uncomfortable sensation
in the eyes, some hoarseness.
July 8, 1916, eyes examined by Carl Williams,
University Hospital, showed retinal veins rather full,
other conditions normal. No evidences of increased
pressure. During this time he was taking pituitary
extract 3 grains and thyroid extract 1 grain in
capsule two or three times a day.
October 20, 1916, no changes in the condition of
the patient were noted. Pressure symptoms were
very Blight. He complained of lack of ambition,
getting tired quickly, and some uncomfortable pain
and sensation across the forehead and between the
temples.
In May, 1918, he was referred by me to Dr. Thomas
B. Futcher, Baltimore, who kindly admitted him to
his service at the Johns Hopkins Hospital. He
was at this hospital from May 20, 1918, to May 28,
1918. His complaints at this time were headache,
numbness and peculiar sensations in the hands and
feet, numbness of the fingers and appearance
of dead-white blanching "spasms" resembling a dead
man's fingers. At this time the blood examinations
showed R.B.C. 3,752,000, W.B.C. 26,280, Hb. 7895..
The differential count showed very interesting
changes. The polymorphonuclears were reduced to
38%, and the small lymphocytes were increased to
No. 1 — Putlcnt in normal health.
50.3%. Subsequent leucocyte counts continued to
show a rather marked lymphocytosis for which at
this time there was no definite explanation. Dr.
Futcher stated that the differential count in his
experience was unusual in acromegaly. His blood
pressure was low, systolic 110, diastolic 70. This
is contrary to findings in some of the more ad-
Phila-. February. 1932}
Acromegalia with Lymphatic Leukemia — Goldstein
vanced cases where the patients not infrequently
have signs of arterial sclerosis with some increase in
blood pressure. Roentgenograms of the skull and
skeleton by Dr. Pearson showed (a) head — large
sella with marked protraction of the lower jaw —
acromegaly; (b) hand — changes usually associated
with acromegaly.
5af*r 7W«n« Tat
The patient showed no spontaneous glycosuria,
bat as is our regular custom we always carry out
a Sugar Tolerance Test by giving 100 grams of
made patient showed a lowering of his carbohydrate
tolerance, as a normal individual takes 100 grains
of glucose without sugar appearing in the urine.
This test would tend to indicate the patient was
still in the hyperpituitarism stage of acromegaly,
when the sugar tolerance is lowered. In the later
stages, in hypopituitarism, we usually find that the
tolerance for carbohydrates ia markedly increased;
this accounts for the increase in the amount of sub-
cutaneous fat that we get at this later stage of the
disease.
glucose in solution in the morning, on a fasting
stomach, and then take the specific gravity and
examine each separate voiding during the day of
the test for the presence of sugar. The first specimen
voided after the glucose was given showed a faint
reaction for glucose. The specific gravity of this
specimen was 1.020. The specific gravity of the
specimen voided before the test was 1.011. The
result of this test was that at the time that it was
ExtMimtnn .1 VumI FUUt
There was some general contraction of the fields
for all colors, but there was no hemianoposia such
as one sees in more advanced cases, with "neighbor-
hood symptoms" of pressure.
In a letter to me Dr. Futcher stated: That
he and Dr. Dandy examined the patient, that he
thought probably the' condition present was teratoma
of the pituitary; that the posterior clinoid processes
118
Acromegalia with Lymphatic Leukemia — Goldstein
[The American Physician
were broken off; that he thought the patient was
now in the stage (1918) of hypopituitarism and
advised the use of posterior pituitary extract; that
he has an increased tolerance for carbohydrates and
that he advised against hypophysectomy, at present,
and that secondary anemia was present.
For a period of four or five years or more, or
until about two and a half years ago, the patient
had lost his sexual power and had no sexual desire.
During the past two years his sexual desire and
sexual function has returned to normal, the same
as it was before he became ill.
Early in 1920 I first noticed some general glandu-
lar enlargement. The spleen at this time was pal-
pably enlarged. October 10, 1920, there was marked
general lymphomegaly and the spleen was very much
enlarged, extending almost to the midline at about
2% inches below the costal margin. He complained
of pain in the right anterior chest, shortness of
breath, weakness and excessive sweating. He had
complained of sweating and some headache for
several months previously, that is, during the entire
summer of 1919. His blood pressure has always
continued to be low, varying from 105 to 110 systolic,
diastolic 80. He presented no ocular symptoms and
no headache in October and none since then. Jan-
uary 13, 1921, examination of his eyes by Dr. de
Schweinitz at the University Hospital, showed no
ocular trouble. He has had no deficiency of central
vision and his visual field was full. (No hemian-
opsia.) His pupils were unequal but reacted to
light and accommodation. There was no atrophy
of the discs. Repeated blood Wassermans have been
negative.
February 2, 1921. He used to wear VA shoes.
Now wears the widest 10-E. Used to wear a 15-size
collar, now wears 16^. Hat is now 7*4 inches,
formerly the proper size of his hat was 6%. He
now tells me that at the time that he first became
sick, he began to notice pricking and sticking sen-
sations over the forehead and became nauseated and
vomited for about two years, aggravated when riding
in a trolley car. However, he does not have this
trouble at present and has not had it for a number
of years. At present he has no headache and no
ocular symptoms. He has a large pad of fat at
the base of the right chest, in the axillary line. The
lymphomegaly is quite marked. He has a huge chest
of the emphysematous type, and fluoroscopic exam-
ination shows marked emphysema and huge posterior
mediastinal glands.
February 5, 1921. Blood examination by Dr. .
Herbert Fox, Pepper Clinical Laboratory, University
Hospital, reports Polys., .66%. Young small lmpho-
cytes, 9.66%. Small lymphocytes, 78.66%. Large
lymphocytes 2%. Transitionals none. Basophiles
none. Large mononuclears 2%. Unrecognized 6.66%.
Very many pink masses which may have been cells
or bits of dots are seen. The masses called un-
recognized cells had some form which the other did
not have. There was considerable anisocytosis. No
nucleated cells seen.
February 7, 1921. Blood examination by Dr. A.
I. Ruben stone, Mt. Sinai Hospital, Philadelphia,
showed hemoglobin 80% (Sahli). R.B.C. 4,240,000.
W.B.C. 85,800. Polys. 1%. Small lymphocytes 97%.
Large monos. 2%. Many degenerated white blood
cells present. Some anisocytosis. Blood Wasserman
negative. Blood sugar 0.23%. One week later white
blood count showed 100,800, Polys. 4%, small
lymphocytes 96%. Many degenerated white blood
cells, blood platelets 100,000. Blood chemistry —
blood urea .018%, blood urea nitrogen .008%, blood
sugar .023%. Urine analysis, morning specimen —
S.G. 1.009 acid reaction, faint trace of indican,
albumen, sugar, acetone, negative, occasional W.B.C,
occasional epithelial cells, some amorphous urates.
Night specimen, S.G. 1.017, acid reaction, albumin,
sugar, acetone, indican absent, some amorphous
urates, no casts.
February 22, 1921. Urine S.G. 1.014, albumin,
bile pigments, sugar, casts, all absent Occasional
mucous threads and a few leucocytes and squamous
cells present.
March 1, 192L Blood examination by Miss E.
A. Healy. R.B.C. 3,500,000, W.B.C. 89,000. Hb.
70%. Color index 1%. Differential count, polys.
4%. Degenerated lymphocytes 22%. Small lympho-
cytes 70.8%. Large lymphocytes 3.6%. Transitional
0.4%, Eosinophils 0.2%.
X-Ray Examimttipn
Dr. Mulford K. Fisher, roentgenologist, Philadel-
phia, examined this patient very carefully, making
complete X-Ray films of the skull, chest, hands, feet,
and teeth. Fluoroscopic examination of the chest
showed enlargement of the ribs and emphysema.
The heart shadow was normal or rather small com-
pared to the size of the patient. Huge posterior
mediastinal glands were evident, resembling a huge
aneurism back of the heart.
Patient's large size of hand now is very striking.
The whole hand is greatly widened, much thicker
than normal, and the fingers are wide and typical
sausage-like in appearance.
As soon as one looks at him, the attention is at-
tracted to the enlargement of the face and head,
particularly the marked prognathism, enlarged nose,
prominent molar bones and large thick lips. The
distinct evidence of thickening and enlargement of
the frontal bone is clearly demonstrated — the marked
protuberances over each eye due to the enlargement
of the orbital arches and frontal sinuses are plainly
seen. Slight kyphosis is present. The bones of the
Phil*., February, 1922]
Acromegalia witk Lympkatfc Leokeaia — Goldstein
119
pelvic girdle and long bones of the extremities, as
well as those of the shoulder girdle, do not seem to
be especially involved, but are still larger than normal.
It appears that the entire skeleton is symmetrically
enlarged, while the face, hands, and feet show dis-
proportionate enlargement, the eyes show nothing
especially abnormal. Hearing is normal. Speech
is a little thick, slow, and heavy. This is probably
due to the marked enlargement of the tongue, prog-
nathism, enlarged tonsils (huge), and pressure on
recurrent laryngeal nerve, and "acromegaly" of the
larynx.
Physical examination of the chest shows a heart
of about normal size but a distinct emphysematous
chest and evidence of marked enlargement of the
posterior mediastinal nodes. Fluoroscopic examina-
tion of the chest shows beautifully the emphysema
and enlarged glands. The ribs are huge in size,
with distinct evidence of increase in compact bone.
Patient, at present at least, shows no pressure symp-
toms. His appetite is very good. Further detailed
description of my case is really unnecessary. The
photographs taken before the beginning of his illness,
and after the condition became advanced, speak for
themselves.
March 4, 1921. Dr. Leon Jonas, of the Pepper
Clinical Laboratory of the University of Pennsyl-
vania, reported to me that the metabolic rate of
patient was 20% above normal Another estimation
of the basal metabolism was done in October, 1921.
The early symptoms of acromegaly are generally
those related to the osseous structure characterized
by little change in the shape of the nose, and general
prognathism characterized by a more massive ap-
pearance of the lower jaw, with separation of the
teeth and broadening of the fingers. There may be
headache. These, of course, are due to the tumor
or change which involves the anterior lobe of the pit-
uitary. The earlier symptoms of hypopituitary stage
of acromegaly manifest themselves by increase in the
amount of adipose tissue, owing to the increased
tolerance for carbohydrates. This results from pres-
sure of the tumor of the anterior lobe pressing on
the posterior lobe, interfering with the hormone
there produced, and which has a bearing on carbo-
hydrate metabolism. In the early stages, the pres-
sure simply irritates the posterior lobe and spon-
taneous glycosuria may result.
On March 7, 1921, the patient was admitted to
Dr. Alfred Stengel's service, University Hospital.
Here he was seen and studied by Doctors 0. H. P.
Pepper, R. Kern, and Ford.
March 8, 1921. Blood. R.B.C. 3,420,000; W.B.C.
82,000. Hb. 80%. Differential— Neut. 3%, Lymphs.
95%, L.M. 1%, and myelocyte 1%.
Urine. 1.021; faint trace albumin. Occasional
hyaline cast. No sugar.
March 10, 1921. Eye examination by Dr. Hollo-
way (University Hospital). No ocular palsies. Pu-
pils equal, rather small, react but moderately to
light, accommodation and convergence. Discs nearly
round, not atrophied, no changes characteristic on
retina. Dr. Holloway has seen him off and on since
March 22, 1915, and has never found any evidence
of intraocular changes. Before referring him to the
University Hospital, I did a phenolsulphonphthalein
renal function test — (February 27, 1921) (intramus-
cular), which showed 25% first hour, 25% second
hour, 50% total for two hours.
On February 28, 1921, a lymph gland removed
from the left axilla, and examined by Dr. Herbert
Fox, Pepper Clinical Laboratory, University of Penn-
sylvania, showed leukemic hyperplasia.
March 10, 1921. Blood sugar: Fasting— .091% ;
one hour after taking glucose .142%, two hours after
glucose .1%, three hours after glucose .105%.
Urine: No sugar (negative glucose tests). Few
hyaline and granular casts (5-10) ; 1.015 S.G., trace
of albumin, trace of mucus, no R.B.C, few cylin-
droids; acid reaction.
Qmttlnn W fa* itafocyfom
Now it is interesting to note that a study of the
blood during 1915 and 1916, showed a nearly normal
picture— of about 4,800,000 R.B.C, W.B.C. 12,000,
hemoglobin 80-90%. Polys. 67%. Lymphs. 27%.
Large monos. 4%. Eosins. 2%. The white blood cells,
however, even at this early period showed a tendency
to a distinct increase up to 20,000. The W.B.C
count while at the University Hospital in 1915 being
as high as 20,000, although the differential count
was apparently normal in all respects. The question
arises, was this leucocytosis the beginning of a leu-
kimic change, an early transition stage, or was it
due to some focal infection, or the pituitary
pathology. In 1918, while at the Johns Hopkins
Hospital, the blood picture had changed considerably,
but no definite explanation could at that time be
given. The blood examinations then showed R.B.C
3,750,000, W.B.C. 26,000, Hb. 78%. The differential
count showed a marked reduction in the poly-
morphonuclears to 35% and a distinct increase in
the small lymphocytes to over 50%. For an un-
complicated acromegaly this is an unusual blood
picture. Was this, then, a beginning of the leukemia
(without evidence of lymphomegaly and spleno-
megaly)? I do not know — possibly this may have
been the explanation of the blood changes that were
noted by Dr. Futcher in 1918, in his careful study
of the case. During the past ten or twelve months,
the marked changes in the blood pictures — with a
white count varying from 80,000 to 115,000 and a
lymphocytic percentage of 90-97% — and the huge
spleen and lymphomegaly left no room for doubt
120
Acromegalia with Lymphatic Leukemia — Goldstein
[The American Physician
that this was a case of leukemia in an acromegalic
(advanced). Whether there is more than a mere
coincidental association between the two conditions
in this case, I am not prepared to state.
March 11, 1921. X-Ray examination of teeth by
Dr. H. K. Pancoast showed abscess of right lower,
second (anterior) molar, left upper second bicuspid,
right upper first molar suspicious. Pyorrhea. March
12, 1921. Basal Metabolism study was made by Dr.
Leon Jonas in the Pepper Clinical Laboratory and
showed 4.4% above normal (up to 10 above and
down to 10 below normal is considered without
much significance and given as a normal estimation
of the basal rate).
Jaccoud's dissociated fever sign and (fever with
a slow, irregular pulse in T. B. meningitis of adults)
Pel-Ebstein's fever sign are absent.
Lymph node examination, by Dr. Herbert Fox,
Philadelphia. Section cannot be recognized as lymph
node. Well encapsulated by a firm acellular cap-
sule. Marginal sinus either pressed shut or occupied
by lymph cells, section is made up of a fairly even
distribution of adult lymph cells and small blood ves-
sels with a small amount of fibrous tissue around them.
Gross trabecular, follicles, cords and sinuses are
absent. Lymphoid cell is only one present in the
cell mass proper. No fibrin, tubercles or pigment
present. Fibrocellular connective tissue absent.
Leukemic hyperplasia of lymph node.
March 11, 1921. Blood— Oxidase stain: W.B.C.
85,000. Differential— Polys. 5%; Lymphs. 94%;
Myelocyte 1%. Blood Wasserman-test-negative. No
glycosuria after sugar tests. (153 gms. of glucose.)
Weight, 188 pounds. Twenty-four-hour specimens
of urine tested for sugar gave negative results for
one week.
March 16, 17, 18 — received X-Ray treatments
over the long bones (femur and tibia) of both legs.
March 16, 1921. Dr. H. K. Pancoast, roentgenol-
ogist, University Hospital, Philadelphia, reports
marked enlargement of the mediastinal glands. Dr.
Pancoast states that this patient presents more
mediastinal involvement than any other case of lym-
phatic leukemia he has ever seen.
March 17, 1921. Blood : R.B.C. 4,880,000 ; W.B.C.
116,000. Differential— lymphocytes 96%. Neutro-
phils 4%. Hemoglobin 90%. Patient feels comfort-
able. Appetite good.
January 4, 1922. Blood Count: W.B.C. 27,000;
Large degenerated lymphocytes 78% ; Large lympho-
cytes 9% ; Small lymphocytes 7%. Polys. 6%.
Mr. S. was admitted to the Jefferson Hospital,
Philadelphia, in Dr. Stewart's service November 17,
1913, and discharged December 9, 1913. He com-
plained of cold hands and feet, and severe pain in
his hands. Enlargement of hands and nose were
noticed by his wife. She stated "his nose was get-
ting larger and larger." General examination was
negative, except for the acromegalic changes. Heart
and lungs, negative. Slight separation of lower
teeth in neighborhood of right lower canine. No
separation of upper teeth.
November 19, 1913. Urine: clear. Acid. Very
faint trace albumin. No sugar. Urea 1.6%. No
crystals; few amorphous urates; few epithelial cells;
pus 30-40 to field; no R.B.C, no tube casts. The
above notes were taken from the charts (D. 2956,
Medical Histories, J. M. C. H.) of the Jefferson Hos-
pital.
No. 14297 Roentgenogram of skull, showed true
acromegaly, selle turcica is % inch long and % inch
deep. Posterior clinoid processes somewhat atrophied.
November 29, 1913. Eye Report: The vision
=20 — 30. The pupils react to light convergence.
The tension is normal. Ocular movements are un-
impaired. Ophthalmoscopic examination is negative.
(J. C. Knife, M.D.)
Laryngological Report. November 29, 1913. Pa-
tient has deflected septum and large submerged
tonsils, which are operative (Dr. B. Kyle). Tempera-
ture was somewhat subnormal getting down to 96.2°,
and hovering between 96.2° and 98°. On two or
three occasions the temperature reached normal or
very slightly above. Respiration rate varied be-
tween 22 and 24 per minute. It is interesting to
note that while the temperature ran a subnormal
curve, the respiration rate was slightly above normal
Urine voided— 800-900 c.c.
Dr. Philip Hawk did metabolic test during No-
vember 26, 1913, to November 30, 1913: He was
given Thyroid Extract gr. Ill t.i.d. at the time of
his discharge.
His second admission to the Jefferson Hospital
occurred on April 20, 1914, and he was discharged
May 2, 1914. He was at this time put in Dr. Solomon
Solis-Cohen's service.
Chart No. D. 5918, May 20, 1914. Examination
shows pupils react normally. lips thick and pro-
truding, chin prominent. Upper and lower incisors
separated. Mouth clean. Thorax normal. Heart
and lungs normal. Spleen not felt. Liver not palpa-
ble. Blood culture (April 25, 1914), negative
Temperature curve was down to 96° and running
between 96° and 98° F. Respiration rate at 24
per minute. Pulse 110-120. At this time he was
voiding urine in fairly large quantities: 900, 1350,
1700, 1100, 1450, 1300, 1950, 2200, 2800, and
1900 c.c.
Chart E, 5574. Third admission to Jefferson Hos-
pital on March 15, 1915; discharged March 20, 1915.
In Dr. Francis T. Stewart's service. History notes
state that in 1911 he felt his Angers becoming numb
and had difficulty in tying string and using scissors
and razor. A small ring on finger had to be filed
Phfla^ February, 1922]
Acromegalia with Lymphatic Leukemia — Goldstein
121
off. His head was getting larger. In February,
1915, he began to have headache (occipital). Gen-
eral weakness complained of and gets tired quickly.
Somewhat hoarse. No sexual desire.
Measurements of head: Occipitofrontal, 19 cm.;
sub-occipito-bregmatic, 17 cm.; maximum of heady
28 em.; bi-temporal, 13 cm.; bi-parietal, 15 cm.; bi-
mastoid, 14 cm.; fronte-mental, 14 cm. Nose:
Nasal cavity enlarged. Deflected septum to left
side. Throat and mouth: Lips thick. Tongue large,
broad and long. Teeth separated. Epiglottis very
large and "beefy." Arytenoids very thick. All tissue
around them thickened. Dr. Kyle believes the im-
pairment of the voice is entirely due to a mechanical
interference by the overgrowth of new tissue.
Eyes: November 10, 1913. O.D. media and
punctae negative, March 8, 1915. Marked concen-
tric contraction of both fields.
Spleen and liver: Normal — not palpable.
Urine: March 16, 1915. Clear amber. S.G. 1.010.
Acid. No albumin. No sugar. Urea 1%. No R.B.C.
No casts. Blood Wasserman March 17, 1915, nega-
tive. Roentgenogram No. 19911, two plates. March
16, 1915. Sella turcica is considerably enlarged.
Clinoid processes are very prominent. Typical acro-
megalia. Temperature 97-98.4° F. Pulse 90. Respira-
tion 20-24. Urine : 600, 1050, 2000, 1700, 1000 c.c
Dr. D. N. Husik, of Philadelphia, made an ex-
amination of the nose and throat on March 25, 192L
His report is as follows:
Nose shows deflected septum towards the left
showing the lower right side of the nasal fossa
as a large cavity, the middle turbinate on the
same side is very much hypertrophied. The
faucial tonsils are hypertrophied but clinically
look healthy. There is a large lingual tonsil at
the base of the tongue. Examination of the
larynx shows enlarged and thickened epiglottis.
The two vocal cords are very much thickened
and pinkish in appearance, the right cord being
more injected than the left. The right false
chord is more enlarged than the left and over-
laps the true cord. The arytenoids and ary-
epiglotic folds are both slightly hypertrophied.
His hoarseness is due to the increased thickness
and chronic inflammatory condition of the true
cords and not to an actual mechanical inter-
ference.
Dr. A. J. Casselman reported a differential count
March 5, 1921, as follows: Small lymphocytes
76.6%, degenerated broken cells 14%, polymorph,
leucocytes 6%, myelocytes 1%, large lymphs. 2%,
eosinophiles 0.2%, transitionals 0.2%.
Dr. David Riesman recently had a case of acro-
megaly in a negro at the Philadelphia General Hos-
pital. (John Davis, Autopsy No. 5645, October 27,
1920.) Autopsy performed by Dr. Crawford. The
patient was a colored man aged 43 years, admitted
to the hospital October 25, 1920, died the next day
from catarrhal (lobular) pneumonia and acute myo-
carditis. Culture of heart blood — streptococcus
viridans.
Pituitary showed a tumor composed of cells of
anterior lobe origin — of edematous type. Adenoma.
Chronic luetic meningitis. Brain weighed 1350 gms.
— was examined by Dr. Winkelman. The pituitary
was markedly enlarged, cystic, and the size of a
small plum, and was distinctly adherent to the floor
and sides of the sella and had to be dissected away.
The pituitary fossa was distinctly shallow and much
widened. When the pituitary was removed it was
found that it had flattened the optic commissure to the
thickness of paper. Patient weighed 250 pounds. Head
25" in circumference; eyes prominent; tongue large.
Height 5'9". Large prominent cheek bones. Lips
are very thick. Lower jaw rather large with promi-
nent chin. Chest is very large. Hands and feet
acromegalic.
Roy, Woods Hutchinson, Schutte, Jeffroy, Caselli,
Dana, Bramwell, Bassoe, Matignone, and the autop-
sies performed by Buday and Jamesco and others,
also demonstrated the ' intimate relationship exist-
ing between these two conditions. Finally, Brissaud
and H. Meigs state that acromegaly and gigantism
are one and the same disease. If the bony over-
growth occurs in adolescence and youth, the result
is gigantism and not acromegaly. If the overgrowth
occurs later on, acromegaly results in combination
with gigantism. In other words, "gigantism is the
acromegaly of the growing period; acromegaly is
the gigantism of the period of completed develop-
ment" Launois and Cesbrow distinguish between
the infantile giant and the acromegalic giant.
Gemini C«uuf«ratt •**
In acromegaly, an interesting question arises as to
whether there is perversion or abeyance of pituitary
function. The fact that the gland is enlarged, even
of hyperplastic or adenomatous character, does not
prove that there must be hypersecretion or hyper-
activity. Similar evidences occur in cases of myx-
edema and cretinism. Louis Comte (Ziegler's Beitrage,
1898), concludes from the examination of over 100
miscellaneous cases that the pituitary and thryroid
act vicariously. Some authors have reported in-
creased activity of the pituitary after excision of
the thyroid, and pathological observations point to
the same conclusion. Boyce and Beadlea (Jour, of
Path. March, 1892) described pituitary overgrowth
in two cases of myxedema. Boyce and Beadles also
include an example of cretinism in which, in con-
firmation of the previous observation of Niepce
("Goitre et Cr^tinisme," Paris, 1851), and one of
Bourneville and Bricon (Archiv. de Neurologic,
122
Acromegalia with Lymphatic Leukemia — Goldstein
[The American Physician
1886), they found the pituitary enlarged.
In pregnancy, and during menstruation, both the
thyroid and the pituitary undergo a temporary en-
largement, and may even give rise to some visual
disturbances. Maximilian Sternberg (Speciele
Path, and Therap. Band, vii, Thiel 2, 1897), has
shown how various are the pituitary lesions that
may be associated with acromegaly. Shattuck con-
cludes that the problem of acromegaly shows the
importance which attaches to the altered physiology
of affected pituitary and that "it has passed into
the domain of chemical physiology."
The absence of symptoms that have been noticed
by observers in cases of tuberculous and syphilitic
disease, or of certain benign or malignant tumors
of the pituitary, is due to the fact that none of
these lesions are necessarily so destructive of the
gland tissue as to entail a complete abeyance or
perversion of its function, any more than they are
in the case of the thyroid. (Shattuck.)
Comrte $mi Dwrmtion
The onset of the disease may be delayed or it can
be precocious, and we may have acromegaly in
children, or in adolescents. Beaver Blake reported
a case in a young negro; Valdes-Surmont reported
a case in which the first stigmata appeared at four-
teen years. Virchow (1889) saw a case in a girl
aged eleven years. Moncorvo reported a case he
had seen in a girl fourteen months old. (He does
not believe this to be a congenital case.) With the
exception of the twelve or fifteen cases of acute
acromegaly on record (sarcoma or carcinoma of the
pituitary, prehypophysis), the duration of the dis-
ease varies from eight to thirty years. In malignant
cases life has been destroyed in three or four years.
Established acromegaly is usually seen in adult
males or females. The initial dystrophic phenomena
appears at the age of 18 to 28 years. In my case,
the ring on the little finger became too small, and had
to be cut off, the scissors handle, which he used in
his work as a barber, became much too small, then he
had to buy a larger sized hat, shoes and collar. The
first thing noticed was the ring on the little finger,
which became tight. Later he had some vague pains
in the head and peculiar sensations in the hands. Oft-
times it is the headache which brings the patient to
the doctor. Others, as in my case, notice their hands
and feet grow larger. In women, the menstruation
may become irregular or cease altogether, as the first
symptom. Launois and Cesbron believe that acromeg-
aly is more frequent in women than in men.
The bilateral enlargement of the extremities and
the enlarged head and face are characteristic. The
long, oval face, the macroglossia, prognathism, re-
verted and thickened lips, prominent malar bones, hy-
pertrophied nose, the prominent forehead (superfi-
cial ridges), the gigantic proportions of the body, the
humped back (in advance cases), the visual disturb-
ances, neuralgic pains, and paresthesia? in hands and
feet, the polyuria, hyperidrosis, polydipsia, somnolence,
weakness, diminution of sexual function, headaches,
and finally X-ray examination of the skull, and the
increased blood sugar and changes in the sugar tol-
erance test, which may be observed in certain cases,
all point to the diagnosis of acromegaly.
The condition is to be differentiated from pulmon-
ary hypertrophic osteo-arthropathy, Paget's disease
(osteitis deformans), localized acromegaly, arthritis
deformans, myxedema, Virchow's leontiasis ossea,
erythromelalgia, syringomyelia, adiposis dolorosa
(Dercum), stigmata of rickets and the lymphatic
diathesis, cretinism (from youthful acromegalia),
dystrophia adiposa-genitalis, Basedow's disease (sim-
ple gigantism) and tabes dorsalis (in the early stages
of acromegalia).
Ponfick, Huebner, and Gerhardt reported a case
of probable acromegalic gigantism in a child aged four
years. This is one of the youngest cases on record.
Thayer in his paper discusses acromegalia and hyper-
trophic osteo-arthropathy.
Harlow Brooks in his article on acromegalia of
221 pages, and an excellent review of the literature
from 1886 to 1898, reports three autopsies of cases
of acromegaly, one in a gigantic female, another in
a female aged thirty-seven years, and a third in a
man aged thirty years.
Prognosis $mi frcafausf
The prognosis, of course, is always bad. There
are no cases of complete recovery on record, although
one of Timme's (New York) cases, recovered after a
cyst ruptured. In many cases the progress of the
disease appears to have been arrested. In other cases,
there is an absence of symptoms to a remarkable de-
gree. In my case, there is at present no headache, and
no visual disturbances; eyegrounds are normal, al-
though the sella-turcica is enormously enlarged. His
sexual power has returned to normal, and has been so
for the last two years, after being impotent for a
period of four or five years.- He even questioned the
advisability of his wife having another child, and
wished to know whether he would transmit any
hereditary taint to his offspring should his wife be-
come pregnant.
Direct hereditary transmission has been observed
by Cyon, Bonardi, Schwoner, and Frankel and a
few others. Friedrich claims to have observed the
stigmata of acromegaly in brothers. Schaffer re-
ported a case of transmission from mother to
daughter.
The treatment is chiefly symptomatic. X-ray
treatment over the pituitary body may be tried.
Operation followed by radium treatment may be
Phil*., February, 1922]
Acromegalia witk Lymphatic Lsmkemia— Goldstein
123
advisable in some cases for the relief of severe pres-
sure symptoms of a serious character. The adminis-
tration of pituitary extract with or without thyroid
extract, or thyroxin and tethelin may be considered.
The use of a capsule containing ergotin gr. i,
arsenic 1/25 or 1/30 gr. and quinin. hydrobromate,
grains v, three times a day, has been recommended
by Sajous and others. In case of impotence and
associated hypogenitalism suprarenal cortex may be
given in doses of one or two grains of the extract
three times a day.
1. A case of acromegaly with lymphatic leukemia
that has been under observation for over ten years,
is reported by the author.
2. The unusual features of the case are the ab-
sence of pressure symptoms or "neighborhood symp-
toms," the loss of sexual power, for a period of six
years or more, followed recently, for the past two
and a half years, by a return of all sexual power,
desire, and function; the occurrence of lymphatic
leukemia, with splenomegaly and lymphomegaly for
the past sixteen months.
3. Improvement followed Roentgen-ray treat-
ment to the spleen, lymph glands, pituitary and long
bones.
4. No other case of acromegaly has been found
recorded in the literature, associated with leukemia,
and such large sella turcica and without ocular dis-
turbances, or any pathological changes in the eye-
grounds, and with a normal basal metabolic rate.
Review of the Literature will appear next month.
REFERENCES AND BIBLIOGRAPHY
1. Hinsdale, G. 441; 529; €27; 724; 813. 1898. IV.
Medicine, Detroit.
2. Bartfett, P. K.: Arch. In* Med., 1918, XII, 201-218.
3. Brooks, H.: Arch. Neurol, and Psycho-Path., Utica, 1898,
L 485-678.
4. Marie. P.: Rev. de Med., Park, 1886, VI. 297-833,
N. Soonogr. de la Saltpetriere, 1888, I. 173; and 1889, IL 45,
96, 139. 188. 224, 227; Proffres. Mad., 1889, 2s.. IX, III.
1579; Lecons de Cliniqne Medicale, Park, 1896, p. 51; Bull.
Med., 1889, III, 1579; Brain. London, 1889, XII, 59; Boll,
et mem. de la Soc des Hop., May 1. 1896 (Hands in Aero-
).
5. Marie, P., and Sottsa-Lelte : Essays on Acromegaly; with
Bibliography. London, 1891.
6. Marie, and Marinesco: Archiv. de Med. Experiment et
d'anat Path., 1891, p. 589.
7. Index Catalogue of the Library of the Surgeon General's
Office (U. 8. Army), Third Berks, Vol. I, 1918, pp. 145-152.
8. RoUeston, H. D. : Acute Acromegaly (sarcoma). Trans.
Path. Soc'ty of London, XLIX. pp. 237-242, 1898.
9. Caepai, K.: Deutsch. Arch. f. Klin. Med.; 1914, CXVL
461.
10. Finlayson, J.: A Case of Acromegaly Photographed
In 1886, before Marie's paper appeared; Intern. Clin. Phil.,
m, p. 109, 1896.
11. 8tarr: Acromegaly; J. Nerv. and Ment. Dk. XXVI,
p. 117, 1899.
12. Paget, S.: Acromegaly; Lancet, Lond., I, p. 289, 1895.
13. Lereboullet, M.: Acromegaly and Diabetes, Progres.
Med. 35-106, March 6, 1920.
14. Webster, J. H. D. : Roentgen Ray Treatment of Acro-
megaly; Arch. Radiol, and Electroth. 24; 261, Jan., 1920.
15. Octane, C. : Acromegaly-like Diseases in family with
chief involvement of bones of extremities; Deutsche Med.
Wchnsehr. XLV, 207, Feb. 20, 1919.
16. Howard, C. P.: Functional Dkgnosk of Polyglandular
Disease in Acromegaly. Am. J. M. Sc 168 ; 830, Dec, 1919.
17. Leva: Familial Acromegaly. Deutsche Med. Wchnsehr.
1914, XL. 929, Med. Klin., Berlin, 1915, XI, 1266-1268.
18. William Engelbach (St. Louis) : Classification of Dis-
orders of the Hypophysk; Endocrinology — July-Sept.. 1920, IV,
No. 2, pp. 847-365.
19. Engelbach and J. L. Tkrney: Pituitary Polyuria;
Internet. Clinics, IV, series 30, 1920.
20. Lowenberg, 8. A.: Acute Acromegaly; Internet Clinics,
m, series 28, 1918.
A Thorough History an Important Factor
in Syphilis
Author's Abstract.
The introduction of the Wassermann reaction as a
means of diagnosing the presence of syphilis made
many physicians feel that it was no longer necessary
to take the trouble to obtain a thorough personal
history for the patient under examination. There-
fore, since 1906, when the Wassermann test first came
into general use, the obtaining of an accurate history
has been given less and less attention.
The author believes neglect to get an accurate and
complete history is a very serious oversight and that
implicit dependence on "the Wassermann" very often
leads to grave errors in diagnosis, and that these may
extend not only to the management of the case but
also to serious imputations upon the moral character
of perfectly innocent persons. He cites several cases
of his own where dependence upon serum reaction
alone would have led to very serious blunders, and
believes that such incidents must be common in the
practice of others, whether specialists or general
practitioners.
The examining physician must use tact and dis-*
cretion in obtaining the history, but he must be firm
and insist upon getting full details, impressing upon
the patient the importance of "making a dean breast
of it," in order that complete and rapid cure may be
effected. The physician's attitude must be always
one of scientific detachment, and moral and social
considerations banished from the patient's mind as
far as possible. If a patient refuses to give the
necessary facts the wise practitioner will be justified
in refusing to treat the case. — C. J. Broeman in
American Journal of Syphilis, 5:565, October, 1921.
Formaldehyd Test for Syphilis
The value of this test lies in its simplicity. Blood is
drawn in the usual manner as for a Wassermann test.
At the end of twenty-four hours the serum is decanted
from the test tube into another clean but not sterilized
test tube; a drop of ordinary commercial liquor formal-
dehyd is added, and the tube plugged with cottonwool.
The serum and formaldehyd are allowed to remain at
ordinary room temperature for twenty-four hours. At
the end of this period observation is made as to the
condition of the serum. Coagulated serum is a positive
result ; fluid serum is a negative result. Suff ern endorses
the method as being of value.—/. A. M. A., from Lon-
ret, November 26, 1921.
Doctor Mackenzie Forbes' Post-Graduate Diagnostic Clinics
A Series of Thirty Clinics Emphasizing Diagnosis thai Should he Most Helpful to the General Practitioner
By A. Mackenzie Forbes, M.D., 615 University St., Montreal* Canada
Twenty-third Clinic
A Case Illustrating a Method for
The Radical Cure of Varicose Veins
THE PATIENT, Miss D., whom I wish to pre-
sent to you as one suffering from varicose veins,
has been affected with a progressing enlargement of
the veins of both lower extremities for some years.
I have chosen the subject of varicose veins for
discussion today because my attention was most
forcibly drawn to this condition during the war.
First at Val Cartier, then on Salisbury Plains, then
in France and, lastly, when conscription was being
enforced in Canada I was impressed with the number
of young men who were suffering from this condi-
tion. Men who, apparently, were otherwise per-
fectly normal were unfit to serve the King. I saw
and shared in many operations performed to relieve
this condition and I saw many patients debarred
from military service because of it. For this reason
I heard with very great interest of the work of Dr.
John Homans, of Boston, on a day on which I hap-
pened to pass through a clinic being given at the
Montreal General Hospital by my colleague, Dr. E.
M. Eberts.
With avidity, then, I sought the publications of
Dr. Homans (Surg. Gyn. and Obs., 1916) and after
studying these arranged to visit his clinic in Boston
with the hope that I might learn enough to be
prepared to do my part in making of service some
of those who were unable to take their part in the
Great Struggle.
Gentlemen, may I then draw your attention to Dr.
Homans' observations quoting verbatim as far as
possible extracts from his publications.
The veins of the legs are divided into two sys-
tems: The deep, among the muscles and well sup-
ported by them, and the superficial, lying in the sub-
cutaneous tissues, and supported only by skin, super-
ficial fascia, and fat. Of these two systems the
former is considerably the more capacious and ob-
viously the less liable to disability, while the latter,
though it probably carries much less blood, is more
exposed to trauma and derives far less support
from the tissues outside its own vein walls. The two
communicate by what are called perforating or com-
municating vessels, in which the valves are so set
that blood can normally flow only from the surface
veins to the deep. These perforating vessels, which*
vary considerably in number and distribution, offer,
therefore, a safety valve for the superficial system.
The surface veins may again be divided into two
sub-systems, the great or internal saphenous, and the
lesser or external saphenous. The great saphenous
vein, after gathering radicals from the front and
inner side of the foot and lower leg, passes upward,
generally as a straight single trunk, inside the knee,
along the inner anterior surface of the thigh, and
into the femoral vein at the saphenous opening. The
small or external saphenous vein drains the back
and outside of the foot and leg, and empties in the
popliteal space into the popliteal vein. It fre-
quently communicates with its more important com-
panion and, like it, is subject to considerable varia-
tion.
All the veins of the extremity are furnished with
filmy, delicate, bicuspid valves.
The arrangement of valves in the perforating
veins, as has already been stated, allows of blood-
flow toward the deep vessels only.
Etiology
For all practical purposes a varicose vein in the
lower extremities may be described as merely a valve-
less vein or more properly a vein whose valves are
incompetent. Having in mind this fact, one may
obtain from a study of the circumstances under which
varicosity becomes established and a knowledge of
the pathological changes which necessarily ensue, an
explanation of the various forms which varix as-
sumes and a rational basis for treatment.
The most obvious cause of the breaking down
of the valves is hard work, by which I mean carry-
ing or lifting heavy loads for long periods, as in
the case of longshoremen, freight handlers, and
laborers. The tension upon the abdominal muscles,
the downward push of the diaphragm in violent
breathing, in fact, the same strain which produces
hernia, lays a heavy load upon the veins of the legs.
Whether the valves become useless through stretch-
ing of the vein walls or are directly broken is im-
material. The occupations which involve standing
for long periods without moving the legs are, in a
lesser degree, a source of valvular incompetence, and
Phila., February, 1922]
Radical Core of Varicose Vein*— Forbes
125
this not from excessive back pressure but from stasis
due to lack of muscular movement Among women,
the venous engorgement of the legs so often seen
even early in pregnancy may, finally, after the birth
of several children, result in varicosity. I have also
seen, in young men, and in young women who have
never borne children, instances of varix which date
from childhood, apparently due to congenital abnor-
malities. All these etiological factors tend to produce
the well-known, large, surface varicosities.
It seems to be true, without going into the more
minute pathological anatomy, that varix may assume
one of two principal forms, depending in a general
way upon whether it results from overstrain and
stretching of the vein walls, or from phlebitis. In
the first case, the valves gradually become function-
less, the vessel walls stretch until their nutrition is
impaired, muscle-cells become replaced by inelastic
scar-tissue, the vein becomes tortuous, local areos dis-
tend into pockets, calcification sets in, and indeed,
all the variations commonly observed in scar-tissue,
ill-nourished and under tension, are likely to occur.
As the onset of these changes is naturally gradual,
effective collateral circulation corresponding to the
degree of stasis in the main channels is frequently
established, and true varicosity is often confined to
the trunk and principal branches of the great
saphenous vein.
The ulcere which occur under these circumstances
are almost without exception in direct relation to
the varicose vessel or vessels. They are said to
"ride" upon veins, occurring almost exclusively in
the lower and middle thirds of the lower leg. Funda-
mentally their occurrence seems to be due to a
chronic irritation of the skin associated with stasis
of impure blood in the vein beneath, as attested by
the pigmentation which so commonly precedes them,
but a frequent contributory cause is undoubtedly
trauma, and the form which they ultimately assume
must depend greatly upon the degree of infection
which follows their establishment.
The perforating vessels do not usually share in
the varicosity of the large tortuous veins. In many
instances they continue for years to fill their role of
safety valves, carrying the stagnant blood from the
surface veins into the deep system which is well able
to care for it. When, however, they in turn become
dilated the' surface circulation becomes the more
embarrassed in that blood may now pour out from
the deep veins to the superficial. Under the cir-
cumstances ulcers are particularly prone to occur
and that over areas independent of the veins them-
selves.
The first and more common variety of varicose
vein is, then, dilated, sclerotic, tortuous, often sac-
culated and calcified. It is not necessarily associated
with very noticeable changes in the nutrition of the
leg, owing to the effectiveness of collateral circula-
tion and the preservation of the useful perforating
veins. Ulcers when present usually "ride" upon the
principal varicose trunk. In the more advanced
cases, particularly when the perforating veins have
become incompetent, the general nutrition of the
leg may be poor, and ulcers may develop over wide
areas.
CUs$i£cmtmm #f Vcticmc V<
For purposes of treatment it is best to divide
varicose veins into two groups: (1) surface varix,
and (2) surface varix complicated by varicosity of
the perforating veins. In the first category belong
the large majority of instances of gradual dilation
and incompetence, and in the second, not only some
of the more advanced cases of similar etiology, but
almost without exception the cases of varicosity
arising suddenly from phlebitis. Certain simple
diagnostic measures distinguish these groups, which
may, and usually do, demand characteristically dif-
ferent treatment
OmkdTuU
The methods by which the true nature of varicose
veins was first effectively demonstrated were devised
by Trendelenburg, who showed that in varix there
is nothing to prevent a back flow of blood in the
veins, and actually measured the pressure which
the long column of blood exerted against the vessel
walls in the leg. The tests devised by Trendelenburg
are easily performed. The leg is raised and held
above the level of the heart until the veins are empty.
It is then rapidly lowered when the blood can be
seen to flow back into the leg and suddenly distend
the surface vessels. This test for varicosity may be
positive even when the reflux cannot be seen to dis-
tend the vein walls, for if the veins are so sclerosed
that no change in the tension of their walls can be
noted by the eye, it can quite readily be felt by
the fingers,
By such means, valvular incompetence of the sur-
face veins as opposed to hypertrophy or distension
of normal vessels can be diagnosed, but still more
information may be derived from a variation of the
same simple procedure. Suppose it has already been
determined that the surface veins allow a free back
flow. The leg is now raised and the veins emptied
of blood. If, before it is lowered, a constriction
only firm enough to compress the surface vessels,
as by a piece of bandage, is made about the upper
thigh, blood cannot flow from above into the varicose
superficial veins, and until they are filled by the
natural circulation they remain empty.
This, French writers have called the contre-
epreuve of the Trendelenburg test, and it confirms
the diagnosis, for on releasing the constriction, the
empty or partially filled veins become distended with
■
*
126
Radical Core of Varicose Veins — Forbes
[The American Physician
a palpable shock. But this procedure tells even more.
Suppose the perforating veins share the varicosity
of the surface vessels. The blood in the deep veins
will then be able, as normally it cannot do, to leak
into the surface vessels, and in applying the con-
striction test it will be found that in spite of the
prevention of back flow down the superficial veins,
these fill rapidly below the constriction. That is to
say, blood is finding its way out from the unob-
structed deep veins through incompetent perforat-
ing vessels to the surface. In varicosity of the sur-
face veins alone, filling below the constriction takes,
place in three-quarters of a minute or more and
even then these vessels may not be very tense, for
the perforating veins are continually carrying off
the excess of blood. If, on the other hand, the per-
forating veins are incompetent, the surface vessels
will fill below the constriction, possibly in ten,
twenty, or thirty seconds, according to the importance
of the leak.
These two tests, which I shall hereafter call re-
spectively the Trendelenburg test and the constric-
tion test for perforating veins, serve to separate
the cases of pure surface varicosity from surface
varicosity complicated by varicosity of the perforat-
ing veins. The tests ignore the possibility of varix
of the deep venous system, a very rare condition if
indeed it is ever fully developed.
Smrface Varix
Distinguishing features:
This condition is distinguished by the demonstra-
tion of a free back flow down the surface veins (a
positive Trendelenburg test) and by the failure of
the lower surface veins to All in the application of
the constriction test for incompetent perforating
vessels (a negative constriction test), on the per-
formance of the second test three-quarters of a min-
ute to a minute is taken as the normal filling time
for the varicose surface veins below the constriction.
A more rapid filling indicates some incompetence of
the perforating channels. In some cases of pure
surface varicosity, however, the superficial veins
never fill completely below the constriction, appar-
ently because they are effectively drained by the
communicating veins. Such cases are often dis-
tinguished by a single enormous tortuous, great
saphenous trunk passing from groin to ankle, but
even in instances of very general surface varix the
effectiveness of the collateral circulation and perforat-
ing channels in caring for the stagnant surface blood
is often surprising.
Opmtie* Pncedmre m Smrface
Relatively simple surgical measures may be em-
ployed to cure pure surface varices, and the least
radical of these is the so-called Trendelenburg opera-
tion. The original operation was a simple ligation
of the great saphenous vein in the thigh and was
intended to relieve the veins below the ligature of
back pressure due to the long column of stagnant
blood. It has been modified into the excision of a
short piece of vein between ligatures in order to pre-
vent the re-establishment of a channel, and this ex-
cision is performed as close as possible to the
saphenous opening. The main trunk of the great
saphenous may even be divided in several places,
cutting it up into a number of isolated segments in
which the blood soon organizes and obliterates the
lumen.
The Trendelenburg type of operation is to be ad-
vised as a palliative measure in instances of vari-
cosity of the great or lesser saphenous veins only
when the perforating veins are proved to be com-
petent. Inasmuch, however, as the great vein is not
actually removed and not necessarily obliterated, there
is always a fair chance of recurrence through the re-
establishment of its channel by the aid of collateral
circulation or by the formation of new veins in the
scar-tissue separating the ends of the divided seg-
ments. Therefore the operation should only be per-
formed upon the aged or infirm, or perhaps to tide
a young person over a difficult period, or indeed,
merely to heal an ulcer temporarily. An analysis
of the results of this operation in the hands of
various surgeons shows an anatomical recurrence
after five years in 60 to 70 per cent, of the cases,
but with symptomatic recurrence in only 20 to 30
per cent.
The radical operation, and one to be advised for
the cure of the common surface varix without the
involvement of the perforating vessels, is Madelung's
full excision of the great saphenous vein.
The radical removal of the surface veins is per-
haps most satisfactorily performed upon the follow-
ing plan: A transverse incision several inches long
is made in the groin about an inch below Pouparfs
ligament. Through this incision the great saphenous
vein is divided at the saphenous opening. At the
same time any other veins which lie parallel to it
or enter from above are found and divided in order
to do away with any vessels capable of re-establish-
ing a large, single, collateral trunk. The internal
saphenous is then dissected out with the Mayo strip-
per or other appropriate means down to the region
just below the knee. At this point open dissection
should begin, for here the larger branches of the
great vein begin to enter it, and, though breaking
the long column of blood by removal of the internal
saphenous from, groin to knee is likely in many
instances to cure, it is always advisable carefully to
dissect out the varicose vessels of the calf down to
the point where they appear small and harmless.
This is most easily done by a long incision to the
Phila., February, 1922]
Radical Core of Varicose Veins— Forbes
127
deep fascia, turning back thick flaps of skin and
fat, and dissecting the veins from inside the flaps.
The fulfilling of the second requisite, the cure of
the ulcer, depends for its success principally on the
accomplishment of the first, that is, the complete
removal of the veins. It is often advisable, how-
ever, in removing the largest veins to take with
them what may be called their tributary ulcers.
Moreover, as was first pointed out in this country
by the Mayos, if in association with the ulcers there
has been found a very thick impenetrable base of
scar-tissue, it is almost always necessary, in order
to secure healing of the ulcers, to remove with them
down to, or better, through the deep fascia the mass
of scar-tissue beneath and about them; otherwise
the poorly nourished tissue may harbor a leaking
perforating vessel not disclosed by the tests and may
never permanently heal. In consequence of laying
bare this often enormous area, an immediate skin
graft (Thiersch preferably) completely covering the
denuded surface should be performed, and it is
notable that such grafts "take" well upon fat, fascia,
or even periosteum.
In this respect the method of making thick flaps
of skin and fat is particularly useful, and rather
than exert much traction on the flaps it is always
better to make a transverse incision at the lower
end of the long wound, half way round the leg if
necessary, in order to secure greater ease of dis-
section.
Swrfmet Vmrix Complicated by VmricwHj W the Perftnimg
Vtm*
Distinguishing Features. The cases falling under
this head differ very considerably from each other in
appearance. Varicose vessels may be numerous and
prominent, or few and almost invisible. In the
second instance the patient's discomforts are strik-
ingly greater than the apparent degree of varicosity
warrants. Ulcers, particularly in those whose cir-
cumstances prevent them from nursing their ail-,
ments, are common. The constriction test shows
that the surface vessels fill rapidly below the con-
striction by way of the varicose perforating chan-
nels. Nevertheless the findings may be difficult to
interpret.
Farmd^xicmi Lmm •/ V«ric«tf Vcias
Straight, small, thick walled veins of the post-
phlebitic type are almost unnoticeable, yet the lesions
which habitually mark their presence — ulcers, edema,
atrophy of the skin — are obstinately resistant to
treatment, and it may perhaps be stated as a law,
that the less noticeable the veins, the more malignant
and resistant the accompanying ulcers, and the more
radical and thorough must be the curative operation.
Large tortuous surface varicosities are gradually
established, perforating vessels and collateral circu-
lation are then usually competent, ulcers if present
ride on veins, and cure is usually easy. On the
other hand, the varicosity of the small sclerosed sur-
face vessel is rapidly established by inflammatory
processes, collateral circulation is ineffective, per-
forating veins are almost invariably crippled, dis-
turbances in the skin are widespread and severe,
and cure is correspondingly difficult.
QptfNta§€ rrtcMifii
In simple surface varix it is seldom necessary to
do more than remove the great saphenous vein from
the groin to mid-calf. In surface varix complicated
by varicosity of the perforating veins, not only must
the great saphenous be eradicated but many of its
branches in the calf must be followed and excised
in the search for incompetent perforating channels.
If these channels are not ligated they will continue
to remain a source of venous stasis, and inasmuch as
they are frequently found beneath ulcers in the center
of great masses of scar-tissue, their removal is gen-
erally as difficult as it is imperative.
All such operations require the usual transverse
incision below Poupart's ligament, and resection of
the great saphenous vein in the thigh. When the
lower leg is not so densely indurated as to forbid
free dissection of the calf, large, thick flaps should
be turned back after the method of Madelung to
expose the deep fascia of the front and inner side of
the leg. The surface veins are dissected from the
internal surface of the flaps and in this dissection
the varicose perforating vessels are likely to be found
(I have never recognized in the calf more than three,
seldom more than two). They are tied beneath the
deep fascia,
In some instances, however, the whole leg below
the knee is so edematous, indurated, and covered
with ulcers that not only is the resection of the
principal surface vessels a difficult matter, but the
turning back of the skin flaps for thorough dis-
section is impossible.
Indeed, it is wisest if the operator has the confi-
dence of his patient, after doing away with the
great saphenous vein above the knee, to work up
the leg, making multiple incisions at several sittings,
picking up and tying one by one the varicose per-
forating channels as one paisses up the leg after
the method of Novaro. In any case the object of the
operator should be, I believe, to abolish the continu-
ity of all surface veins of any considerable size, and
to find and divide, or at least cut off from the surface
circulation, the varicose perforating veins. If this
is accomplished the superficial circulation is carried
on by small vessels emptying probably by way of
devious connections in the thigh. The skin of the
lower leg may perhaps remain edematous but ulcers
will not tend to recur. The operator must keep in
128
Empyema — Nour
[The American Physician
mind that tissues served by almost invisible channels
are better off than those drained by a varicose vessel.
Dr. John Homans' conclusions are thus enumer-
ated by him :
1. Varicosity of the veins of the legs is confined
for anatomic and physiologic reasons to the super-
ficial and perforating vessels.
2. Trendelenburg's tests distinguish between pure
surface varix and surface varix complicated by vari-
cosity of the perforating veins, a distinction impor-
tant for purposes of treatment.
3. Surface varix is curable, by relatively simple
surgical procedures, preferably excision of the great
saphenous vein from groin to mid-calf.
4. Surface varix complicated by varicosity of the
perforating veins requires for its cure not only eradi-
cation of the great saphenous vein but a thorough
exploration of the lower leg in order to ligate vari-
cose perforating veins.
5. Varix following phlebitis is not uncommon, pre-
sents a characteristic appearance, is prone to be com-
plicated by varicosity of the perforating veins, and
is usually accompanied by obstinate ulceration soon
after its establishment.
6. It is a very general rule if not a law, that the
more prominent and tortuous the surface veins the
simpler the cure: the less noticeable the surface veins
the more malignant and resistant their attendant
ulcers and the more radical the operative procedure
required for cure.
7. Varicose ulcers, if of long standing and espe-
cially if they are surrounded by an area of thick
scar-tissue, are best treated by free excision and
immediate skin graft in connection with the radical
removal of the veins to which they are tributary.
The war is over but the necessity for making men
and women fit remains. Varicose veins and ulcers
are common and are often almost as distressing as
common. To those of you, then, who have patience
to study and work for the comfort of individual cases
I would strongly recommend the valuable contribu-
tions of Doctor John Homans, of Boston, especially
that published in the Journal Surgery, Gynecology
and Obstetrics, February, 1916.
Treatment of Two Empyema Cases
Substantiating Dr. Mackenzie Forbes*
Fourteenth Clinic
Cyitoctl* md Pnlap$e
Robert Earl, St. Paul (Minn. Med., December, 1921),
in conclusion, says:
1. The uterus is maintained at its normal level in
the pelvis by its ligaments; because of the elasticity of
these ligaments it has a considerable range of motion.
2. The pelvic diaphragm when in normal condition
prevents the intra-abdominal pressure from stretching
the supporting ligaments of the uterus.
3. That any operative procedure for the cure of pro-
lapse or cystocele should aim to restore to as nearly a
normal condition as possible the normal supports of
the uterus and bladder.
4. That the alteration of the normal relationship of
the pelvic organs or their fixation to the abdominal wall
should be measures of last resort.
By Geo. E. Nour, M.D.,
Beyrouth, Syria.
About twelve years ago I reported, to the readers
of the Medical Council, two cases of empyema, which
occurred in infants of two and three years of age re-
spectively. Now the reading in The American Physi-
cian, September, 1921, of "A Case of Empyema,"
brought to my mind two very severe and hopeless
cases of empyema, which occurred in my practice in
the early part of 1919, and I take the liberty to re-
port the same to readers of The American Physician,
with the object of substantiating the views experssed
in "A Case of Empyema," under treatment by aspira-
tion. Following are the two cases:
Mr. N., about fifty years of age, married, resides
in a small village in Mt. Lebanon, situated at a dis-
tance of five miles from the seashore and about six
hundred feet altitude. The village lies southeast of my
native town, Batroun (a little town on the seashore).
The journey of five miles was made partly on foot
and partly assisted on a little worn out donkey, which
had survived the war and its privations. On reach-
ing the patient's home, which was devoid of all furni-
ture and most necessary household utensils, I found
the patient lying on a bed on the floor of a dark
house full of dust and dirt. The bed and coverings
were almost in rags, and above all this misery and
discomfort was added the smoke from the fire, which
was being burnt to heat this large and empty house,
so that if one's eyes did not water from emotion and
sympathy, they surely did from the effect of the
smoke.
The patient was examined and diagnosis of empy-
ema was made and proved by the hypodermic needle
and an aspiration was performed immediately with a
20 cc. hypodermic needle. The needle was left in the
chest every time the pus was aspirated and hypoder-
mic barrel emptied. This was continued for fifty
minutes and about two liters of pus were removed.
The empyema was on the left side. The heart was
displaced to the right chest with apex beat under the
right nipple; but soon returned to right of xiphoid
cartilage after operation. A tonic was administered
and next day the same operation was repeated and
about three more liters of pus removed, whereupon,
the apex beat approached the normal position.
Phila., February, 1922]
Asthma and the Internal Secretion* — Brown
129
Two days later the patient was brought down to
Batroun and a consultation by Drs. Zaeni, Bafoul and
Aboud was held, all agreeing to the necessity of re-
section and drainage.
Dr. Zaeni operated and I assisted. Dr. Zaeni
opened a space between the eighth and ninth ribs,
anterior and posterior to axillary line, and about two
liters of pus were withdrawn. Drainage tube was
inserted, cavity washed with a solution of tr. iodine
and water and then with sterile water. The washing
was repeated every twenty-four hours. Patient prac-
tically recovered within three weeks after the opera-
tion, but died three months later from galloping
tuberculosis.
Cm Jfc.2
A youth of about eighteen years of age, from a
village ten miles distant from Batroun (Abdilli), was
carried over boards and brought to the American Red
Cross temporary hospital, of which I was in charge
(1919-1920). The little patient looked like a barrel,
face, head and body swollen. I administered strych-
nine and aspirated with the same hypodermic syringe,
about four liters of pus, the next day over five liters
and the third time over three liters more. The empy-
ema was on the right side. Patient improved rapidly
and in a few days was able to stand the journey to
Beyrouth City, where he was sent to the headquarters
hospital of the American Red Cross and made a
rapid and uneventful recovery.
Importance of the Internal Secretions
in the
Treatment of Asthma
OPPOSITE VIEWPOINT FROM LEADING EDITORIAL, DECEMBER ISSUE
To the Editor: —
Your editorial in the December issue on "The
Daylight and Darkness of the Asthma Problem"
strikes me as no answer to many problems that this
disease presents.
Allow me to state first, that since my third week
on this earth I have been a victim of this "toxic
idiopathic manifestation." Have studied, experi-
mented, tested and failed with most of the things
that have had their day in the past thirty years.
Adenoids, turbinates, tonsils and teeth have gone
to the altar of this disponsic god of respiratory
difficulty, and today the terrible attacks continue, not
as of old, but they are there, with every hour of
"daylight or darknes8.,,
Perhaps it was the milk in the mother's breast
that was tainted, but the fact remains that never
since that date have I spent a night in that same
room without an attack. Going back to the grand-
parents, the disease is marked in the male and fe-
male sides of both, with my own father carrying
on the transmission to his heirs. I cannot believe
that anaphylaxis, as applied to asthma, is much
more than a good guess; certainly it will not work
out in more than ten per cent, of the cases in Illinois.
There is not a thing in the etiology to which I could
not ascribe some one of my attacks, no season of
the year that I could not lay the cause of the trouble
to with as much certainty as in the average case.
The renal function, I believe, has an important
place in troubles of this nature, but above all there
is an imbalance of the secretions of the ductless
glands, and this is so vicious that a stated treat-
ment is impossible. Until late in life I had always
considered myself lucky to go two months without
an attack, but due to the use of glandular extracts
I have been able to go as long as three years without
an attack and when there was one there was always
some way of finding the cause through some de-
ficiency in some of the glandular secretions. So
firmly do I believe the trouble lies in this direction
that I believe as soon as our physiological chemists
can determine the normal condition of the blood and
be able to ascertain the lack of the glandular ele-
ments in the blood stream, that then the solution of
this vexed question will be reached and the hundreds
of sufferers relieved. That day is not far away
and the progress toward a solution of the ills of
the asthmatic is rapidly nearing the goal of perfection.
I am treating a number of asthmatics at present
and find that each one has the one thing that is
peculiar to his case; however, all do well on the
glandular extracts. Those with renal symptoms do
best on thyroid; this applies as well to the cardiac
cases, so called. Hygiene, diet, elimination of nerve
strain and worry, and the glandular extracts prop-
erly used, will cure or relieve the majority of the
cases. How long would you give the glandular ex-
tracts f Just as long and as often as there is an
imbalance of the glandular secretions manifest in
the patient.
As in the case of a recently examined case of
cretinism, I would keep up the thyroid just as long
(Continued on page 134)
Common Formn of Nasal Obstruction — Long IThl
Some Common Forma of Nasal Obstruction
in the Adult
PRODUCES MANY DISEASED CONDITIONS
L. F. Long, MJD,
114 North Sixth Street, Zaneaville, Ohio.
Extant Tku* Cat* CwnttUy
A deviated septum does not call for opera-
tion unless ventilation and drainage are
interfered with. Also it is important to
carefully examine these cases and institute
proper treatment since natal obstruction
causes great discomfort and produces many
diseased conditions. — The Editors.
SOME FORM of nasal stenosis, either unilateral
or bilateral is exceedingly common, and we
will consider the results of chronic nasal obstruction,
a few of which are:
Chronic nasal catarrh which predisposes to tubal
catarrh with resultant deafness.
discomfort produced. When these results are con-
sidered, nasal obstruction should be actually looked
after and corrected. The diagnosis in the majority
of cases is not difficult, if a careful examination is
The illustrations in this article cover the most
common types of nasal obstruction.
No. 1. Shows a nasal cavity about normal.
No. 2. Hypertrophy of middle turbinate. This
is a serious obstruction because it interferes with
ventilation and drainage of the sinuses and the upper
part of the nasal cavity often interfering with, or
even abolishing the sense of smell.
Treatment is the removal in part or entire of the
enlarged turbinate, sufficient being removed to give
free nasal respiration.
No. 3. Hypertrophy of the inferior turbinate. —
Is not so serious as No. 2, as it does not obstruct
(Original lead pencil drawings by the author.)
Sinus disease by blocking their drainage.
Post nasal, pharyngeal and laryngeal catarrh
which predisposes to tubercular infection of upper
respiratory tract.
Closure of the lower opening of nasal duct caus-
ing lachrymal troubles which are often probed without
results.
Impairment of the quality of the voice.
The whole process of metabolism is interfered with
because of the mouth breathing not to mention the
drainage and ventilation to the same extent, but
often does interfere so that it should be reduced by
cautery or a small piece removed. This turbinate
should be spared as much as possible because of its
physiological function.
No. 4. A septal spur which impinges on the
turbinate and keeps up a constant irritation, and
also obstructs the air passage to some extent. — Spur
can easily be removed with a saw.
No. 5. Hypertrophy of both middle and inferior
Phils., February, 1922]
Therapeutic Essentials in Acne— Lorenze
131
turbinates, completely blocking the cavity. Middle
turbinate should be removed and the inferior should
be reduced.
No. 6. Deviated septum, crowding over against
the turbinates producing obstruction. Should be
corrected by sub-mucous resection of the septum.
No. 7. Shows another form of septal deviation,
producing obstruction of the upper part of the cavity.
Sub-mucous resection would correct it.
No. 8. Shows appearance of polypus, which looks
much like a bubble of mucous. This should be re-
moved with the snare and the base cauterized.
It should be remembered that a deviated septum
is no indication for operation unless ventilation and
drainage are interfered with. Knowing that nasal
obstruction causes great discomfort and produces
many diseased conditions, it is important that we
carefully examine these cases and institute the
proper treatment — and anything short of free nasal
respiration is inadequate — and not simply prescribe
Seilers sol. or something similar without making a
careful examination. Any surgical procedure neces-
sary for the removal of nasal obstruction can be
done very readily under local anesthesia.
Therapeutic Essentials in Acne
By Edward J. Lorenze, M.D.,
249 West 76th Street, New York City.
Treatment So OfUm Fmb
So often does the treatment of acne spell
failure that we gladly publish the short
paper of Dr. Lor em, giving the therapeutic
essentials of this disease — a disease as
troublesome to the physician as it is to the
patient. — Editors.
ACNE IS AN acute or chronic inflammation
of sebaceous glands and periglandular tissue,
eaused by lack of hygiene of skin, focal infection, lack
of endocrine balance (as shown by occurrence at
puberty, menstruation and masturbation), faulty di-
gestion.
First give proper local attention to the akin by
washing same with hot water and a good soap, using
a coarse washcloth. Follow with very cold water and
dry thoroughly. This should be done thoroughly every
morning, and a simple washing at bedtime. All come-
dones should be removed with comedone remover,
after first using hot soapsuds. The writer uses a
thymol, soft soap and spirits of wine mixture, as
follows :
Thymol, dr. L
Sapo mollis spiritus vini rect. aa oz. V/i each, M.
et gig.
Use externally once or twice a week by rubbing one
minute on part, blond skin perhaps less, following
immediately with very hot compresses and very cold
water or cake of ice (to tone up periglandular muscle
fibres, thus closing gland). All pustules and indura-
tions should be cut diagonally, with a small, narrow,
sharp-pointed knife, and contents expressed, after-
ward cleansing with pure peroxide, 1 per cent chlora-
zene solution, iodine or 50 per cent ichthyol solution,
Dietary
Avoid the four P's (pork, pickles, porridge, pastry)
also fried foods and cheese. Regular action of bowels
should be secured by free use of cold water, fruits,
bran and abdominal massage, dilating the anal sphinc-
ter and if not successful, resort to a sulphur laxative,
such as Epsom Salts, or the laxative waters. I do
not use mineral oil.
Gemerwi Hygiem
Simple life, summed up in regular meals, frequent
baths, early hours; omit cigarettes and late suppers,
correct masturbation, get plenty of outdoor life.
Brewer's yeast, salol strychnine, bacillus bulgaricus,
calcium sulphide, hexamethylenamine, iron, according
to indications.
Lmcei Moiicdtmm
Zinc and calamine lotion or sulphur lotion. In the
very indurated and scarred faces, a weak ointment of
the red oxide of mercury.
Special Memmres
Treat the accompanying seborrhoea capitis with tar
soap shampoos and the use of a resorcinol hair "ton-
ic." Stock acne vaccines or an autogenous vaccine
may be of value. Pelvic congestion should be over-
come by hot douches, recumbent posture, hot enemas,
local massage, ergot, etc. Attend to diseased tonsils,
tooth sockets and sinus disease. High frequency cur-
rent and light doses of x-ray, given with care, have
occassionally given the author very good results.
An Efficient Future for Medical Practice
Medical organization and practice, lo piomote efficiency, requites
tmo thing*:
1 . '1 hat the public make the fullest use of efficient pimctitiooen.
2. That mnmcal men receive adequate income lo provide the meant
and methods neceuarp to efficiency.
These two thing* «m interdependent
This department is conducted as a forum foe comtmcttce
$hn of these vital factocs in medical progress.
Coordinating the Work of the Family Physician
and the Hospital.
THE GREAT CHANGE IMPENDING IN THE PROFESSION
Compeitiiom vg. Cbmstructive Co-0p€ratiom
Can there be any doubt that in the "Family
Physician" with his traditional relation to the
rank and file of solid industrious people we
have the health factor of most fundamental
importance? Have we any evidence that in-
stitutional medicine or state medicine can
adequately fill his place, effectively perform
his function?
Which points the way to medical progress :
an attitude of competition toward the general
practitioner on the part of modern collective
medical agencies — the hospital, etc.; or an
attitude of constructive co-operation through
properly and fairly co-ordinated effort to the
end that the health interests of all the people
may be most effectively served and in a man-
ner satisfactory to them? — The Editors.
THE NEW POSITIVISM is a great philosophy
being developed by medicine and the physical
sciences and in agreement with the dictum of Prior,
"One single positive, you know, weighs more than
negatives a score." The old positivism was a way
of thinking that regarded nothing as ascertained or
ascertainable beyond the facts of physical science, or
those things cognizable by the senses. Comt6 was the
great apostle of positivism, who made phenomena his
god, excluding all metaphysics and philosophy, as
well as all knowledge of the supernatural. All knowl-
edge, he claimed, proceeds by three stages: first, the
theological or supernatural; second, the metaphysical;
third, the positive. He aimed at a utilitarian altru-
ism based wholly on positivism. Yet, strange to say,
he finally returned to a sort of theology which ad-
mitted neither a revelation nor a god; and he set up
Humanity as the idol or god of his cult.
The real positivists of former times were the math-
ematicians and astronomers, for they were the first
to develop exact science. They were followed by the
physicists and chemists. These were the contained
and balanced men of their age and were opposed
by the speculative school of thought. The latter have
arrived nowhere in particular but still persist, the
theory of relativity being their latest output in
physics and psychoanalysis the latest in medicine.
Perhaps they do good in opposing a rampant mate-
rialism. Yet the fact remains that modern advances
are almost wholly due to the positivists of exact
scientific bent; and the greatest wonder of all is the
fact that such science is gradually blotting out the
old materialistic conceptions and is advancing mate-
rial science into the domain of what was once re-
garded as supernaturalism.
The So-cdUA ItdmmgibU
Bacteriology deals with what was formerly re-
garded as intangible causes. The microscope makes
visible the infinitely small and the telescope the in-
finitely distant; and these two instruments have
opened up two new worlds of thought. The spec-
troscope analyzes the intangible into positive science.
Electricity deals with imponderable forces of mighty
power; and yet we cannot see electricity. The chem-
ist deals with atoms that even the microscope can-
not reveal, and the physio-chemists have divided the
atom into electrons still more minute. The student
of radio-energy has elaborated the X-ray and other
rays of potent activity and bordering on the super-
natural. Radium possesses proved characteristics as
supernatural as any conception of ancient philos-
ophers in their study of light. The wireless tele-
graph carries thought instantly from continent to
continent. Thus has science proved that what was
formerly merely a belief in the intangible and super-
natural was well based in what we now demonstrate as
phenomena and prove as true and powerful forces.
Yes, science is creating faith — a faith that makes
for belief that the evidence of things not yet seen
will finally come to light. And where will it all endf
Phtla., February, 1922]
Great Changes Impending In the Profession
133
Th*N
The new positivism adds to man's natural five
senses a host of other ways to apprehend phenomena
and breaks down the old line between physics and
metaphysics, believing that the so-called supernatural
lies only a little ways beyond the veil, and that it
will soon be penetrated and its mysteries solved ; that
the substance of things hoped for will be found, and
the evidence of things not yet seen will be forth-
coming in due time. If this is not revelation, what
is itf If God is not yet speaking to man, from whom
do all these wonderful revelations come — one after
another, as they are duef The new positivism is a
better religion than Comt6 taught.
The Mem Medkime
No longer an empiricist exploiting mere material-
ism and promulgating a theory or philosophy; no
longer a mere individualist intent on nothing but
what his five senses reveal to him and his own deduc-
tions therefrom make plain, the modern physician is
an apostle of the new positivism, a contained man
of science who modestly searches the whole realm of
human knowledge for answer to his daily problems.
He knows his limitations ; he knows that instruments
of precision are necessary to add to what he can see
and hear and taste and feel and smell; he knows
that he is a high priest of science and no longer a
mere worker in material and business affairs; he
knows that he cannot interpret the sounds of the
heart without modern instruments, or trace an infec-
tion merely by following symptoms, or define the
extent of many fractures without that "other eye"
that science! affords, or learn the secrets of many dis-
eased conditions without those helps that are found
in modern hospitals and diagnostic laboratories. And
hence —
The Mem Doctor
And what are his characteristics f Hobbes called
Comtek idol, Humanity, "The Leviathan," while
Comte regarded Humanity as the "New Supreme
Being." Hobbes, like most men of his time, even the
eminent theologians, were individualists, elevating
certain men but showing little interest in humanity
at large, as most men were to be finally damned any
way and only a few saved. Comte1 set up an abstract
Humanity. The New Doctor sets up no abstraction,
nor does he believe that men at large are to be
damned; he views Humanity collectively in so far as
wide necessities are involved, but individually in ap-
plying these necessities. Individualism characterized
the old empirical doctor, even as it did the old dog-
matic theologian; but the new generation of phy-
sicians— the new positivists in medicine — are fast get-
ting away from the individualistic point of view;
they are members of a group, each one according to
his several talents and lines of special training co-
operating to attain to all precision in diagnosis and
case-management made possible by their own unaided
five senses plus the aids that modern research adds
thereto. The physician of modern training may not
be always as much of a dealer in the social amenities
as was the old-time doctor who had more leisure; he
is less self-opinionated, less self-assertive, less readily
swept off his feet; he pays but little heed to mere
talk, values only sustained opinion, demands proofs
and controls in all experimentation and research, and
discounts a vast deal of what is printed. A large
proportion of physicians of recent training are en-
gaged in hospital work a portion of their time, or
are in institutional or public health work; their daily
association with their colleagues makes for broad
vision and a collective point of view, and they are
in affiliation with sociologists, chemists, laboratory
workers and humanitarians in many lines of work.
A wide and exact literature is open to them, and
they lose all provincialism, obsessions, predispositions,
etc., and become judicial in attitude and far from
commercialized in bent.
The new doctor regards humanity highly, is char-
itable in his views of human weaknesses, and he is
deeply interested in the larger things of modern med-
icine and its inter-relationship with men and affairs
in many lines. Fraternal with his colleagues, even
when defective in training, he exalts the medical
prerogative and resents any overplus of lay control
in medical affairs.
Impemdrng Chemget
Thus it will be seen that the new positivism and,
as well, the large part that modern medicine is tak-
ing in affairs, tend to the rapid integration and cor-
relation of the modern humanities in the many lines
of private and public effort. The modern physician
is compelled to drop his old individualism. It is,
perhaps, not to be expected that the man of the old
training will find it easy to get his bearings. It is
hard to drop the old conventions and take up his
professional work in far from the traditional attitude.
Yet the rapid multiplication of hospitals and labora-
tories, dispensaries, group clinics, health centers, san-
itary services, special institutions, etc., call for a new
orientation and a revision of the economic status of
the medical profession. This adjustment is especially
hard for the general practitioner and calls for much
patience on his part. Just here we want to call for
a little patience on the other side.
Certmim NeglecU
It is a great weakness in the modern program that,
while the very rich and the very poor are well taken
care of, the great mass in between is neglected; and
while the very skilled specialist and the young physi-
cian willing to work on a salary fit in well to the
modern scheme, the hard working general practitioner
who visits the rank and file of sick and injured peo-
134
Great Changes Impending in the Profession
[PhiU., February, 1922
pie in their homes is largely left out of the account,
as well as the people he treats. Inevitably the physi-
cian so placed, who has not access to modern instru-
ments of precision that cost so much money, works
under a handicap, try as he may. Knowing this
handicap, and that he will inevitably retrograde under
it, the new medical graduate hesitates to locate in
small communities. An effort is being made to repair
this defect of small communities by establishing small
community hospitals with proper laboratory equip-
ment. This is a proper move, but it needs wise
direction.
We have just visited a small community in which
is located one of the most up-to-date general hos-
pitals in that section of the country. It is heavily
endowed and has a staff of about a dozen full-time
physicians on adequate salaries; and they are doing
splendid work in every sense of the word. Yet a
small group of general practitioners in the town are
doing most of the general work in the community —
the hard and poorly paid work. These outside men
are having hard getting along; most of them have
retrograded in attainment, and they are giving the
people of that place rather poor service, compared
with what the hospital is giving to the surgical and
special cases, or compared with what residents of
other places are receiving from physicians who do
not have the competition of an endowed hospital to
meet. Here is a big medical problem.
We cannot afford to promote classes in the profes-
sion, as is done in that town ; it is bad for the people
themselves, and it makes for sumptuous medicine for
the favored staff members and back-number medicine
for the outside men who cannot compete successfully,
the result being that while a splendid hospital is
doing fine work, the great majority of the residents
are receiving less than average attention from physi-
cians who make so little money that they cannot
afford to keep up to the times or properly equip
their offices.
The better plan is for a local hospital with part-
time staff members who do the outside work the rest
of the time. By this plan all necessary hospital serv-
ice is rendered to the community and the resident
practitioners have both a professional and an eco-
nomic chance to do good and modern work.
The New Positivism ami the Doctor's Income
Intensive medicine and scientific positivism are
demanded by the age; it is being largely given in the
field of preventive medicine, by the hospitals and by
the specialists. It must also be given in general med-
icine, to all of the people, else the whole structure
will finally topple to decay; but all of this costs
money. Economically it will pay to give it, for
morbidity and mortality will decline, the loss from
unnecessary sickness and injury will diminish, the
efficiency and happiness of the people will be pro-
moted, and the general morale of the people will be
infinitely higher.
We cannot expect scientifically trained men of
scholarship and technical skill to be at the same time
financiers and business managers, be they physicians,
chemists, architects, or what not. In many technical
lines the economic status is well worked out and the
scholars engaged in such work are relieved from
business and financial care and are provided adequate
incomes for their services. Furthermore, these gen-
tlemen do not have to compete with quacks and pre-
tenders. Who ever heard of a quack architect, fraud-
ulent engineer, fake chemist, ignorant bank president,
or pretender to executive ability ever keeping his job
for longf We are not arguing against business dis-
crimination on the part of a physician, but we do
contend that one of the greatest of handicaps is to
be compelled to make bricks without straw. History
records what happened in Egypt when such tactics
were followed by Pharaohs and that history has been
repeated in many poorly adjusted economic condi-
tions; it is being repeated among the ranks of the
general practitioners of medicine today.
What is the remedy t It must be found, else the
wonderful advances that medicine and the cognate
sciences have made will fail to be the blessing to
humanity that they ought to be. Can their be any
doubt that in the "Family Physician" with his tradi-
tional relation to the rank and file of solid industrious
people we have the health factor of most fundamental
importance T Have we any evidence that institutional
medicine or state medicine can adequately fill his
place, effectively perform his function?
Which points the way to medical progress: an at-
titude of competition toward the general practitioner
on the part of modern collective medical agencies —
the hospital, etc.; or an attitude of constructive co-
operation through properly and fairly co-ordinated
effort to the end that the health interests of all the
people may be most effectively served and in a man-
ner satisfactory to them? — T. S. B.
(Continued from page 129)
as the patient showed any symptoms of the trouble
and then discontinue, only to begin again as soon
as the patient showed the least sign of a return to
the old conditions. Unlike a sore thumb, these
patients are never cured; they are only relieved
and helped and some of them almost restored to the
normal, but they are more easily thrown off balance
as to the endocrine secretions than is the average
normal person. Anything that irritates or disturbs
the secretion of these glands causes a return of the
symptoms and should be relieved by the indicated
glandular extract.
R. 0. Brown, M.D., Mt. Morris, HL
Probably a case of thymus deficiency in early
life — Ed. (Continued one leaf over)
The American Physician]
An Honest Market Place
135
1
Dom«* im Chfldrmi
Start with a half to one
teaspoonful 3 times a day
before meals. Increase or
decrease dose until one
good movement is obtained
daily. Then gradually de-
crease to tile point where
a small dose at bedtime
will maintain the forego-
ing result
Constipation in Children
is a field of use in which
INTEROL
has proven particularly serviceable and effective.
Tasteless, odorless and notably free from the dis-
agreeable greasiness that so many object to, Interol is
readily taken by the most squeamish child.
Used systematically in doses properly adjusted to
each patient's needs, peristalsis is gently excited, and with
the bowel contents softened and lubricated, complete and
satisfactory evacuations follow regularly, without requir-
ing straining, or causing the slightest pain or discomfort.
Sample and useful brochure on the successful use of
Interol sent on request.
Allied Drug & Chemical Corporation
2413 Third Ave. New York City
What does it mean
When the patient's tissues are water-logged, the heart is laboring to
overcome circulatory stasis, and the kidneys are unable to functionate
adequately? It should mean prompt prescription of
ANASARC1N TABLETS
Because
The contained active principles of Squill (scQlitozm and scillipicrm)
increase die force of cardiac systole and regulate cardiac rhythm,
beside stimulating diuretic action. €J Because die combined sam-
bucus and oxydendron promote free elimination of urinary fluids
and solids.
ANASARCIN strengthens the heart, regulates iU overcomes circulatory stasis, promotes
absorption of effused fluid and its prompt elimination.
Sample and literature to physicians on request
THE ANASARCIN CHEMICAL CO. Winchester, Tenn.
Mentioning The American Physician Insures Prompt, Careful Service
136
Proposed Re-organization of the U.S.P.H. Sendee
[Philm., February, 1922
Proposed Reorganization
of the
United States Public Health Service
NO GENERAL LEGISLATION providing for
the reorganization of the United States Public
Health Service has been enacted since 1889; nothing
but necessary patching to meet emergencies has been
undertaken.
Senate bill 2764, the Sixty-seventh Congress, was
introduced by Mr. Watson and was referred to the
Committee on Finance.
This bill provides for the addition of 450 medical
officers, 50 dental officers, and 50 officers to be at-
tached to the scientific personnel, all to be in the
regular corps of the United States Public Health
Service. This force the bill provides for recruiting
from the reserve officers now on duty but not com-
missioned in the regular service corps, all such re-
cruits being commissioned after suitable examination
for the grade to which they seek entrance and se-
lected only from among those who have shown profic-
iency in actual duty. The act does not provide for
any increased appropriations for the needs of the
service.
Owing to resignations and retirements, the number
of regular officers now on duty is less than in 1917,
and this has necessitated a Reserve Corps largely
made up of seasoned men who take care of responsible
work incurred by the increase in the merchant marine
of about ten millions gross tons, the millions of men
who are beneficiaries of the service through the Vet-
erans' Bureau, increased quarantine work, the rush
of immigrants to the United States, and interstate
work in epidemiology imposed upon the service.
These emergencies have been met, very patriotically,
by emergency men recruited for the occasion.
Now that the war is over this is a very unsatisfac-
tory status, and competent doctors do not care for
such appointments. It is only fair to the service
and to physicians serving under it to provide a proper
status for commission, so that a life career is open
to them, not a mere position of uncertain tenure.
This bill, we are informed, has the support of the
regular officers of the service, and we hope every
physician interested will do what he can to secure its
enactment into law; and especially should he express
himself favorably to the bill to the members of the
Senate and House from his district.
The plan proposed is a good one, in that it will
secure mature and experienced men of ability to
enter as a life work this highly necessary branch of
the government's work in public health.
BEST CURRENT MEDICAL THOUGHT
Th* ReUtmmlup ©/ Cmrcbumm to Meet*—
W. Ford Robertson (British Medical Journal, Decem-
ber 3, 1921), in the course of many years of bacteriologi-
cal work applied to therapeutic immunization, has devel-
oped some special culture methods by the aid of which
he has been able to observe facts regarding the behavior
of bacteria, which, although not altogether new, have
attracted little attention. One of these facts is that many
bacteria that we regard as aerobes commonly assume,
when their attack is prolonged, an anaerobic habit of
growth, and can be cultivated only under anaerobic con-
ditions. This applies, for example, to such important
pathogenic species as Micrococcus catarrhalis, the gono-
coccus, Streptococcus pyogenes, Streptococcus fecalis
hemolyticus, and several types of diphtheroid bacillus.
If a bacterium of this kind establishes itself in an
epithelial cell and multiplies, the cell may die on account
of the toxic action that ensues. It is far from likely
that in every instance the cell will succumb. One action
of bacterial toxins on cells is to stimulate growth. It
is possible that some types of bacteria, if established
within an epithelial cell, would have chiefly this effect.
With these facts and possibilities before him the hypo-
thesis suggested itself to the author that the rods he
has observed within cancer cells by means of the palli-
dum methylene violet method might be anaerobic bac-
teria that had established themselves within the epi-
thelial cells, and that the continued proliferation was
due to these bacteria. He has tested this hypothesis in
various ways during the past two years and submits
evidence to support it which he claims is, to put it
mildly, sufficient to arrest attention. There is evidence
to support the belief that there appears to be a race
of anaerobic bacteria, comprising several species belong-
ing to the large diphtheroid group or to the closely allied
streptothrix group, which are capable of infecting epi-
thelial cells and maintaining within them a parasitic
existence. There are some rounded or oval bodies that
may occasionally be seen in the cultures which cannot
be called either bacilli or micrococci, but which are not
incompatible with the polymorphism of some of the
higher bacteria, especially the streptothrices. It is prob-
able that bacteria of other groups are capable of acting
in the same way. If this is so, cancer may have to be
regarded as dependent upon a special mode of bacterial
attack, rather than upon a specific infection. Invasion
of the cell would appear to be effected, as a rule, by
bacteria of comparatively vigorous growth and easy to
cultivate, but when these bacteria adapt themselves to
purely parasitic intracellular growth they become com-
paratively feeble and extremely difficult to grow in cul-
ture media. Tumors can be produced in mice by both
the vigorous and the feebly-growing strains. Focal re-
actions can be obtained in some cases, success probably
depending upon the vaccine having been prepared from
the same species as that in the case. The possible
diagnostic value of such reactions is a question for
future investigation. He thinks the prospect of being
able to exercise some control over the growth of cancer
by means of therapeutic immunization is distinctly good.
In the discussion of this paper, Dr. James A. Murray
(Director, Imperial Cancer Research Fund, London)
said that he would state the objections that occurred
to him against the argument that Dr. Ford Robertson's
diphtheroid bacillus was the cause of cancer. In the first
place, mammary tumors in mice were common. It was
(Continued one leaf over)
The Ameriemn Phy^danl i4n Hottest Moffat PlaCt \$J
( To sleep or not to sleep
| That may be the pro blem
S
| Sleep, "that knits up the ravelled sleeve of care/*
I may be difficult to achieve for a patient who drinks tea or
S coffee excessively, whose nerves are probably kept on
I tension by the irritating effect of caffeine.
I Every doctor knows that without sleep, reconstruct
| tion of any debilitated state is impossible. During sleep
| the final conversion of food into vital nutrient material
s is largely accomplished.
I If your patient is neurotic and doesn't get the proper
| amount or the proper quality of sleep, it might be well to
§ interdict tea and coffee for a week or two, and order
Instant Postum.
With thousands of people, Postum is as satisfying in
flavor as the average coffee. This is undoubtedly one of
the reasons for the increasing popularity of Postum
throughout America. It serves every purpose of a hot-
meal-time drink, and as it contains no harmful ingredi-
ents, no ill-effects follow its use.
Postum is an absolutely pure cereal beverage, scien-
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Suggest Instant Postum to your next neurasthenic,
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Samples of Instant Postum for individual and clinical test will
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i
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Mentioning The American Physician Insures Prompt, Careful Service
138
Beet Current Medical Thought
[PhiU., February, 1922
interesting that none had occurred in Dr. Robertson's
controls, but that did not exclude the possibility of their
spontaneous development in the inoculated animals. It
was well known, however, that any form of chronic
irritation might give rise to cancer, and Dr. Murray was
quite prepared to admit a non-specific relation between
tumors and bacteria. A point against the specificity of
Dr. Robertson's organism was the very great variability
in the length of the incubation period in the experi-
ments— that is, from a few weeks up to eighteen months.
He had seen the bacteria-like structures in the tumor
cells when they were demonstrated at Oxford fourteen
years ago; he held then, as he still did, that they were
not bacteria. There were so many intracellular struc-
tures, such as mitochondria, which could be mistaken for
organisms, and under pathological conditions the intra-
cellular appearances might alter considerably. No evi-
dence had been forthcoming to prove that the rod-like
structures were bacteria. Dr. Murray mistrusted metallic
impregnation methods for the demonstration of special
structures. They were very uncertain in their action.
One never knew whether the whole or only part of a
structure would be impregnated. One part of a section
might stain beautifully, while similar tissue nearby
might be only partly colored or not at all. Much con-
cerning the minute structure of cells was still obscure.
A combination of morphology and staining reactions was
needed in deciding histological questions. Another point
against Dr. Robertson's theory was that there was no
constant relation between the site of inoculation and
the site of the tumor. Scarification of the ear did not,
for instance, explain the occurrence of a tumor in the
mammary gland or uterus. Dr. Murray thought that
the failure of the site of the tumor to correspond in
all cases with the site of inoculation, together with the
variability in the incubation periods, was strong evi-
dence that Dr. Ford Robertson's bacillus was not a
specific cause of cancer.
Dr. McAdam Eccles (Surgeon, St. Bartholomew's
Hospital, London) said that Dr. Ford Robertson's paper
was of the greatest importance, and was another link in
the chain of evidence of the infective origin of car-
cinoma. As an operating surgeon frequently dealing
with carcinomata, such scientific investigation of the
cause of carcinoma was of particular and practical im-
portance. All the material investigated appeared to
have been from a neoplasm which might have been in-
fected from the surface, the mamma through the ducts
in the nipple, the rodent ulcer, etc. If similar results
were to be obtained from a carcinoma which had arisen
in a "buried" organ, say a testis, it would be a very
striking fact.
The infection of and subsequent development of an
epithelial growth in so many mice was of the greatest
value. He ventured to throw out the suggestion that
because mice were the animals most easily infected with
later growths, might they not be a possible source of
the bacteria which infect the human, seeing also that
they were with us everywhere, and did not hesitate to
run over and help themselves to our food ? Had any of
the tumors arising "spontaneously" in the mammae of
mice shown any of these distinctive bacterial-like struc-
tures ?
1. As an emergency in eclampsia, uraemia, suppres-
sion of urine, etc. The more desperate the extremity
the more certainly it should be discussed, and cases have
been snatched from apparently impending dissolution.
2. In chronic cases, when medical treatment has
failed after a thorough trial In both the above classes
the heart and arteries should be reasonably sound, which
probably means that most success will be obtained in the
first half of life.
The EM*gy of RickeU
De Capmlmtiom of the Kiimeys n Bright' s Dumm
T. H. Sanderson-Wells (British Med. Jour., December
3, 1921), after reviewing the literature on this subject
and reporting a case in which this procedure has been
successful, at least for the time being, says the operation
deserves consideration under two conditions:
Frederick F. Tisdall, Toronto (Can. Med. Asso. JourH
December, 1921), conclusions are:
Pathological conditions have been produced in the
bones of rats, which bear a fundamental resemblance
to the bone lesions present in human rickets. These
changes have been produced by feeding (1) diets con-
taining an insufficient amount of phosphorus and an
unidentified organic factor, the other organic and inor-
ganic constituents being at an optimal concentration ; (2)
diets containing an insufficient amount of calcium and
the unidentified organic factor, the other organic and
inorganic constituents being at an optimal concentration.
Congenital or fcetal rickets, if it occurs at all, is an
extremely rare condition. No proof has been given
that rickets is due to a derangement of the function of
the glands of internal secretion and no evidence has
been advanced that infection, confinement or defective
hygienic conditions are more than contributary factors
in the production of this disease. A deficiency of phos-
phorus alone, calcium alone or the anti- rachitic factor
(fat soluable A?) alone, in the diets given to rats, will
not produce rickets.
The geographical distribution of rickets may be ex-
plained on the basis of the effect of the diet, and pos-
sibly of sunlight, on the prevention of the disorder. In
the tropics the children are not only exposed to sun-
light, but their diets generally have a large percentage
of leafy vegetables which contain a considerable quan-
tity of both the anti-rachitic organic factor and the
inorganic salts. The anti-rachitic organic factor is con-
tained in large quantities in cod liver oil and so far as
it is known rachitic lesions cannot be produced by any
means provided this oil is supplied in the diet. The use
of fish as a staple article of food by the inhabitants
of the far North gives an adequate explanation for
the infrequent occurrence of rickets in that region.
The possible effect of sunlight on the prevention and
healing of rickets and the favorable results obtained by
means of ultra-violet rays, are extremely interesting
when considered with the known effect of the anti-
rachitic organic factor. When cod liver oil is given to
rachitic children it causes a marked deposition of
calcium salts in the bones. Ultra-violet rays appear to
have an identical effect. The question arises whether
the ultra-violet rays produce or cause to be liberated
in the body a substance similar to that present in cod
liver oil, which stimulates the deposition of calcium salts
in the bones, or, on the other hand, whether the bene-
ficial effect is due to the emanation of certain rays pro-
duced by the oxidation in the body of the unidentified
substance in cod liver oil, which rays might be similar
to those present in the light from the mercury vapor
quartz lamp, or sunlight. It is known that the per-
meability of plant cells for certain inorganic salts is
increased by exposure to light. It is also known that
fatty oils emit light on oxidation. Further experimental
work is necessary for the settlement of this most inter-
esting question.
(Continued one leaf over)
The American Physician]
An Honest Market Place
139
i
Treatment of
CONSTIPATION
in OLD AGE
jOCVESCOHSTlMnOfl
syrup
KMoggf*
Bran Geuns
1 cup bran
1 cup flour
94 cup milk
2 tablespoons
or molasses
$4 teaspoon salt
1 tablespoon melted
shortening or cook-
ing oil
2 teaspoons baking
powder
Sift flour, baking
powder and salt into
bowl; add milk,
syrup and shorten-
ing; beat a few
minutes; brush gem
irona with melted
fat; fill three-fourths
full; place in hot
oven; bake 10 min-
utes. They should be
crisp.
Prevalence of constipation among the aged is very
general and a condition, as you know, that demands
considerable attention. In old-age cases as well as
those that are bed-ridden, Kellogg's Bran, thoroughly
Cooked and Krumbled, is offered as a natural and
very satisfactory measure of relief.
Besides the positive work of Kellogg's Bran, be-
cause its bulk serves to distend the intestine and
thereby induce better peristaltic action, it is particu-
larly pleasing in flavor and in edibility. Unlike
common brans, Kellogg's Bran, thoroughly Cooked
and Krumbled, does not become tiresome to the
patient. In fact, as a cereal with milk or cream, or
on the patient's favorite cereal, it is most appetizing!
Or, used in baking products Kellogg's Bran is par-
ticularly appealing to the most sensitive appetite.
Physicians may anticipate satisfying results from
prescribing Kellogg's Bran for both mild and chronic
cases. The average amount specified is two table-
spoonfuls for mild cases— in chronic cases, it should
be eaten with each meal.
Physicians are requested to send to us for a large
package oi Kellogg's Bran, which will be supplied
without any obligation. We are anxious that they
personally know the value of Kellogg's Bran.
the original BRAN ~coafte<? and krumbled
Mentioning The American Physician Insures Prompt, Careful Service
140
Book Reviews
[Phila., February , 1922
The recent work of McCollum, Simmonds, Shipley
and Park, although it constitutes a distinct advance in
our knowledge of the production of experimental rickets
in animals, does not solve the problem of human rickets.
Many children develop this disease when they receive a
diet of cow's milk, which contains a large amount of
phosphorus and calcium. In fact, rickets may be seen
in certain infants receiving almost any diet Never-
theless, it is a striking fact that the diets of most of
the children who develop rickets are ill-balanced and
low in the anti-rachitic organic factor. In all prob-
ability it will be shown that rickets in the human is
due to dietary defects with a possible combination in
certain cases of an insufficient amount of sunlight.
Eook %eyiews \
Duodenal Ulcer
T. R. Martin, Duluth (Minn. Med., December, 1921),
conclusions are:
(1) A little more than one-half of duodenal ulcers
in this series treated by gastroenterostomy got complete
relief. The relief was absolute; they are free from any
digestive disturbance, and usually eat what they please.
Twenty-five per cent were benefited, and 12 per cent
not improved.
(2) Thirty-five per cent in this series of uncom-
plicated duodenal ulcers responded to rather simple
dietary restrictions and alkalies, at least insofar as re-
maining symptom free for a reasonable period of time
is concerned.
(3) At the present stage of our knowledge, the fear
of possible malignancy arising on gastric ulcer must still
be a large determining factor in the choice of surgical
treatment; but the situation deserves the most intensive
study.
(4) Considering the fact that duodenal ulcer is
exceedingly common and relatively benign, and many
people go through life with this ailment without treat-
ment and without much inconvenience, it seems entirely
reasonable that all cases not presenting definite and
well known surgical complications should be given the
benefit of medical treatment. This must remain true
despite the remarkable surgical results of treatment in
properly selected cases. The successes enumerated, from
50 per cent to 80 per cent., variously estimated, still
leave 20 to 50 per cent, whose only remaining hope is
further questionable surgery, or medical treatment.
Would it not be advisable to try medical treatment
first?
The Deterwammtion of Dental Focal Infections by Mean* W Cm
Radiogram
Maximilian John Hubeny (///. Med. Jour., December,
1921) conclusions are :
First — The future of medicine and dentistry lies essen-
tially in prophylaxis.
Second— The burden of early treatment should rest
on the patient
Third — Co-operation of dental and medical profes-
sions in re-educating the lay people.
Fourth (a) — It is inadvisable to devitalize teeth and
when that stage is reached, extraction should be ad-
vised, although it must be admitted that devitalized teeth
are carried by patients, which teeth are not symptom
producing.
(b)— However, these teeth are potentially bad and
infection may occur at any time, without any local
symptoms becoming manifest.
Fifth— If the radiogram gives evidence of disease, it
is of value, in a positive sense; however, if no evidences
of disease are present, a definite exclusion of pathology
cannot be made, since considerable time elapses between
the onset of infection and X-ray manifestations of dis-
ease.
Infections of the Hand
By Allen B. Kanavel, M.D., Assistant Professor of
Surgery, Northwestern University Medical School. Lea
& Febiger, Publishers, Philadelphia, 1921. Price, $5.50.
Infections of the hand leading to permanent deformity
are of such paramount importance that one is amazed
that the literature upon the subject is as meager as it is.
The study is one not only of great importance to the
surgeon as well as to the patient, but the resulting
deformities and the uselessness of many hands play
an important part in human efficiency and thus becomes
too often a grave problem affecting the whole social
fabric, that may be traced to inefficient and improper
treatment, as well as to neglect on the part of physician
or patient or upon both.
In a well-written volume of 500 pages, Kanavel com-
pletely covers the ground, laying unusual stress upon
the all-important subject of tenosynovitis, which he
discusses in a masterly manner and indisputably shows
that "hands suffering from this dreaded complication
may be restored to complete function."
In the complete list of infections one is impressed
with the thoroughness with which such subjects as
erysipelas, gas-bacillus infection, anthrax, etc, are dis-
cussed.
A chapter full of practical application is devoted to
"Hand Infections Among Employes." Kanavel recog-
nizes that in these instances a great economic principle
is at stake and emphasizes the necessity of the removal
of external causes of accidents and of predisposing
causes for infections found in employes. He urges im-
mediate medical attention and advises iodine as a prophy-
lactic measure.
The work is printed in large readable type and is
embellished with 185 illustrations, a number of these
in colors to elucidate more clearly anatomical relations.
Taken as a whole the work reflects credit on the knowl-
edge and discrimination of its author. — A. W. H,
A Physical Interpretation of Shock, Exhaust** ami Restoration.
An Extension of the Kinetic Theory
By George W. Crile, M.D., Professor of Surgery,
School of Medicine, Western Reserve University.
Edited by Amy F. Rowland, B.S. Cloth, illustrated, 232
pages. Oxford University Press. Price, $8.75.
Dr. Crile, who was with the American Expeditionary
Force, was in position to study shock in France and con-
duct practical researches in justification of the kinetic
theory of shock and shockless operation through anoci-
association. This book sets forth the findings and gives
justification to the theory that shock will kill, even with-
out trauma, and did kill many thousands of soldiers. Of
course much laboratory experimental data is given,
largely studied in a regional manner and thus of direct
clinical value. Valuable studies are incorporated on the
effects of various drugs in shock. A study of sleep
follows and the effects of various agents in producing
shock and the phenomena produced under differing con-
ditions of exhaustion and trauma.
While there is much of theory in this work, there is
also marked clinical desiderata that seem so well based
that the treatment of shock and exhaustion is clarified.—
(Book Reviews continued one leaf over)
The American PhyaicUn]
An Honest Market Place
141
Home Treatment In
Tuberculosis
With over a million active cases of tuberculosis, home treatment is
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Dr. Beverly Robinson has stated "that we have absolutely no medi-
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treatment properly used and insisted upon."
Mistura Creosote Comp. (Kilgore's) contains the genuine wood
creosote unchanged by the addition of chemicals and will meet all the
requirements of the creosote treatment.
Dose : — Teaspoon ful in one-third of a glass of milk or water after
meals.
Sample Sent To Physicians On Request
CHARLES KILLGORE
Manufacturing Chemist Established 1874
82 FULTON STREET NEW YORK
Has it ever occurred to you
that your "rUn-ClOWI* patlCIltS who are tired all the time,
whose oxidation and elimination are slow, temperature subnormal and
blood-pressure low, especially in cases following an attack of grippe,
pneumonia or even a bad cold,
are suffering from hypoadrenia?
You can modify these common symptoms by supporting the adrenals.
ADRENO-SPERMIN CO. (Harrower)
is a splendid remedy in such cases (Sig: 1, q.i.d. at meals and bedtime).
This pluriglandular formula is effective because it contains the missing
internal secretions from the thyroid and adrenals, plus spermin (the
musculo-tonic principle from the gonads).
The excipient is calcium glycerophosphate — an accepted "nerve re-
constructant." It is a physiologic "pep-producer" and, figuratively speak-
ing, "it helps to burn up the carbon in the cylinders."
Try This, Doctor — It Work*!
The booklet "Adrenal Support" sent to physicians on request.
THE HARROWER LABORATORY
HOME OFFICE* GLENDALE, CALIFORNIA
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Mentioning The American Physician Insures Prompt, Careful Service
142
Book Reviews
IPhila., February, 1922
Roemtgem Imterpretatiom
By George W. Holmes, M.D., Instructor in Roent-
genology, Harvard Medical School, and Howard £. Rug-
gles, M.D., Clinical Professor of Roentgenology, Uni-
versity of California Medical School. Second edition
profusely illustrated. Cloth, 228 pages. Price, $325.
Lea & Febiger, Philadelphia.
A very practical work setting forth the subject from
an exact pathological point of view and written by ex-
perienced men who know the value and the limitations
of the field they so capably discuss. — '. .
The Assessment of Physical Pitmeu
By Georges Dreyer, C.B.E., M.A., M.D., Professor of
Pathology in Oxford University, and Geo. Fulford Han-
son, with a foreword by Charles H. Mayo, M.D. Cloth,
128 pages, with 24 tables. Published by Paul B. Hoeber,
New York City. Price, $3.50 net.
A scientific study of physical fitness as based on the
correlation of vital capacity and body measurement.
Men are divided into three classes: those developed
physically by training or occupation, those in semi-active
business or professions, and those leading sedentary
lives. The text and tables show standards for all three
classes which are fair in assessing physical ratings in
life insurance and for industrial and military examina-
tions. The work is a valuable contribution in its especial
field.
A Mammal of Physic* for Medical Students
By Hugh C. H. Candy, B.A., B.Sc, F.I.C., Lecturer
on Chemistry at the London Hospital Medical College
and Professor of Natural Philosophy in Queen's Col-
lege, London Second edition, cloth, 451 pages, freely
illustrated. Paul B. Hoeber, 67-69 West Fifty-ninth
St., New York City. Price, $2.75 net.
While this book is especially prepared for students,
the changes in physics, more especially in theory, of
the last twenty years are unfamiliar to physicians long
in practice. This work is an excellent one for a review
of the subject. Of especial interest to medicine are the
chapters on optics and electricity.
The New Pocket Meiieei Porumdary
By William Edward Fitch, M.D., third edition, revised,
with an appendix. Flexible leather, 470 pages. F. A.
Davis Company, Philadelphia. Price, $2.50 net
A well-selected list of formulae arranged in a con-
venient manner for ready reference and brought fully
up to date. The appendix gives formulae for hypodermic
medication, for fluid foods, etc., followed by diet lists,
hints on differential diagnosis and tables of doses. This
is one of the best work of its kind. —
Moierm Italia* Surgery ami OH Universities at Italy
By Paolo De Vecchi, M.D., F.A.C.S., Corresponding
Member of the Royal Academy of Medicine, Turin.
Cloth, illustrated, 250 pages. Published by Paul B.
Hoeber, New York City. Price, $5.00 net.
The American profession is under obligations to the
author of this interesting volume for his previous publi-
cation for Italians of a booklet entitled "Note ed Osser-
vazioni sulla Chirurgia e sui Chirurgi degli Stati Uniti
d'America," and this present work is a companion one,
though larger, wherein the American profession is in-
formed regarding surgical advances in Italy, more spe-
cifically the remarkable work done during the late war in
surgery of the chest, hernia, bone tuberculosis, kidneys
and certain procedures in amputations.
The book is well written, is not particularly technical,
gives a wealth of information on the Italian universities
and hospitals, and should be of great interest to Ameri-
can surgeons. —
Staties im Neurology
By Henry Head. M.D., F.R.S., in conjunction with
several other authors. Two volumes, cloth, illustrated,
862 pages. Oxford University Press, London. Price,
$17.00.
This is not a general treatise on neurology; it em-
braces studies on the peripheral and afferent nerves,
nerve division, spinal reflexes and the relationship be-
tween sensory disturbances and the cerebral cortex. The
work deals with the physiologic mechanism of somatic
sensibility and is in opposition to previous psychological
and physiological teaching; it represents a world of
study and careful observation, but the reviewer feels
justified in saying that the average neurologist will not
agree with the findings or conclusions reached. — '
Peehlemeu of Growth ami Congenital Dwarf h
With special reference to Dysostosis Cleido-Cranialis.
By Dr. Murk Jansen, O.B.E., Lecturer on Orthopedic
Surgery, University of Leiden, Holland. London : Ox-
ford University Press, 1921. Price, $5.00.
Quoting from the foreword by Sir Robert Jones:
"This book aims at establishing principles explaining
the manner in which body growth is affected by injuri-
ous influences. The author discusses the influences of
pathological changes and those of pressure upon the
determination of deformity. His aim has been to select
what he terms 'quantitative* changes of growth from
pathology, uniting them into a new chapter and linking
them together by simple laws or rules. This philosophic
and suggestive contribution carries a torch into the
dark places and displays a new line of research both
fascinating and scientific, and of great social and prac-
tical promise." The value of this monograph is greatly
enhanced by an abundance pf illustrations, including
radiographs and photomicrographs.
Disease* of the Nervous System
By H. Campbell Thomson, M.D., F.R.C.P., Physician
to the Department for Diseases of the Nervous Sys-
tem, and Lecturer on Neurology, Middlesex Hospital;
Physician to the Hospital for Epilepsy and Paralysis,
Maids Vale. Third edition, revised. Cloth, 566 pages,
profusely illustrated with figures and plates, several
in color. Paul B. Hoeber, 67-69 East Fifty-ninth Street,
New York City. Price, $5.00.
Beginning with a discussion of the neurones and
the reflexes, the author takes up the autonomic system,
cerebral localization, examination of the higher func-
tions of the nervous system and the paths of infection,
before proceeding to clinical differentiation, pathology
and treatment For the practitioner who desires a
compact volume which discusses neurology from a
modern standpoint, the work is well designed, for it
eliminates much of theory and controversy. The work
connects up well with other branches of clinical medi-
cine and is well designed to serve the needs of the
general practitioner. — '
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Helpful Points
[PhiU., February, 1922
Treatise ©a
of the
By Oliver S. Ormsby, M.D., Professor of Skin and
Venereal Diseases, Rush Medical College, etc., and
dermatologist to several hospitals. Second revised
edition. Cloth, 1166 pages, 450 illustrations, some in
color. Lea & Febiger, Philadelphia. Price, $10.00.
Dr. Ormsby has accomplished what he set out to do,
for his work is thoroughly practical and satisfactory,
both for the student and the practitioner. This is no
incomplete work, as it describes even the rare skin
diseases. An especial feature of value is the thorough
presentation of introductory data on the anatomy and
physiology of the skin, and general symptomatology,
etiology, pathology, diagnosis, prognosis and thera-
peutics. The work is to be cordially commended. —
Treatment of Rkewmmtitm
That salicylates cure rheumatism is one of the few
therapeutic facts which all admit, regardless of school
or creed. But even this statement requires modification
— two modifications in fact. The first of these is that
the diagnosis is correct, that the patient is really suffer-
ing from rheumatism and not from some specific com-
plaint, and the second is that the true, natural salicylates
made from the natural oil of birch or oil of wintergreen
are used and not the synthetic salicylates made from coal
tar. The careful physician can make sure that his
patient receives the true, natural salicylates by specify-
ing "True sodium salicylate, Merreir on his prescrip-
tion. All pharmacists have it or can get it from their
jobbers.
To insure the purity of their true salicylates, The
Wm. S. Merrell Company have purchased and now
operate three birch oil stills in Connecticut, where they
distill their own birch oil which they convert into true
salicylates at their Cincinnati laboratories. Write them
at Cincinnati for their brochure on the "True Natural
Salicylates and Their Uses."
JVfltereJ StwmUti— of CaUmrtU
Medical science has found a substitute for the cathar-
tic in the humble outer coating of wheat The substitute
is bran, a substance known for generations, but never
fully appreciated until intensive study of the relation
of food to human efficiency showed that the cellulose
so necessary to a proper diet was contained in large
percentage in it.
Dietitians have been studying nutritive food values
extensively within the past few years and with startling
unanimity have settled upon bran as one of a few very
necessary ingredients which should go upon the table
daily. They have found it invaluable for its beneficial
effects, and desirable because of its cheapness and sim-
plicity of preparation.
The digestion, medical science has found, is given a
false and artificial stimulus by the cathartic drug, and
its use is generally regarded as an important factor in
the alarming death rate. Physicians are prescribing
diet lists instead of laxatives and bran is always included
in these lists.
Chemical analysis of bran has shown it to contain
about 8 per cent, of mineral salts and also small per-
centages of phosphorus and calcium. Of these mineral
(Helpful Points continued one leaf over)
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It's here that Anusol Suppositories score some of their best results.
Besides, they materially reduce the need of internal laxatives.
Meaning better and more readily digested milk for the infant, and quicker
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The physical and psychic benefits are evident.
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Helpful Points
[Phila., February, 1922
salts is a particularly valuable ingredient, and physicians
state that there is no danger of there being too great a
supply of the latter elements in the diet.
Medical consideration of the prescription of bran has
followed not only the substitution for cathartics, but has
reasoned also that the human system is a finely wrought
mechanism which functions with greater efficiency when
not requiring laxatives, and that a regular diet, including
bran, fruits and other cellulose-containing foods does
away with the necessity of artificial stimulation for
catharsis.
has long been looking for, notwithstanding the acknowl-
edged value of the arsenical compounds. Both Salvamn
and Mercurosal are needed.
The manufacturers, Parke, Davis & Co., Detroit, Mich*
have a booklet on the subject which will be sent gladly
to American Physician readers, on request
A New Mttcwrim
The Old World gave us Salvarsan. The New World
has given us Mercurosal. Salvarsan is placed directly
into the vein ; Mercurosal may be also. Never until now
has the medical profession had a mercurial preparation
that could be administered intravenously, by the mere
introduction of the needle into the vein and the custo-
mary technique, without the practical certainty of oblit-
erating the vein.
In Mercurosal, the new P. D. & Co. mercurial, the
molecular form of the mercury compound is such that
it has no irritating effect upon the delicate tissues of
the venous walls; at the same time, characteristic mer-
curial effects upon the spirochetes are secured by the
intravenous administration of this compound.
One physician reports having made twenty-seven con-
secutive injections into the vein in a space not more
than half an inch in extent, without any ill effect upon
the blood vessel.
The chemical synthesis of Mercurosal must be re-
garded as a triumph over difficulties as great as those
which had to be overcome in the development of Sal-
varsan; and its accomplishment is what the profession
A if tfecttevy « erf #* ■ iwsssiesjef C^npflMflf
Today the physician, as much as the business man,
feels that he cannot trust to the vagaries of hand writing
— that he must be equipped with a typewriter.
In addition to the favorable impression typed instruc-
tions, histories, labels, directions, etc., make, and the
minimizing of the chance of mistakes and errors — there
is the important time-saving element Many physicians
are finding that a typewriter is one part of professional
equipment they cannot afford to do without.
American Physician readers have a very favorable
opportunity to get a good typewriter with medical key-
board, at a very moderate price, and on a monthly pay-
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When Mmerd Or* h MicaW
Lack of intestinal secretion, with over-absorption of
fluid from the feces, can be best relieved by mineral
oil. Too great care cannot be taken in selecting the
particular oil to use, in order not only to assure the
beneficial results desired, but to avoid the objectionable
effects that are invariably produced by oils of question-
able purity and indifferent quality.
In Interol practitioners have a mineral oil that pre-
sents in the highest degree the purity, quality and phy-
(Helpful Points continued one leaf over)
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any field of medicine.
Such American Workers as Osborne, Mendel, McCollum and Hess
have contributed vast new knowledge relating to foods. The concep-
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Helpful Points
[Phil*., February, 1922
sical properties that give it maximum efficiency as an
intestinal lubricant. Especially is it free from the lighter
hydrocarbons and sulphur compounds liable to prove
irritating to the intestinal canal or the renal structures.
Whenever mineral oil is indicated, Interol may be pre-
scribed with the gratifying knowledge that it will pro-
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Address: The Allied Drug and Chemical Corporation,
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and the salicylates, and a new viewpoint was developed
concerning the process which brings about their charac-
teristic reactions."
Physicians interested in intravenous medication, and
that includes most of us, will be interested in the clinical
reports, reprints and the Journal of Intravenous Therapy,
which will be sent to American Physician readers on
request. Address: New York Intravenous Laboratory,
100 W. 21st St., New York.
Discovery of lmhrmmow$ Method
David Loeser, Ph.G., writing in the New York Med.
Journ., gives an interesting angle on the discovery of
the intravenous method:
"It is recorded in the transactions of the Royal Society
of England by no less an authority than Robert Boyle,
the famous chemist and physicist, that the idea of the
intravenous injection of medicine was suggested to him
in the early months of the year 1657 by Sir Christopher
Wren. That Wren was not a physician, but an archi-
tect, is probably known to everyone who has ever heard
of St. Paul's Cathedral, and it is a curious fact that the
first record of such a revolutionary suggestion should
have come from one outside the medical profession.
"But it was not until the introduction of Salvarsan,
two hundred and fifty years later, that really serious
attention was given to the subject of intravenous medica-
tion. Before that time the action of medicinal remedies
was generally supposed to be dependent upon their pre-
dilection for certain tissues and organs. Practically no
studies had been made for the purpose of ascertaining
what effect such remedies produced upon the blood and
body fluids. The introduction of Salvarsan, however,
focused attention upon the possibilities of intravenous
administration of other drugs, such as the iodides, iron,
Have Yom Tried It?
In a discussion on the value of antiseptics, one doctor,
known to be a very successful practitioner, was very
emphatic in his expression of opinion regarding Alkalol
"You may say what you like," he concluded, "but in
my mind there is absolutely no doubt of the practical
efficiency of Alkalol. I know it because I have tried it.
Having gotten results, I use it. If a patient comes to
you with an inflamed conjunctiva, sore throat, tonsillitis
or a mouth that feels as if it had been sand-papered, use
Alkalol and note its prompt and satisfactory action.
"It does wonderfully good work in cuistitis. I use it
both as a urethral and vaginal injection. Its action on
irritated or inflammed tissue beats any peace congress
you ever heard of. I use it internally as an antacid,
particularly in hot weather. You can take it from me,
that irrespective of your present opinion of so-called
antiseptics and mouth washes, a trial of Alkalol will
convince you that the claims made for it, that it feeds
the cells, tones up tissues, overcomes congestion, and is
soothing and healing, are founded on fact. It's easy to
try it because you can obtain a sample of Alkalol with
literature giving the how and why of its action by
writing to the Alkalol Company, Taunton, Mass."
(Helpful Points continued one leaf over)
TESTOGAN
THELYGAN
For Men For Women
Formula of Dr. Iwan Bloch
After seven years* clinical experience these products stand as proven specifics.
INDICATED IN SEXUAL IMPOTENCE AND INSUFTIOENCY
OF THE SEXUAL HORMONES
They contain SEXUAL HORMONES, L e., the hormones of
the reproductive glands and of the glands of internal secretion.
Special Indications for Testogan:
Sexual infantilism and eunuchoidism in the
■ale. Impotence and sexual weakness.
Climacterium virile. Neurasthenia, hypo-
chondria.
Special Indications for Thelygam:
Infantile sterility. Underdeveloped mam-
mae, etc Frigidity. Sexual disturbances: to
obesity and other metabolic disorders. Cli-
macteric symptoms, amenorrhea, neurasthe-
nia, hypochondria, dysmenorrhea.
rwriifcil to TABLETS for (atonal m* aal to AMPOULES, for totraffeteal tofcdiM.
frUm: TaMtto, 4t to . bra, I2.it; impmIm. *• to . bra, IS.if.
EXTENSIVE LITERATURE ON REQUEST.
CAVENDISH CHEMICAL CORPORATION
Sole Agents.
Pearl Street
Established 1905
New
You can buy with Confidence— See "Service Guarantee to Readers" on page 166
The American Physician]
An Ftonesl Market Place
149
NATIONAL BIOLOGICS
Diphtheria Antitoxin (National) is of the highest quality,
physiological activity and therapeutic dependability. Supplied
in our Special Ready-to-Use Syringe with needle already in end
rubber, thus eliminating all possibility of Infection.
1000 Unit Pkff. $1.25 5000 Unit Pkg. $3.75
3000 Unit Pkg. 2.50 10,000 Unit Pkg. 6.50
For COLDS, use our MIXED VACCINE
(Ear, Nose A Throat)
An efficient prophylactic and an effective treatment in sinus infec-
tions, middle ear disease, chronic tonsillitis, bronchitis, etc Dosage,
200, 500, 1000 and 2000 million bacteria.
4 Amp. Pkg. ..$1.50 Sec Vial. .$1.00 20cc Vial. .$3.00
NATIONAL VACCINE & ANTITOXIN INSTITUTE
Oldest in America
WASHINGTON, D. C.
THE BEST TREATMENT OF High BloOCL PreSSUTC
should be studied and understood by every doctor
Hypertension is always a danger signal
Pulvoids Natrium Compound
(High Tension Dr. M. C. THRUSH)
is a scientific and clinically tested combination of safe, non-toxic, non-irritating agents, whose
action is prompt to appear, reliable and prolonged in effect
COMPOSITION
Potassium nitrate, sodium nitrite, sodium bicarbonate, nitroglycerin and Crataegus oxya-
cantha (tonic for heart muscle and to prevent shock). Special (green colored) sugar coat-
ing, to dissolve in intestinal tract, and avoid gastric disturbance.
Dosage: One pulvoid ti.d. increased when necessary to twelve daily, until pressure
reaches normal, then reduce the dose.
Booklet on High Blood Pressure. How to take,
interpret and treat it, sent free on request.
If you dispense, ask for price liat
SPECIAL OFFER TO PHYSICIANS AND HOSPITALS ONLY
200 Pulvoids for $1.00. One time only.
1000 Pulvoids for $5.00 on 60 days' trial: money back if not satisfied.
Either mailed free when cash accompanies order, or if sent C. O. D. mailing and
collection charges added.
IHE DRUG PRODUCTS CO., Inc., 150 Meadow St, Long bland City, N. Y.
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
[Phila.. February. 1022
Wrttk Victim* Twttd Wkk Hfp^UmU
The value of the Mulford Hypo-Unit, as an inject-
ing device, had a practical test in a wreck which occurred
on a branch line of the Philadelphia and Reading Rail-
way on the morning of December 14, 1921.
Calls for assistance were sent to a nearby hospital,
which, fortunately, had its ambulance and receiving room
equipped with this "ever-ready hypodermic," with the
result that immediate relief was administered to those
who were injured, and those who were passing into the
great beyond did so insensible to their agonies or the
surrounding conditions.
On the scene of any catastrophe, whether fire, wreck
or panic, it is impossible to administer a hypodermic
without loss of time and inconvenience ; every minute of
delay is an eternity of agony to the sufferer ; the Mulford
Hypo-Unit is instantaneous — immediate administration,
immediate relief.
Hypertension, or as it is more commonly referred
to, high blood pressure, is a subject that is constantly
receiving more attention from the more progressive class
of medical men. High blood pressure always means
something, and while it is true that there has been a
tendency to overestimate its value as a symptom and
even a disposition on the part of some careless thinkers
to consider it more or less of a fad, the fact remains
that it is of vital importance in most cases and of valu-
able significance in all.
In order to successfully and satisfactorily treat hyper-
tension, it is necessary first to understand thoroughly the
technique called for in the making of accurate estima-
tions of increased pressure, and, secondly, to understand
thoroughly the significance of increased pressure read-
ings in any given case. Then, and not until then, is the
physician in a position to lay down effective treatment,
which, by the way, consists not only of the administra-
tion of certain drug agents, but also of a very rigid
overhauling of the patient's method and mode of living.
Facts and figures regarding hypertension, what it is,
what it signifies, and how it can be treated efficiently,
are set forth in a booklet, which has recently come
from, the press and is now being distributed gratis to
any physician on request, by the makers of Pulvoids
Natrium Comp. (High Tension, Dr. M. C. Thrush.)
This combination has for a number of years past
been steadily growing in popularity and increasing in
use among many progressive physicians. Judging from
the clinical reports that have accumulated from its use,
it may be relied upon as an efficient means in the treat-
ment of high blood pressure.
This booklet and other data regarding the preparation
can be obtained by writing to The Drug Products Co.,
Inc., 150 Meadow St., Long Island City, New York.
Otttptl a At Umg Aaa
Wise car owners do not make the mistake of esti-
mating the cost of lubricating oil by price alone — but
take into account the more important element of saving
on repair bills.
A high-grade oil, regardless of its price, will often
be found the cheapest in the long run. Emco Oils, re-
fined from Bradford, Penna., crude, are among the really
cheap oils, as they are pure, have least possible free
carbon content and are backed by a most liberal guaran-
tee. For further information, address : Emery Manu-
facturing Co., Bradford, Pa.
[Helpful Points continued one leaf over)
Yon can buy with Confidence — See "Service Guarantee to Readers" on page I
TheAaeric^PhyMcUn] An Honest Market Place 151
Benzylets Are Tasteless
and free from any tendency to disturb the stomach;
compare them in this respect with any of the solu-
tions of benzyl-benzoate, one taste of which, were
you the patient, would be quite q. a.
The most particular patients will readily take
"Benzylets/'
The most particular prescriber will concede their un-
questionable ethical status.
The best-stocked druggists supply "Benzylets" only
in ethically-labeled boxes of 24 gelatin globules,
each carrying 5 min. of medicinally pure benzyl-
benzoate.
Benzylets Sharp & Dohme
" The Wonder Remedy of the Age "
Radium Capsules
For Internal Administration
The physicians who have employed radio-activity in the form of our RADIUM
CAPSULES are enthusiastic over the remarkable results secured through their use.
There are ample proofs for knowing that the radium emanations are incorporated in
these Capsules. The photographic plate and electroscope, as well as the highly favor-
able clinical results, prove it Convenient and accurate for internal administration. No
possible harm can come from over-dosage.
Therapeutic Indications. — Gout, Rheumatism, Neuralgia, Eczema, Acne, Pruritus,
Psoriasis, Glandular Enlargements, Chronic Ulcers, Arterio-Sclerosis, Nephritis, Diabetes,
Menstrual Disorders, Neurasthenia, Impotence, Pre-Senility.
EXPERIENCED CLINICIANS have demonstrated the following therapeutic facts by administering
Radium internally: Elimination of Carbon Dioxide and Uric Acid — marked increase of the red blood
corpuscles and hemoglobin — Constant improvement of metabolic changes — Arthritis, Gout, Sciatica, Myalgia,
promptly relieved — Pain in general yields quickly — Increases the quantity of urine — Regulates all glandular
activity — It has proved a powerful aphrodisiac — It is a remarkably effective and harmless TONIC for the
aged and infirm — In chronic skin affections its results are often but little short of wonderful — It lowers
blood pressure, through its influence on the vasomotor nerves.
RADIUM CAPSULES are supplied at $2 per hundred or $15 for one thousand.
Guaranteed radio-activity. Containers protected by heavy X-Ray Lead Foil
SO YOU MAY CONVINCE YOURSELF by a thorough clinical test, Doctor,
accept our INTRODUCTORY OFFER of $10 worth of these Capsules for only $5.
Regent Drug Company, Detroit
MAIL THIS COUPON TODAY
R*gwt Drug Company,
Eliot Station, Datroit, Mica.
For the enclosed $5, send me at once, postpaid, insured, five hundred RADIUM CAPSULES, with
complete directions, as per your special introductory offer in Th« Amkbicaw Physician.
NAME
ADDRESS
Mentioning The American Physician Insures Prompt, Careful Service
152
Helpful Points
[Phila., February, 1922
SINCE VITAMINE
DISCUSSIONS ARE
SO POPULAR
NOWADAYS—
The experiments with fruits place
the dietary value of these foods,
hitherto recommended because of
their salt content, their laxative
properties, or their antiscorbutic
potency, m a new light as sources
of water-soluble vitamine. . The
edible portions of apples and pears
furnish some water-soluble vita'
mine, but prunes apparently are
richer in this food-factor.
— from a summary of en investigation
m the waUT'$ohible vitamine con'
tent of fruits as published in the
Journal of Biological Chemistry
Because they're iun'dn^d, Sunsweet Prunes
lose little, if any, of their vitamine content
in the drying process. No artificial heat is
used in"cunng"this fine, full-flavored fruit.
But vitainines-important as these growth
elements may be— are not the major reason
for urging prunes in the dietary of your
patients. Properly prepared, these natural
sweetmeats offer a relish that makes them
decidedly eatable. Their simple fruit sugars
are easily digested. Their salts and organic
acids are readily assimilated. Nor should
you overlook their traditional laxative
value in mild [and often in obstinate] cases
of constipation.
You will be interested in our semi'sciety
tine brochure,MFbr the good that's in them'*
—and it s free. California Prune €f Apricot
Growers Inc., 180 Market St.,San Jose,CaL
SUN5WEET
CALIFORN1AS NrYnjRE'ELAVORED
Wit Imertmat Ymtr EGciemcy
It is a wise physician who invests in equipment which
will increase his efficiency — this indeed is an investment
that yields dividends.
Many clinicians are finding the Pulse Wave Recorder
an aid in diagnosis and treatment that they cannot afford
to do without. Turn to page — and you will find a
proposition of the Sanborn Company, 1048 Common-
wealth Ave., Boston, Mass., that will interest the active
physician.
Dtmiutrmte to Yamr Omm Srtiffafm
Every physician can demonstrate to his own satisfac-
tion that the careful preparation and the scientific and
clinical tests which go into the making of Nujol, have
resulted in a mineral oil of assured purity, quality and
efficacy. Sample and authoritative literature will be sent
gratis. Turn to page — and send in the coupon.
A DeptmimbU Prodmd
Hydroleine is a pleasant, palatable, easily assimilable
emulsion of pure Cod Liver Oil, and is a powerful
blood enricher and tissue builder, increasing the power
of resistance of the body, fortifying against disease at-
tack and fending off germ invasion. Hydroleine is an
old and proven product, and has gained and holds many
friends through its dependable qualities.
For booklet and sample, mention The American Phy-
sician, and address : Century National Chemical Co.. 86
Warren St., New York.
A Complete My F—i
Nestle's Milk Food is not a modifier, it is a con-
centrated dry milk powder, already modified with cereals
and sugar that only requires the addition of water and
boiling for one minute to provide a complete food pre-
senting the elements the infant needs to assure normal
growth.
A liberal supply of samples for professional use and
copies of "The Mother Book" for distribution to your
patients, will be sent to American Physician readers on
request. Address: Nestle's Food Company, Nestle
Building, New York, or 112 Market St., San Francisco.
Succeuhd in Treating TotuB'du
Benzomint — a compound of sodium benzoate with
alkaloids of calisaya— -has been found to be an effective
internal remedy for tonsillitis. Benzomint is antiseptic
and antipyretic. It acts both locally and systemical'y in
reducing inflammation and congestion, in rebuilding
strength and quickly relieving all constitutional symp-
toms. It has a clinical history covering many years of
consistently successful treatments.
Samples and literature will be sent to American Phy-
sician readers on request, address: Throat Specialties
Laboratory (Milburn Pharmacal Company, Inc.), Bald-
win, L. I., N. Y.
(Helpful Points continued one leaf over.)
MORPHINE
NEW HOME TREATMENT
For all Drat and Alcokofio AdcBctfo— Doctor tstut
•J doom ptfTfttafar yon raw. No pin* vtxj fifth ovcomfi
—.fatihirt foe tooie who tHrmm. Endow ftanpfot fal
DR. QUAYLE'S SANITARIUM
MADISON, OHIO
BOX 5
You can buy with Confidence — See "Service Guarantee to Readers" on page 166
An Honest Market Place
Endocrine Derangements
Functional Unbalance
of the Ductless Glands
Endocrine products have largely replaced other medication in the many conditions now
known to be due to functional impairment and unbalance of the ductless glands.
Attention is particularly called to the following perfected pluriglandular formula.
PrtMto-OrcBOid Compound (Mayson) is the most successful pluriglandular remedy
for the treatment of Impotence, Sexual Neurasthenia, Prostatic Disorders, Hypertrophied
Prostate, with Bladder Irritation, and Pro sialorrhea.
Proato-Orchoid Compound (Mayson) contains prostate, orchic extract, lymph
glands, with nuclein in suitable proportions. The synegistic relations of the prostate and
orchic glands are perhaps more pronounced than those of any other two glands in the
body, and physicians are obtaining the most gratifying clinical results by the use of this
remedy. Cases are reported in which the need of catheterization with its attendant danger
of infection was avoided by the persistent use of this formula..
Procto-Orchoid Compound (Mayson) is indicated and has been used with success in
Chronic Prostatitis, Senility, and after Prostatectomy. It is a most valuable Genito-Urinary
tonic.
Try it in your stubborn cum
Pickax* •■ IN tablet* in sanitary glaa* via]., «3Jlo
Booklet containing list of per-
fected pluriglandular formulas,
therapeutic uses, etc., free.
The Mayson Laboratory
S S. Wabash Annua Chicago, HI.
The Fat-Soluble Vitamin "A"
and Alkaloids
MORRHUOL and
MORRHUOL CREOSOTE
Prescribed for over thirty years
with gratifying results in the
so-called "deficiency diseases"
Recent studies on the Vitamine have con-
firmed previous clinical evidence and have
definitely established the therapeutic value
of these Chapoteaut preparations in the
routine treatment of —
T. B., Rickeoj and Bronchial
Catarrh
Prescribe in original vials
Literature and samples on request to
E. FOUGERA & CO., Inc.
GUIOLEUM
10 fa- Cent Electrolytic Iodine in OH
An Effective
Remecjj) in
Gonorrhea
5cc. of Guioleum
should be introduced
into the urethra
daity by means of an
ordinary urethral
syringe and retained
five to ten minutes
PRICES:
Jounce package $ 2.50 '
4 ounce packaga *aoo
Ihtra^nous FtoduckCa of America, 6c
121 MadisonAve, New York
Mentioning The At
Physician Insures Prompt, Careful Sen.
154
Helpful Points
[PhiU., February, 1922
Specialties for
Tonsillitis
Benzomint
INTERNAL REMEDY
Compound of Sodium
Benzoate with Alka-
loids of Calisaya
A TIME-TESTED, highly
therapeutic ■ formula which
has proved a veritable
wonder worker in many thou-
sands of cases of Tonsillitis.
Benzomint has pronounced anti-
septic and antipyretic properties.
It soothes instantly the intense
pain from swollen, inflamed
glands, and quickly counteracts
both local and systemic infection.
Glycodin
(GARGLE)
AN efficacious astringent
and antiseptic gargle of
great value in the treat-
ment of Tonsillitis.
Pint, $1.00; Five Pints, $4.50;
Gallon, $6.00. Either preparation.
Send lor samples and literature
THROAT SPECIALTIES
LABORATORIES
(M1LBURN PHARMACAL CO., INC.)
BALDWIN, L. 1. NEW YORK
McKesson A Robbins
Wholesale Distributors
New York City
RkmU /a Attctmm eS Jfac and fare*
Rhinol in Affections of Nose and Throat
A Boston physician writes of Rhinol: "You have a
very superior preparation, and I was astounded at the
quick results produced. I cleared up my own acute
frontal sinusitis in a few days, then gave it to a hay-
fever patient, who has been more relieved than by any-
thing she has ever used. I dread being without the
outfit for fear I may have another attack of sinusitis."
The price complete is $3.00 — refilled packages, $2.50.
Address: Rhinol Company, Inc., 1416 Broadway, New
York.
A Mew Amgle
Constipation is one of the problems which seem to
be ever with us. It has been approached from many
different angles. Regulin offers a new principle in the
conquest of chronic constipation — treat the bowel con-
tents rather than the bowels themselves. Regulin will
be found to correct the physical condition of the intesti-
nal mass, restoring its normal bulk and softness and
resulting in a resumption of natural bowel function.
Thus Regulin is a true bowel corrective. For samples,
address: Reinschild Chemical Co., 47-49 Barclay St.,
New York City.
A Comttrmctvot Edmcatiomti Cmmpmgu
February 27 to March 4 will be Prune Week. This
is the first National Prune Week inaugurated by the
California Prune and Apricot Growers — a co-operative
state-wide association of 11,000 growers.
The nation-wide advertising featuring Sunsweet
Prunes, in addition to fostering interest in the particular
brand, has served a valuable and varied educational pur-
pose. In stimulating an increased desire and demand
for fruit-foods, such as prunes and apricots, a better
health understanding on the part of the public at large
has resulted.
Every physician should know about the particular
qualities these fruit-foods embody and should be able
to give his patients any information they may desire, as
a result of the interest created by the very constructive
campaign that is in progress. If you have not yet
received it, you will find the health-brochure "For the
Good That's in Them" of interest and benefit. It will
be sent to you gladly on request. Address: California
Prune and Apricot Growers, Inc., 180 Market St., San
Jose, Calif.
Tie Importance of Momik CUmVmtu
The mouth offers an ideal dwelling place for germs;
it is of just the right temperature and moisture, and
unless regularly cleansed, there are always enough
decomposing food particles in the deep tissue folds and
around the teeth to provide a favorable medium for the
growth of all sorts of pathogenic bacteria. Oral clean-
liness has become, therefore, an essential detail in the
prevention of many diseases.
For cleansing the mouth, there is no antiseptic more
servicable in every way than Dioxogen. Owing its
germicidal qualities to pure oxygen, it penetrates to the
deepest recesses of the mouth, where it softens and
detaches all accumulated material, and cleanses and puri-
fies everything with which it comes in contact.
Dioxogen, in consequence, can be used as freely as
necessary, or desired, in even the youngest patients, with
absolute certainty not only that it will keep the moutn
and teeth in a clean and wholesome condition, but that
it will always do its work in a safe, pleasant and agree-
able manner.
{Helpful Points continued on* leaf over)
You can buy with Confidence— See "Service Guarantee to Readers" on page 166
Th. AB«riean Phy tk
An Honed Vartri Place
Liquid Petrolatum, the
Emollient and Lubricant
"Liquid petrolatum . . . when taken into tie stomach panel into the in-
ttitinal tract unchanged; it nat dignted by the im.ymti and it thut able
to exert to the fall tti emollient and lubricating action, it ii absolutely
» n- irritating.
"A Protmntnt Medical Authority"
NUJOL is the most suitable liquid petrolatum for use in intes-
tinal stasis. The unexampled resources and experience of its
makers, the Standard Oil Co. (New Jersey), guarantee its purity,
wholesomeness and applicability to general requirements.
Nujol is scientifically adapted by both viscosity and specific gravity
to the physiology of the numan intestines. In determining a vis-
cosity best adapted to general requirements, the makers of Nujol
tried consistencies ranging from a water-like fluid to a jelly. The
viscosity of Nujol was fixed upon after exhaustive clinical test and re-
search and is in accord with the highest medical opinion.
Sample and authoritative literature dealing with the general and
special uses of Nujol will be sent gratis. See coupon below.
NijiOJ
A Lubricant, not a Laxative
Nujol Laboratories, Standard Oil Co. (New
Room 765, 44 Beaver Street, New York.
Jeney),
Please tend booklets marked:
CI "In General Practice"
Q "A Surgical Auiitant'
□ "In Women and Children"
O Also simple.
Name
Add™,
The American Physician Insures Prompt, Cartful Servict
Helpful Points
[Phil.., February. 1922
MEDICAL KEYBOARD
Witho
i million cases of tuberculosis, home treat-
i absolutely necessary. It consists of rest, food
and fresh air, supplemented by proper medical atten-
tion and medication.
Dr. Beverly Robinson has stated "that we have abso-
lutely no medical treatment of pulmonary tuberculosis
at all equal to the creosote treatment properly used and
insisted upon."
Mistura Creosote Comp. (Killgore's) contains the
genuine wood creosote unchanged by the addition of
chemicals and will meet all the requirements of the
creosote treatment. Sample will be sent to American
Physician readers, on request. Address: Charles Kill-
gore, 82 Felton St., New York.
"jjjj^J Q*<Jity Prtdmctt At a 30 Pa cat Stag
■fy More and more is modern therapeutics recognizing the
value of the intravenous method. Every physician should
TYPEWRITER SENSATION u^YiTpU be inf<"'nie<:l on *e advantages of the method and be
utv trtu Hud u onir is.w * month unm tio lew touj prion of ready to use intravenous medication when indicated.
IW.U la paid, ud the nucMn. >> run, Thta U ibwiuteir the George A. Breon Co. have been pioneers in this field
maO/SrSS ffwM p*V UM "mmS ud an tnekfttak af and today are one of the most progressive and largest
it— nojini ■ fioo.uo iiuhine for im.m. Ouh prioo i«.oo, jurt producers of intravenous products, from the newest and
. utti. mnx. th»n haw iu oruriui frio*. best of prove<i formulae. Now "they are offering their
L. C. SMITH No. 5 w88$.'$Bl&m Tnty pr<?T V- 1 TT °f 2? pf cenLT,he7 IlT
•>..*_. _..m__ <■„-— ™.^.-». i« it j . - o. j _, « . always set the highest standard of quality for their
Perfect machine.. Comepondenoe alae, Keyboard of Standnrd Uul- . . . ,, _ ,,- .- ■ ,,_..■
.e™»i arrangement, SB Key., wrttnif to chuecten, with four products, and now they are establishing a price that »
medical character, and ipcdal paper bolder, for writing card* ud of further advantage to the physician.
t»iaSrIiaiurtb,1t»bota5, £i^«^1SSii^KiMt«latS Wri,e for ktest priec ,is,s today' il wM1 n,ean a
iBTeree. the buck ■pacer, ball bearing t/pe ban'baU bearing car- considerable saving to you. Address: George A. Breon
*B*#J« NWtoJ ■«(*■«£", in fact, ererj i.t. .trl. Co., Dept 102, Coca-Cola Bldg., Kansas City, Mo.
thing complete: tool., cover, operating book and matnujtlono— , .. „ "
nothlDf eitra to buy. /■ tit Meaopemt*
Ten eannot imagine the parfoetfofi of thia beautiful noofurrnntad ir .« ,,t-. . j .__ ■ .
typewriter until"™ h»,eiwn it. W. ban aold ttmieand, rfthiae Maranon said : "The menopause is not due Simply to
perfect late itji. maebiDu at thu bargain prio* and erorj one of insufficiency of the genital glands, but is the expression
thea.th.BMnd. of .atlened Mm had thi. beauUfnl, .triotlr of an 'endocrine crisis' complex, varying in different
Hp-to4at* machine on five out free tarial before deoidina to bur It. r l ■ i_ .,_ - j ■ en ■ r .l -.1
We will nod it to jon w. o. b. Chicago for Btb iiT? fre. trial! persons, of which the said insufficiency of the genital
it will icii itatif. but if jou tru not latiafled that thii 1. the glands is the central factor, but with it, other glandular
f^uwt w^nt'to nfirT't t£r^' tr/Tt," ft,lt,,t °" tIBtB"- disturbances play an essential part."
cannot equal thi. wonderful t.Id. anywher*. ™ w* ""* ,ou The menopause, therefore, is a functional pluriglandu-
lar, tin unucv <*. m — *a, aaaat AFTER Iar derangement and is best treated by pluriglandular
SEND NO MONEY fc^_ Q Cf *"** therapy, fn hypotensive cases, good results may be
Put in Your Order now V^aaTm^mmW^^ TRIAL had by the use of Hormotone, and in high blood pres-
When the typewriter arrive, d.poait with the ,lpre« agent W.Sa sure eases, Hormotone Without Post-Pituitary isindi-
and take the machine for Ore daji' trial. If too are conTlnoed cated. For further information address: G. W. Carn-
luLm'i "nJnr* ^hi1"*"^1" fog ^JI ?S& " ""' ""ld u* rick Co., 419 Canal St., New York.
M.00 a month nntil our bargain price of tSB.SS l> paid. If »on ' _J
don t want it, return It to the eipren .gent. recelTe roor S4.BS —— '
and «tnra the machine. We will par the retnrn rxpren charge.. B* Prtpottd
1. ttandard. Over half a minion* people"" Jl? .n* um th«e tjpe- ^"ne Dest immunizing response in pneumonia is obtained
writer, and think them the beat ever manufactured. The eupply at during the first twenty-four hours after the initial chill.
afi^,,iSS.tt.:£?',air'"s;5"1,';hrr„rsJ:" Ev^ k™' hv™- ^ily- »>»«»<< ■»««.",•■' .■»
the trpewrtter will be ahlpped promptlr. There i» nored tape. munologists make inoculations in respiratory infections
■Tmpi?PuMe™tood'cth,7— "" Sf* i«I ^! ct"ne' tnorl*»ee- tt i» at their first call. Many find it easy to be prepared by
SSO.bb li paid. Ton* ranno "liee t™* wiii'pwha™"^ ™?' h*™ carrying an assortment of Sherman's Polyvalent Vac-
a greater typewriter opportunity. Do not lend na one eenV Set cines and self -Sterilizing syringe in convenient case, made
the oonpon ".«•»»",■••-«»'-"". by G. H. Sherman, M.D., Detroit, Mich.— largest pre-
SMITH TYPEWRITER SALES CO. ducer of stock and autogenous vaccine.
Dept. ISO. 218 N. Well. St-. Chicago
Smith Typewriter Bala Co.. Dept ISO, Ml K. Vell»™St_ Chiii^ ^n 0*4 Bjfirnt
^^~a^Si,^^^f^^%^u%,^S^***^ Dr. R. B. Waite's Anti-py-0 DenUl Cream best
until the sw.oo balance of the hpecial S09.SS i.ie price it paid. meets the requirements of oral hygiene. It is antiseptic
that I na« Bre'to. in'wiir*' to '""^ E» Sfi Tt '* anaer*,om' and a thorough cleanser; it leaves the mouth refreshed
If 1 ehooae not to kcPp it I wffl'carefnllr i™ck It anTTTtHrn and wholesome, and helps to eliminate dangerous bac-
'* tp the *«p™«. .gent, it it understood th.t too give the et.nd- teria. Sample tuhes and a full-size tube for your per-
iled guarantee. sona] use of Antj.py.o Dental Cream, will be scot to
*"* America.^ Physician Readers. Turn to page 94 and
8tr*** *anra§i !erK| jn the coupon.
°*^ State (Helpful Points continued one leaf over.)
You can buy with Confidence— See "Service Guarantee to Readers" on page 166
The American Pnjjriciin]
The American Physician
LINE w*va tb* fir.i ml»i.l oil pat
market In tbla rouutrj. It kaa
been astanalvalr advartlaad. and
*or It, therefore pbyiicLana hava baan
■taadlly and fncnutngly ptaacrfblna; it
for tntaraal u
OIL PRODUCTS CO., Inc.
H Ualea Scjanra, Nav Yarn, N.Y.
To ALLEVIATE PAIN, to PROMOTE DIURESIS
and to PROTECT the membrane of the urethra, especially
THE POSTERIOR PORTION— these are the important
object! of the treatment of acute cases of Gonorrhea.
The entire urinary tract should be influenced by means
of proper internal medication. Local injections alone will
not be sufficient
This is the rationale of GONOSAN.
RlEDELACO.,Inc
LISTERS DIABETIC FLOUR
Strictly Starch-free. Produces Bread.
Muffins. Pastry that makes the
. I distressing features
t I ■afcfcaa.^
Grow
Less and
less ■
Lifters prepared casein Diabetic Florji — self rising. A month's supply of 30 boxes $4.65
LISTER BROS. Inc., 405 Lexington Avenue, New York City
i
TEs
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
[Phil*.. February. 1*»
Light and Hul la Skin DIhuu W
been Proven.
In the microbic skin diseases,
such as acne, furunculosis, erysipe-
las, tinea sycosis, and similar infec-
tions, the
STERLING
THERAPEUTIC
LAMP
liai been found of distinct value. Heat
waves bring pure arterial blood to the
part and take away the venous blood
by dilating the smaller vessels in the
periphery. The main action of the
lamp, however, in germ or microbe dis-
eases is, that the germs cannot live in
light. The penetrating effect of the
2000 cp. lamp is fata] to most germs
in 10 minutes' time.
Illustrated booklet end literature *ent on
Sterling Therapeutic
Lamp Co.
I 546 Garfield Ave, Chicago, ffl.
De»k 203
A CampltU Liar of fat rav«a
To the modern physician, awake to the advantages
of direct medication, a complete line of pure and Stable
products, which may be injected into the blood stream
with the certainty of no untoward effect, is offered by
the Intravenous Products Co. of America, Inc., 121
Madison Ave., New York City.
For catalogue giving complete formulae of specialties,
reprints of interesting articles, and price lists, address
as above. Correspondence is invited and will be promptly
replied to by one of the physicians on the company's
staff.
Tbt t
1 For tf™
Many physicians have found Styptysate the effective
remedy for hemorrhages. It is of particular advantage
in monorrhagia and metrorrhagia, and has also been
found to be of great value in vesical hemorrhages and
hemorrhages from mucous membranes in general.
Results in many cases have been surprising; there are
no secondary ill-effects upon circulation or respiration;
Styptysate is therefore a safe remedy. Turn to page —
and see special introductory offer.
AtMftnaU* Irm
In post-febrile anemia and convalescence from acute
illness, where hematinic reconstructive treatment is indi-
cated, you will find that Hemaboloids is especially
adapted. It is bland, palatable and easily acceptable to
the irritable gastric mucous membrane, for it is axio-
matic that organic iron is assimilable iron and free from
all harsh or constipating effects.
Samples and literature will be sent to you. Mention
The American Physician and address: The Palisade
Manufacturing Company, Yonkers, N. Y.
Tiry Cat Rcariti
Many physicians have found that Merz Santal Comp.
Capsules are unsurpassed for happy effect in urethritis,
cystitis, prostatic troubles, difficult micturition, etc.
There are new prices on these excellent capsules now,
and dispensing physicians can buy direct. For prices and
samples, mention The American Physician, and ad-
dress: The Merz Capsule Co., Detroit, Mich.
/■ferritins *
As a result of his efforts aimed at "the development of
information pertaining to the internal secretions in gen-
eral practice," Dr. Harrower has for some months been
publishing a quarterly journal called Harrower's Mono-
graphs on Internal Secretions. The first two issues are
ready, the third is in press, and the fourth is ready for
For full information, subscription price, etc., address :
The Harrower Laboratory, Library Dept., Glendale,
Calif.
RtUtf of Pom mti Cot***"*
Atophan gives you, not a "hit and miss" relief of
pain and congestion at the expense of the heart, kid-
neys, intestines and nervous system, like in the old-time
coal-tar derivatives— but a very prompt and reliable anal-
gesic and decongestive action, with notable freedom from
heart-depressant, kidney irritant, constipating and cumu-
lative toxic by-effects.
Information, literature and ample trial quantity will
be sent to Americas Physician readers. Address:
Schering & Glatz, Inc., ISO Maiden Lane, New York.
{Helpful Points continued one leaf over}
Yon can buy with Confidence— See "Service Guarantee to Reader/' on page 166
The American Phviician]
yln Honest Mattel flace
159
The Peculiar Advantage
Marvel
"Whirling Spray"
Syringe
ts centrif-
I flushes
a volume
smoothes
s the In-
n contact
irface.
fiARVBLS:
rata, Vaginil
mm. It ali
Diploma an
SMMtalVH
ABDrnggis
MARVEL COMPANY, 25 W. 45th Street, New York
%
TAUROCOL COMPOUND TABLETS
THE PAUL PLESSNER CO.
JP
Malnutrition
if produced by an obstruc-
tive sluggish intestine and
the gratifying results ob-
tained by using
Pluto Water
in these cases show it to be
the best agent obtainable in
disorders of this kind.
Many practitioners di-
rect convalescent patients to
the spring for rest and com-
plete treatment.
French Lick Springs Hotel Co.
French Lick, lad.
Mentioning The Am
i Physician Insures Prompt, Careful Service
Helpful Points
{Phil... Ffhrmuy, 1)22
It is Not
a Modifier
Nestle's Milk Food is a
concentrated dry milk
powder already modified
with cereals and sugar
that only requires the
addition of water and
boiling for one minute
to provide a complete
food presenting every-
thing the infant needs to
assure normal growth.
NESTLE'S
MILK
FOOD
Aliberal supply of samples for professional
uie and copies of" The Mother Book" f o r dis-
trilmtJon to your patient* sent on request.
Nestle'*. Food Company
A Very Crust ftarfM
By means of a tremendous purchase from the U. S.
Government of unused Army Operating Tables, it is pos-
sible to offer a very special bargain to physicians— $19-75
instead of $40, and on a very easy payment plan, $2.50
per month. Just $225 brings the table— try it for thirty
days and if not thoroughly satisfactory, return it and
your money will be refunded. It seems to us there
could not be a fairer offer. If you prefer to pay cash,
10 per cent discount is allowed, making the price $1778.
Address A S. Aloe Co., 551 Olive St., St. Louis, Mo.
CtmfUu ArtatftU
Chinosol is described by authorities as: "A powerful
antiseptic, somewhat stronger in this respect that mer-
curic chloride and considerably stronger than phenol."
Another product by the same manufacturer, "Asepti-
kons." vaginal suppositories, produce complete antisepsis,
but are non-poisonous, non-irritating and give no injury
to membranes. They are indicated in cervicitis, lencor-
rhea, specific and non-specific vulvo- vaginitis, and in all
cases where complete vaginal antisepsis is desired. For
further information, address : Parmele Pharmacal Co.,
47-*9 West St., New York.
Truly Tasteless!
Kdlogg's Tasteless Castor Oil is the result of pains-
taking laboratory research, undertaken to secure, by
super-refinement, a castor oil especially adapted for
medicinal use. It is pure, unfavored, unadulterated, un-
disguised castor oil— truly tasteless. Kdlogg's Tasteless
Castor Oil does not disturb the stomach or irritate the
bowel; in fact, the after-effect is soothing to the
mucous membrane. You will find it an efficient agent to
(Helpful Points continued one leaf over)
A Stand-By in
Uterine Troubles
VIBURNO
(BEACH)
The best evidence of thU is the
repeat orders received from physi-
cians and druggists.
Nervine-Tonic and Anticongest-
ive, with calmative and corrective
action on the bladder. Employed
with much satisfaction in ovarian
congestion and congestive dysmenor-
rhea; weak pregnancy and deficient
lactation ; menopause and its phe- .
nomena, including hallucinations, hot
flushes, etc.; nervous and menstrual
derangements after "flu," and the
troubles of adolescent girls. Sterility
often responds after 2 or 3 bottles if
no lesion exists.
Until* similar product*. VIBURNO
Dose: 2 taup. (undiluted) Ltd!
baf or* mauls.
Put up In 11 os. bottles
Sample m& Fnrmale on Rtqetd
THE VIBURNO COMPANY
116 Maidun Lane, New York
Yon can buy with Confidence— See "Service Guarantee to Readers" on page 166
The American Phjociao]
An Honest Market Place
161
44
The Answer to Every Question
Is Found in Experience"
For instance, What is the best agent for the relief of an
irritated or inflamed nasopharynx?
ALKALOL. To prove it — use it and watch results.
ALKALOL is not only remedial but prophylactic. Why?
Because it helps to restore normal mucous membrane tonus
and restores secretory normalcy. Test ALKALOL in an
inflamed eye, a suppurating ear, an "angry" throat, a
"running" nose. Its results will demonstrate its practical
worth. So too in cystitis, urethritis, vaginitis, in skin irri-
tation, internally as an antacid, ALKALOL is the some-
thing different that assures results, because it acts to assist
Nature, not in spite of her.
Sample and "Reason Why?* literature an request
The Alkalol Co. Taunton, Mass.
RHINOL
in Ail Affections of the Nose and Throat
Th» Rhinol Company, Inc.,
Th* Rhinol Company, Inc.,
Sirs:
Permit me to state that we have need Rhinol
at the Quality Hill Sanatorium with several of
oar patients that were suffering from Hayfever.
The results were indeed good and pleasing.
Will be glad to have you publish this state-
ment for the benefit of the medical profession.
(Signed) J. S. MASSEY. M.D..
Physician and Surgeon.
Quality Hill Sanatorium,
Monroe, N. C
Tha Rninol Company, Inc.,
July 6, 1921.
1 want to inform you that during the last year
1 have treated a large number of patients suffer-
ing from Coryza, Chronic Rhinitis, Pharyngitis,
Laryngitis and Hayfever with your Rhinol, and it
gives me great pleasure to state that the results
have been very satisfactory in each instance.
Rhinol is one of my standby* in my practice
and now that 1 have realized its great therapeu-
tic value in the treatment of the above named
conditions, 1 could not do without it. You may
make any use of this letter in any way you may
desire.
Sincerely yours,
(Signed) CHAS. B. GRAF, M.D..
Physician and Surgeon.
230 E. 15th St., New York City.
Enclosed please find check for three dollars for which send me one complete Rhinol outfit. You
have a very superior preparation, and I was astounded at the quick results produced.
I am very much disappointed that you cannot or will not supply my druggist, Theo. Metcalf
Cow, as I would like to prescribe your outfit for some of my patients. 1 cleared up my own acute
frontal sinusitis in a few days, then gave It to a hayfever patient who has been more relieved than
bv anything she has ever used. I dread being without the outfit for fear 1 may have another attack
of sinusitis. Hoping for an outfit by return mail, I am, gratefully yours,
mMmwk m m « mm (Signed) JACOB D. SNYDER. M.D.
542 Boylston St, Boston, Mass.
Price Complete, $3.00— Refilled Packages, $2.50
RHINOL COMPANY, Inc. 1416 Broadway, New York
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
DOCTOR; Write Us-
sasamas
Hip. •
9 Apply.
r Lw Set. Splinti Rated Ready ti
■»".■» i~r $JJ.f» for t mini Uu or lew. YourtL ...
With the A MB PLATO RV PNEDM ATIC SFTJWT, id OI out
of bed. eecurt* uood bone union, comfort, strength end
health In the least possible (
patient; fracture; wfcieh limb. .
to heel: circumference of cheat; hip*; ana
■t perineum. Wire snd null order* ear,
on receipt, adjusted la fit, with completi
Hon* for application. Specif j oor Splint a
AM BUM ATI C WASHABLE ABDOMTKA
MUJJ.I.eUJ.
Hands, Arms, Leg*. Extension Shoe*, Si
Corsets. Cratches. Invalid Wheel Chali.
Suppiie*. Write for Measurement Bianha and Illustrated
Circular!. Superior Co-Opem Uie Service. Higbeat Quality
Prompt Delivery and Bight Prices. GUARANTEED.
AMBULATORY rHEHMATIC aTLDfT MFC. CO.
M (C) E. baaabta St.. CHICAGO,
GRIFFITH'S COMPOUND MIXTURE
of Guaiac, Stillingia, etc.
_ A Powerful Attentive — Composed of Guaiac
Stillingia, Pnckly Aih, Turkey Corn, Colchicum.
Black Cohosh, Sarsaparilla, Salicylates of the Alka-
lies, Iodide of Potaisa and other well known reme-
dies, combined in such a manner that it it tolerated
by all patient! suflerina: from Rheumatism, Gout,
Lumbago. Neuralaia, Sciatica, etc.
Prescribe It tor "That Stubborn Casa"
To PhysiciaHt only— we will upon request, send •
regular eight ounce bottle (*1.2S inTe), for trial, upaa
receipt of 2S cent! for express charges.
Griffith*! Rheonutic Remedy Company
Newburgh, Naw York
Woodlawn
Maternity Home
nancy and confinement with best medical
care, nnramg and protection. A home found
for the infant br adoption if desired. All
publicity avoided. Prices reasonable. For
moisten and soften the fecal mass, and to clean out the
bowel thoroughly and gently.
An interesting booklet, "Therapeutic Uses of Oleum
Ricini" and sample will be sent to American Physician
readers on request. Address the sole distributor, Walter
Janvier, Inc., 417-21 Canal Street, New York City.
A* ldt«l A
Sodium Diarsenol marks a distinct advance in syphilol-
ogy. It dissolves very quickly in water, giving a solu-
tion ready for immediate injection. No addition of
sodium hydroxide is necessary. It has the therapeutic
advantage of arsphenarnine with the solubility and con-
venience of neo-arsphenamine, and gives very favorable
clinical results. Neutralization with alkali being obviated,
there is no undue handling and consequent decomposition
of the highly reactive solution. Samples and literature
will be sent to American Physician readers, address:
Diarsenol Company, Inc., in Buffalo, Boston, or Atlanta.
Potieai'i Rtedi/m to Diagnasii
Your patient's reaction to diagnosis is important to
you. If, when you make diagnosis, you not only tell
your patient what is wrong, but actually show him, you
create an everlasting impression. When he leaves your
consulting room he feels that you have rendered him a
service of inestimable value.
A Pilz Anatomical Manikin installed in your office is
invaluable in explaining diagnosis and it keeps you from
ever "getting stale" in anatomy. They are life size, fe-
male (complete with elaborate obstetrical attachments),
price $18.00; male, $15.00; sexless, $15.00. Sent on
receipt of New York check or C. O. D., and a money-
back quarantee with every Pilz Manikin. Free booklet
will be gladly sent on request. Address : American
Thermo-Ware Co., 16 B. Warren St, New York.
Your Patient's Reaction to Diagnosis
If, when you
make diagnosis,
you not only tell
your patient what
is wrong but ac-
tually show him,
everlasting i m -
pression. When
h e leaves your
consulting room
he feels that you
have rendered
him a service of
inestimable value.
A PILZ ANATOMICAL MANIKIN
mUlled I
«.*•»•
and also i:
This suggestion ia worthy of your careful consideration.
The Pili Manikin is lithographed in natural colors —
built in hinged layers showing every part of the body In
absolutely accurate. Used by physicians and medical
irutitutioni from coast to coast.
LIFE TliT H'f High
elabora'
Sent on receipt of New York cheek or C. O. D. Fn
booklet furnished upon request.
Money back guarantee with every Pile Manikin.
AMERICAN THERMO-WARE CO.
1SB Wamn St.. New York, N. Y.
You can buy with Confidence— See "Service Guarantee to Readers" on page 166
The American Pbyaidan]
An Honest Market Place
163
^1
<■ S/'/t/v \ S';//y///:%,7//
(S1LVER-ARSPHENAMINE-METZ)
Tha •odinn. wit of *Uy«
D ELATIVE infrequency of reaction, rapid disappearance of contagious
lesions, and general therapeutic effectiveness seem to indicate that Silver-
Salvarsan is a drug of real value in the treatment of syphilis.
#
ua
Trad. Mark
(a* U. 3. Pat. CM
Silver Salvarsan requires no alkalinization and its ease of admin-
istration commends it to many practitioners.
More than two million injections of Silver- Salvarsan have been
given in the United States and abroad.
H-AMETZ IABOR/WaUESthc
Q,te-Tii#nty%X> Huabo* tiinwi, AU>%»*.
Mentioning The As
Physician Insures Prompt, Careful Service
Helpful Point*
[Phil*., February, 1922
Sanborn
Pulse Wave Recorder
A simplified polygraph for the active
practitioner-
Tracings [mm the jugular vein and
brachial or radial artery; apex beat may
bo taken if desired.
Presents a number of advantages over
the usual forms of polygraph.
SANBORN COMPANY
IMS Commcnvsalta Ava, Boston 47. Mas*.
Cheapness in lubricating oil is not
measured in cost of oil, but in saving
of repair bills. Buy a high grade
oil regardless of its price and you will
find it the cheapest.
Emco Oils, refined from Bradford
Penna., Crude, are among the really
cheap oils as they are pure, have least
possible free carbon content and are
backed by a most liberal guarantee.
Emery Manufacturing Co.
Bradford, Pennsylvania
These Advertising Pages are tm
Honest Market- Puce
Our Advertising Standards ■
Advertisements must give honest service to our read'
ers and their patients— is the basic principle for these
standards and for the conduct of Tm A-iebica*
Physician's advertising pages.
Our attitude in applying these standards is not oat
of narrow technicality but of practical service —
Advertisements must give honest service te our rend'
ers and their patients.
Advertisements of the following classes arc not
acceptable for the pages of The American Physician:
Fraudulent pharmaceuticals; those making dishonest
Pharmaceuticals charging excessive price; price not
warranted by content and by trade conditions.
Pharmaceuticals and other mixtures containing nar-
cotics or other habit- inducing drugs in quantities suffi-
cient to promote their repetition on prescription
(chloral-bearing proprietaries, etc).
Potent pharmaceuticals which justly merit profes-
sional disapproval because of their lay advertising or
manifestly unethical exploitation.
Financial advertisements that claim returns net com-
patible with conservative investment. Only conserva-
tive investments are advertised.
Further
Advertising copy is subject to revision try the
editorial staff.
The Amekican Physician agrees heartily with the
principles of the Council on Pharmacy and Chemistry
of the American Medical Association and we exclude
from our advertising pages such pharmaceutical prod-
ucts as they have definitely shown to be unworthy of
Kofessional confidence and the manufacturers of which
ve not removed the cause of objection; but we do
not accept such findings as are based on academic data
without due recognition of general clinical experience.
Concerning formulae, The American Physician is
urging pharmaceutical manufacturers to give full thera-
peutic data regarding formulae, stating quantitatively
active medicinal content, in order that physicians may
intelligently prescribe. We do not accept advertising
of secret pharmacueticals.
But We do not Decline - - -
Advertising of original drugs, compounds or preparations ins-
isted in current edition* of the U. S. Fhsnnaennina or Nations!
■mnlarv (except habit- inducing prcparati
t seem to be honest and valuable, tot *
"* incil on Pharmacy
aufacturcrs have not j
will always consider proper el
a limited nomber of drags in a
You can buy with Confidence— See "Service Guarantee to Readers" on page 166
An Hartal Market Place
4 FORMULA
PNEUMO-FHTHYSINE
Pneumo-Pkthysine
The best remedy (Pneomo-Phthysiue)
misapplied, may defeat the combined
skill of all who have contributed to iti
success. More especially in the treatment
of pneumonia, the unconquered foe of
medical science.
If FNEUMO-PHTH VSINK has failed
you, there is a reason.
How to Apply in PNEUMONIA
Apply ■ thin layer, thickneaa of ailver dollar, to
chccaedoth, cut to cover front of chut, including
•oprm-cliTiculir apace and reaching below to anJ *-
eluding the tame rib*. Do not heat pluter I
temperature of body. Exceaaive heat haatetu
CTipontion of Goaiacol, ao efficient u an
pyretic. Heat plaater to deaired temperature by
hrat applying to cheesecloth and then holding rt
high"
«fi*K
>ine Chemical Co.
tgo, 111.
Mentioning The American Physician Insures Prompt, Careful Service
The American Physician
Qnr Advcrtinng Standard*
New Prices on
Merz Santal Comp.
Capsules
DISPENSING PHYSICIANS CAN BUY
OF US DIRECT
10 Minim Elastic Capsules, box of 100
Abe bona al 13 and bo»* of 24
5 Minim Perles bottle of 36
B " " bottle of 500
» " " botUeoflOOO
Unsurpassed for happy effect in Urethritis,
Cystitis, Prostatic Troubles, difficult mic-
turition, etc.
PRICES AND SAMPLES UPON APPLICATION
THE MERZ CAPSULE CO.
DETROIT, MICH.
Product! composed of minor botanic remediei in adequate
Bosigt, provided thetc drug* have a real place in medical fits*.
lure and are well defined in materia medica, since many thon-
ged &£?$££ t'"em ,beni d"pile »*•"■•«*»* ±»
. lEBf "'!»?P««. ■«(>• «d loitet artidea honestl, adrertued
to both pbTaiciana and laymen witho
ment; honestly advertised mineral *
toed product!, umlt tallica, etc.
Service Guarantee to Readers
IF YOU HAVE ANY UNSATISFACTORY
DEALING WITH AN ADVERTISER IN THE
4MERICAN PHYSICIAN, WRITE US THE
"ARTICULARS AT ONCE.
WE WILL IMMEDIATELY TAKE THE MAT-
FEE UP WITH THE ADVERTISER AND SEE
THAT THE ADVERTISER EITHER MAKES
"OOP. OR HIS ADVERTISEMENT IS ELIMI-
NATED FROM THE AMERICAN PHYSICIAN'S
'AGES.
THE STORM BINDER
AND ABDOMINAL SUPPORTER
r child.
11C BINC
•OUT IN Vieceroptoiia, Obeait/,
B STORM BINDER IS FOl
■OKT m hernia, floating kidney, duo
THB STORM BINDER IS FOR GENERAL
SUPPORT IN Vieceroptoiia, Obesity, etc, etc.
™ STORM BINDER IS FOR SPECIAL
THE STORM BINDER IS FOR POST-
OPERATIVE SUPPORT of bcUfoni in upper,
middle and lover abdomen.
Aik foi
Orden tiled la Philadelphia „
and Mat by parcel poet
lIjf — in 24 boon
You can buy with Confidence— See "Service Guarantee to Readers" on page 166
The American Physician]
An Honest Market Place
167
r
Fair Questions
Is there a better or safer antiseptic, or germicide,
for alL-'round surgical, medical or hygienic use than
peroxide of hydrogen?
Is there a purer, more stable or better peroxide of
hydrogen than
Dioxogen?
Is there any antiseptic more widely or generally
employed in clinics, hospitals, offices, factories,
schools and homes by physicians themselves, or
on their recommendation, than
Dioxogen?
Need more be said?
THE
OAKLAND
CHEMICAL
59 Fourth Are.
New York City
In purity and oxygeivliberating power,
Dioxogen exceeds U. S. Phar. standards for
Ht O, by 25*.
Dioxogen is odorless, almost tasteless,
and entirely free from adds and acetanilid.
It is also colorless and does not stain the skin.
Absolutely non«poisonous and notvirritat'
ing, Dioxogen is not only the most potent,
but the safest and most harmless of antiseptics.
Applied to wounds, Dioxogen promptly
destroys bacteria and stimulates the reparative
processes of the tissues.
Dioxogen is the one powerful germicide
at the physician's command that can be freely
used anywhere and anytime without the
slightest danger.
Mentioning The American Physician Insures Prompt, Careful Service
1 he American rHyataan I
LIBERAL DOSAGE-MINIMUM EXPENSE
under the aclaotlflc i
I Bnlgarlcua Cnltnrel
of Profeaaor Motch-
mlDent medical practlrjonere. we
eoBTlctlon that edoqute doeac*
mportant factora In toe effoctlie
:.cillui Bnlcmrlcna to tberapeqtie
■ urprliinsll rapid reaulta when- in individual, sua-
THE BIG THREE
(ACTUAL SIZE)
llilered three to al
( LIBERAL DOSAGE—
F ('■■ P. St Ut. *.
■'FlJ.'EAl'l'I.E CULTURE. J
BULG A RIO US, M ETCHN IK 0 FF . '
one and one-half o
t the leading druggists or will be delivered at
BSS
All the above products can be obtained a
patients' address without extra charge.
Literature and Sample* on Rcqneat
FRANCO-AMERICAN FERMENT COMPANY
225-7 SIXTH AVENUE, NEW YORK
The American Physician
Here's where genuine Atophan is
manufactured by a special process
completely precluding the possibility
of unpleasant empyreumatic admix-
tures
This means a still further im-
proved Atophan for your cases
of Rheumatism, Gout, Neural-
gia, Neuritis, Sciatica, Lumbago
and "Retention" Headaches.
Ample trial quantity and literature
from
Schering & Glatz, Inc.
150-152 Maiden Lane Now York
AN IDEAL ARSENICAL
SODIUM DIARSENOL
SODIUM ARSPHENAMINE
Sodium Diarsenol marks a distinct advance in syphilology. It dissolves
very quickly in water, giving a solution ready for immediate injection. No
addition of sodium hydroxide is necessary. It has the therapeutic advantage
of arsphenamine with the solubility and convenience of neoarsphenamme,
and gives clinical results equal to or better than either of the two latter com-
pounds. Neutralization with alkali being obviated, there is no undue hand-
ling and consequent decomposition of the highly reactive solution.
SODIUM DIARSENOL has been accepted by the Council on Pharmacy and
Chemistry of the American Medical Association for inclusion in "New and Non-
official Remedies."
Manufactured by Diari
DIARSENOL COMPANY, Inc.
BUFFALO BOSTON ATLANTA
You can buy with Confidence — See "Service Guarantee to Reader^' on page 240
An Honest Market Place
]yj ORE people die from pneumonia than
any other disease.
Approximately 25 out of every 100 cases end
fatally. Dr. Gustav Goldman has demon-
strated that at least twenty of these twenty-
five deaths may be prevented by employing
Bacterial Vaccines.
Why delay and chance a fatal termination?
Dr. Cattail CcUman't article appcartd in Awtmrican MtJkiat. March. 1921
Ricterloloiicd li » b • r ft t • r i • ■ •(
G. H. SHERMAN, M. D.
DETROIT, U. 8. A.
-, Publiihtr; bin. J. 3. Taylor, Ed. Mgr. £■
* ■ i/ March 3. 1879. Tht A
of distincti
dtly Circulated Midicol Monthlv, continuing tht Qvarttr ctntury of distinctive linnet of HMUJKUKg
COPYRIGHT laii, by Th, Taylor,, Publiihtrs,- «o Walnut St., Philadelphia, V. S. A. AH riehtt rtitrvti.
172
The American Physician
[Phils., March, 1922
Reg. U. S. Pat. Off
Butyn (pronounced Bute-in, with the accent on the first syllable) is
a very powerful, synthetic, local anesthetic especially intended to replace
cocaine for anesthetizing mucous surfaces.
This new product is structurally related to both Cocaine and Procaine, but ex-
tended clinical tests have shown BUTYN to be superior to cocaine in practically every
respect.
The following extract is quoted from the Special Report of the Committee on
local anesthesia of the section on Ophthalmology of the American Medical Association,
which appeared in the J. A. M. A. on February 4th, concerning the clinical use of
BUTYN:
'The results of the clinical and experimental use of BUTYN seem to
justify the committee in arriving at the following conclusions:
**!. It is more powerful than cocain, a smaller quantity being required.
**2. It acts more rapidly than cocain.
**3. Its action is more prolonged than that of cocain.
"4. According to our experience to date, BUTYN in the quantity
required, is less toxic than cocain.
"5. It produces no drying effect on tissues.
**6. It produces no change in the size of the pupil.
**7. It has no ischemic effect and therefore causes no shrinking of
tissues.
"8. It can be boiled without impairing its anesthetic efficiency.'*
In addition to these advantages over cocain, BUTYN Requires No Narcotic Blank
in Ordering.
It is antiseptic and its solutions keep well.
BUTYN has been used with success in removing superficially and deeply embedded
foreign bodies in the cornea; for minor and major operations on the eye and for cer-
tain types of operative work on the nose and throat. It has also been used with
excellent results in the extraction of teeth.
Reprints reporting the clinical work done by the Committee may be obtained
by writing to The Abbott Laboratories, Chicago.
Forms and Prices
BUTYN may be secured in the following forms and at the prices shown. Until
druggists are stocked, your orders will be filled as rapidly as possible from the home
office or branches of The Abbott Laboratories.
Butyn, 2% solution, 1 oz. $1.16 Butyn Tablets, grs. 3
Butyn and Epinephrin Tablets, \Q Tablets $2.14
each tablet containing: Butyn, gr. . ,
1/6 and Epinephrin, gr. 1/1250. Butyn Powder, 5 grams 5.06
100 Tablets 1.54 25 grams 24.00
THE ABBOTT LABORATORIES
DEPT. 49, 4739 RAVENSWOOD AVENUE, CHICAGO
31 E. 17th SL 227 Central Bldg. 559 Mission St. 634 I. W. Hellman Bldg.
New York Seattle San Francisco Los Angeles
Toronto, Canada Bombay, India
0
You can buy with Confidence— Sec "Service Guarantee to Readers" on page 240
The Antrieu Phjncun)
An Honest Market Place
LOESER'S INTRAVENOUS SOLUTIONS
INTRAVENOUS MEDICATION, an
evolutionary step toward rational
medicine and improved clinical
results.
DEMANDS solutions of higher standard of
scientific accuracy for safe and practical
employment.
ANTICIPATING this demand, we devoted
years of intensive study, developing a higher
branch of pharmaceutical art.
RESULTS — Scrupulous laboratory routines,
exacting chemical, physical and toxicity
tests, producing intravenous solutions that
are the established standard of comparison.
AVOID SUBSTITUTES with fanciful names
and ambiguous statements as to contents,
offered with low price inducements.
For ula at your local drnggiat
Descriptive Literature, Price List, "Journal of Infravenotu
Therapy," fill be tent to nnjj physician on request
New York Intravenous Laboratory
Mentioning The American Physicio Insures Prompt, Cartful Service
The American Physician [PbiUi Mardl# l922
Yon can boy with Confiiroc*— Sw "Service Guarantee to Rtaitr/' on page 240
The American Physician]
An Honest Market Place 175
STYPTYSATE
THE REMEDY FOR HEMORRHAGES
Not Subject to Narcotic Law
The least disappointing remedy in uterine hetnorrages. Very often acts
where Ergot and Hydrastis fail. Dose gtts.x-xv. Prescribed in 10 c.c. bottles.
Sold on prescription only.
A Few Short Clinical Reports Will Prove Interesting
W. H. Age 23. Menstruated regularly up to a year ago. Twice then every 10 days —
profuse hemorrhage. After Styptysatc, duration and quantity of flow considerably lessened.
T. V. Age 25. Menses erery 3 weeks, very profuse during the last months — Styptywte
reduced the amount of flow to normal quantity.
L. A. Age 28. Menstruated regularly, duration 5 days. However, for the last several
months menses were irregular, and the flow, lasting 8 days, was very profuse. Styptysate
shortened the periods and reduced the flow.
£. T. Age 28. Menstruated first at the age of 14. Menses regularly up to about 10 weeks
ago, when they appeared CTery 2 weeks — accompanied by severe backache. After the use of
Styptysate the frequency of the periods was lengthened and the action of the drug regarding
the amount of the flow was surprisingly prompt.
A. Sch. Age 24. Menstruated formerly regularly; since 3 years very profuse flow lasting
3 days and appearing every 2 weeks. The hemostatic action of Styptysate manifested itself
after every administration in a surprisingly favorable manner.
A. W. Age 35. Menses appear regularly, but are of long duration, the last having per-
sisted for 3 weeks. Styptysate treatment for 3 days limited the flow to 4 days. Lasting result.
T. M. Age 49. Menses every 4 weeks, but very profuse flow of 8 days' duration. After
Styptysate medication a lasting limitation of the flow to from 3 to 4 days.
In all these cases, in spite of the difference in the ages of the patients, the dis-
turbance apparently was a functional one only, as the gynecological status was
normal, judged from the pathological point of view. However, the excellent results
obtained led Krummacher to employ Styptysate also in pathological conditions. In
particular does he mention a case of myoma, the size of a child's head, in a 43 year
old virgin. Frequent and very profuse hemorrhages — lasting 8 days or longer —
were not influenced by Hydrastis or various Ergot preparations, but were favorably
acted upon by Styptysate, so much so in fact, that the patient herself described the
action of the drug as unbelievable. In this case, Styptysate was given in doses of
gtts. XV t. i. d. and limited the hemorrhage, moderate in amount, to 3 days. It is
of importance to observe that Styptysate does not have any influence upon heart
action or respiration, although it has occasionally been given in massive doses (up
to gtts. XXXV single dose). The gynecologist as well as the obstetrician and
general practitioner will, therefore, find in Styptysate a safe, reliable and active
hemostatic
Samples and literature on request
INTRODUCTORY OFFER
One Dozen Bottles of STYPTYSATE (or $5.00
Ernst Bischoff
(Regular Price $7.50)
Fill out, detach and mail the corner coupon with N. Y.
draft for $5.00, and we will send you one dozen bottles
of Styptysate. Co., Inc.
85 W. Broadway,
New York
For $5 remittance enclosed
send 1 dozen bottles of Styp-
tysate as per your Introductory
ERNST BISCHOFF CO., Inc. offer
Name..
85 West Broadway
New York Address «.
Mentioning The American Physician Insures Prompt, Careful Service
176
Contents
Copyright, 19&, by The Taylors. All rights reserved.
Editorials
A Reaction Against the Allen Starvation Treatment of
Diabetes to Be Expected Because So Many Physi-
cians Are Inclined to Out-Allen Allen 187
Qulnldlne Sulphate and Auricular Fibrillation Qulnldlne
Treatment Somewhat Overrated 188
St. Louis and the A. M. A. Meeting 189
A Real Man Among Men, His Work Will Live After
Him. _
By C. C. Taylor 189
Original Articles
Some Pediatric Don't*— A Practical Survey of Every-
Day Pediatric Problems— Don'ts That Will Help the
Qenerat Practitioner Both In Diagnosis and Treat-
ment.
By H. Brooker Mills, M.D., F.A.C.P 191
From his wide experience, the author gives practical
points which will help the physician both in diagnosis
and treatment, with bis small patients; interestingly
written in the shape of brief, pertinent reminders on the
more frequently met pediatric problems.
Complications Following Qastrlc Operations — Possible
Complications Must be Considered Before Operation.
By A. Wiese Hammer, M.D., F.A.C.S 196
To Know What to Tell the Patient Complications and
sequelae of gastric surgery are frequent and important.
To know the probabilities and possibilities of the pro-
cedure under consideration is to know what to tell the
suffering patient In quest of vital advice. This paper
of Dr. Hammer is excellently presented and covers its
S round admirably well. We hope our readers will bene-
t by it.
A Clinical Comparison of Intravenous and I ntrs musclar
Therapy Using Iron and Arsenic— Certain Definite
Results May be Expected When Injected Directly
Into the Circulation.
By Melchior F. R. Saverese, M.D 198
Rectal Fistula Symptoms Which Lead to a Diagnosis —
Thorough Digital Exploration Imperative to Deter-
mine Stricture, Neoplasm or Other Pathology.
By Charles J. Drueck, M.D 201
Knowing Little of an Important Condition. The gen-
eral practitioner knows little of rectal flstuhe and usu-
ally "bothers with it" as much. That It is real, obsti-
nate, and worthy of serious attention those who have
suffered with it will tell you in no uncertain terms.
Dr. Drueck's paper presents this rather neglected but
important subject in clear, concise and practical form.
He discusses all the phases of this disease in a way that
the reader cannot help benefiting by it. Don't miss it.
A Case of Acute Osteomyelitis, Twenty-fourth Clinic.
By A. Mackenzie Forbes, M.D 204
The Value of Hydrotherapy In General Practice — Elab-
orate Equipment Not Necessary.
By O. M. Hayward, M.D 207
Enrich Your Therapeutic Armamentarium. The effect
of hydrotherapy is often remarkable, even In its most
humble form. The washing of the face with cold water
removes "sleeping feeling" and sensation of fatigue as
if by magic. The exhilarating or soothing action of the
cold or hot bath, as the case may be, and its beneficial
influences in both health and disease cannot be denied
by even the so-called opponents of this form of treat-
ment Combine these simple truths with the facts so
clearly elucidated by Dr. Hayward in this paper and
you will enrich your therapeutic armamentarium with
a series of "simple procedures which will serve any
physician well if he will only make use of them."
(Content* continued on pagm 178)
HINOSOL
"A POWERFUL ANTISEPTIC. SOMEWHAT STRONGER IN
THIS RESPECT THAN MERCURIC CHLORIDE AND CONSID-
ERABLY STRONGER THAN PHENOL."
(COUNCIL ON PHARM. AND CHEM. A. M. A.)
AsepwkonS"
/ VAGINAL
^SUPPOSITORIES,
producing complete antisepsis
But
Non-poisonous, Non-irritating and No injury to membranes
Indicated in cervicitis, leucorrhea,
specific and non-specific vulvo-vaginitis, in all cases
where complete vaginal antisepsis is desired.
PARMELE PHARMACAL CO., 47-49 WEST STREET, NEW YORK.
You can buy with Confidence — See "Service Guarantee to Readers" on page 240
The American Physician]
An Honest Market Place
177
Yeast in relation to dietary
defici
lencies
THE constant need for a suffi-
cient supply of water-soluble
vitamine in the diet is now well-
known. Physicians are aware that
general debility a»d susceptibility
to miscellaneous infections follow
the continued ingestion of food
containing too little of this dietary
factor.
Yeast is richer in the water-
soluble B vitamine than any other
known substance — in laboratory
experiments it was found to be
four times as efficient as dried
spinach.
"A scrawny, lethargic animal,
rapidly dwindling in size, with
unsleek coat and evident malnu-
trition, will completely change its
appearance and responses in a few
days at most on a diet unchanged
except for a tiny bit of yeast" —
this is the description given by
one of the foremost physiological
chemists of America.
In experiments carried on at
the Laboratory of Physiological
Chemistry of Jefferson Medical
College the ordinary household
yeast (Fleischmann) was utilized
as a source of vitamine and was
found to have very important
properties.
The American Journal of
Physiology (vol. xlvii, no. 2) has
an interesting report on this test
of yeast in remedying dietary
deficiencies. Young white rats,
starting on a diet of beef, butter-
fat, casein and starch, given the
same diet plus 5 per cent Fleisch-
mann's Yeast shotved gains as
high as 100 per cent in fourteen
days.
The success of these and sim-
ilar experiments has given impe-
tus to the study of yeast. Physi-
cians are now prescribing it for
certain dietetic troubles, and the
yeast treatment, both in hospitals
and in private practice, has been
attended with marked success.
Fleischmann's Yeast offers an
easily obtainable, economical, and
scientifically standardized scource
of vitamine. It is obtainable fresh
daily, from grocers, or if the phy-
sician prefers he may write The
Fleischmann Company in the
nearest large city and it will be
mailed direct on the days wanted.
Usual dose one cake adminis-
tered, t. i. d., plain, or in suspen-
sion in water, fruit-juices, or milk.
As whole milk is a rich source of
the fat-soluble A vitamine the dos-
age with milk insures a bountiful
supply of both vitamines, a very
favorable combination in correct-
ing deficient diets. Yeast may be
taken with meals or on the empty
stomach. If the patient is troubled
with gas formation, dissolve the
yeast in boiling water before ad-
ministering or administer living
veast between meals.
The Fleischmann Company, Dept. S3, 701 Washington St., New York.
Mentioning The American Physician Insures Prompt, Careful Service
The American Physician
Hillary of Dental Anaestheiks~No. 1
1844 — Laughing Gas
(Nitron* Oxide)
FROM the dawn of creation efforts
have been made to prevent pain.
To a member of the dental profession
mutt be given the credit for the great
discovery of modern anaesthesia.
Dr. Horace G. Well., a dentist of Hart-
ford, Conn., first demonstrated the fact
that painless operations might be per'
formed under the influence of Nitrous
Oxide, then referred to a* "Laughing
Gas."
On December I I, 1844, Dr. Well, had
a molar tooth extracted while under
the influence of the gas and on regain-
ing consciousness, exclaimed, "It is the
1 didn't
feel i
prick." He
used the gas ii
all through 1645, after
which he went to Europe
for several years.
It was easy to administer
and pleasant to take, but
owing to the rapid recov-
ery, anything but the short-
est operations were impos-
sible.
Antiseptic
Local Anaesthetic
(■with Procaine 2%, or with
Cocaine I'fe)
i it possible to
the
ng operatli
perfor
Mock!
of the operator, and
freedom from pain or
my ill after effects on
the part of the pa-
tient.
IN BOTTLES
Check and Mail This Coupon Now I
□ Please trad sampla box of ampules
of Dr. R. B. W site's Local *m«-
THE ANTIDOLOR MFG. CO.
32 Main Street
Springville, Erie County, N. Y.
[Phila.. March. 1922
L,OntentS — continue./ /ram page 176
Rectal Etiology of Gastroentero ptosis — Permanent Re-
sults Can Only be Achieved, by Elevating the Ano-
rectal Line.
By E. Jay demons, M.D 211
Excellent Logic and Worthy Review. The paper of Dr.
(.'lemons Is well written and well to nip I led. It la based
on excellent logic of causo and effect. It furthermore
reviews briefly but clearly a seriea of embryo logic, ana-
tomic and physiologic (acts wblcb the general physician
lioa a tendency to forget. They are all subjects or
Importance and are well worth reviewing.
Efficient Future of Medical Practice
Halt-way Through. The Plight Of the Middle-aged
Doctor '.
Protest Against Cornell University Establishing a Pay
213
.-.214
International Ixl ng Sera Standards 216
More Light on Argyrla 216
Heal Current Medical Thought
Treatment Of »Tubereulo»ls by Nasal Insufflation
Method tW
Infection not Inflammation 200
Radium In Non-Malignant Gynecological Conditions 206
Arrest Of Auricular Fibrillation by the Use of
Symptomatic Treatment of Pneumonia 212
Painful Scare 212
Book Reviews
Nut Growing SIS
The Oxford Medicine 211
Vice and Health 2tt
The Diagnosis and Treatment of intussusception 220
Money Back Guarantee to Subscriber* \
This AuxaicAH Physician is published for oiw and only one
purpose — to give the aenerai practiliener the efficiently frielioll
to promote and protect the opportunities and interests of thei
gtntral practitioner in every possible way; snd, if this work be
torll doit, to be financial!)' self. supporting and to earn a reasoo-|
° It ^"completely free from any outside influence, of either mi
roi.ner.wn or entanglement in any way with either.
If any subscriber, ai oay time, feels that The Ahiiicas
II "ae wiiTwrlte us*we "w'tlerVfJlly refund, wit1iou\" VesSo"; I
Tue Aueucah Physician seeks only satisfied, interested,
readers.
Subscripting Continuance
Practically all of our subscribers, as a matter of convenience.
p"h a?'
W.™"!
bill, ■
r the
■nt promptly n
t' after
ee),
Sabtcription Price
»nts a copy current issue (back issues (1.00 a copy—
its not available); (2.00 for One Year; (3.00 for Twt
11.50 a year); (5.00 for Four Years ($1.25 a year);
>r Ten Years (only (1.00 a year).
i tor Domestic postage — U. 5. and possessions. Cuba,
j alt communications 'and mo*, all funds payable to—
The American Physician, i
410 Walnut Street, Philadelphia, U. S. A.
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The American PhynidinJ
An Honest Market Place
Hay Fever Memoranda
Early Spring Type. Patients whose hay fever develops in tate March,
April, or beginning of May. should be tested with pollens of early flowering
trees, as: — Poplar, birch, maple, willow, walnut and oak, which pollinate
in the order named.
Late Spring Type. Patients whose hay fever develops in the latter part
of May, during June or early July, should be tested with the pollens of
sweet vernal grass, June grass, orchard grass, timothy and red top. The
one giving the major reaction should be selected for treatment to the
group. The unrelated rose pollinates simultaneously and is the primary
or secondary cause in an occasional case — hence, should be included in
tests, especially where direct exposure exists. The same is true of dandelion,
daisy and in some sections alfalfa.
ARLCO - POLLEN EXTRACTS
For Cutaneous Tests and Treatment cover early and late spring,
also summer and sssfassssj
Literature end litt of palUru on rcqaeil.
THE ARLINGTON CHEMICAL COMPANY
Yonkers, New York
BLAUDULES
Corresponding to Pill* of Ferrous
Carbonate (Blaud'. Pills) U.S.P.
— not a new iron compound
— just the old reliable mass of ferrous carbonate
— but always fresh and permanent
Each Blaudule represents 5 grains of fresh, active ferrous carbonate mass
made up with an oily excipient and enclosed in a soft gelatine capsule with
exclusion of air thus preventing oxidation and assuring for the patient a
full uncontaminated dose of
ferrous iron.
Prescribe Blaudules if you want
permanently fresh Ferrous Car-
bonate.
Your druggist has them
in stock.
M FOUNDED 1l»
ERRELLcompant
Mentioning The American Physician Insures Prompt, Careful Seniict
The American Physician
[Phil*., Hard, 1922
combination, approximately equal
weight* of creoaote and lime
CALCREOSE differ, from
creo*ote in
that it doe* not have any
untoward
•fleet on the stomach: hen
ce patient*
do not object to its admini
tration.
Price: — Powder, lb., $3.00.
(Prepared by add!
tg 1 lb.
to 1 gallon of
water.) Tablet*: 4 gr.
1000, $3.00; 500
$1.60
100. 40c.
Sample* (tablets) and literature
ree.
THE MALTB I E CHEMICAL CO.
Newark, N. J.
You can buy with Confidence— See "Service Guarantee to Reader^' o
The American PhTuciu}
An Honest Market Place
|J/"\.l 1 £ 1 aU EsUrcfScmflct
for the INTERNAL TREATMENT of
raa. Iran irritant actios
Do**: 3 captalc* J or 4 time* dsirr
R BILHUBER, Iwu, « John St, N.w Tort
KtfXsto or "I Calm"
KELENE
For Local and General
ANESTHESIA
(Pure Chloride of Ethyl)
In automatically closing tubes. Convenient to carry. Easily applied. Uniform results.
Widely used for many years. For general anesthesia, useful in minor surgery and dentistry.
Manufacturer*
FRIES BROS.
S2 Rud* Strwt, New Yarh
Sals diitrlbutor* for the U. S. A. *
MERCK & CO.
St. Louis NEW YORK
JT(gcK*g)l"
Why you can depend upon
The Genuine Russian Mineral Oil
7VERY physician and V
lalili
No mineral oil can
pare with the Genuine Rus-
sian oil for this softening
lubricating effect.
ind
and the di»-
Rememfaer that Sir Ar-
buthnot Lane'* experiment*,
which definitely establish the
value of mineral oil at a
with
ral oil.
It !■ the only mineral oil
from which results may con-
fidently be expected.
Send for "Below the
Equator." one of the mo..
helpful and instructive book-
let* ever written on the treat-
ment of constipation.
McKESSON & ROBBINS
INCORPORATED
Manufacturing Chemist
1S33 NEW YORK CITY
able
fidently expect from the ad-
minrtration of Liquid Albo-
lene — the Genuine Russian
Mineral Oil.
Liquid Albolene facilitate*
liquidAti
Mentioning The American Physician Insures Prompt, Careful Service
The American Phvsician
Serobacterin
Immunity
Only One
"There is only one concern in
this "hole conntrr which puts
tAlnere that will not nb*olm^l j-
rain & platinum needle."
Is a development of the researches of
Besredka and Metchnikoff, in the Pasteur
Institute, Paris.
Serobacterins are suspension of killed bac-
teria, with their corresponding antibodies.
They produce both passive and active
immunity.
The Passive Immunity is conferred im-
mediately by the specific antibodies carried
by the serobacterin and promptly liberated
when injected into the body.
The Active Immunity follows when the
body cells of the patient have responded
to the stimulation of the injected bacteria,
by producing additional antibodies which
replace the antibodies of the serobacterin
and remain for a considerable period.
The following Serobacterins are available
from the Mulford Laboratories:
ACHB aiEBOBACTEBIN ST AT H Y LU-SEB OB A CTSM *
0(11.1 SSBBOBACT8BIN 9TAPHTLO-ACNB Si Kl 0 B ACTBHIF
Phe II u n-t tan » n MTTEZi •)
A,k for Mulford Working Bulletin No. 18
. K. MULFORD COMPANY. Philadelphia. U. S. A.
You can buy with Confidence — See "Service Guarantee to Readers" on page 240
An Honest Market Place
specialties
for Direct Medication
*0>tKe
Intravenous
ENDOQUIN
ENDOSAL M
imuputnaSlnftKofiaUnfHil
END0-50DIUM IODIDE
(Asthma)
ENDOMtTHYLE N AMIN
ENDOFTRARSAr
(AnemiAi)
//w-7 aaif Aneit'C
ENDOGLOBJN
^"j/.'eA^"1"1
ENDOCAODIN
Method
Intra venous medication lias
long since pasted the experi-
mental stage. The favorable
attestations of thousands of
reliable physicians are unani-
mous in their endorsements of
this method of remedial treat-
ment.
At the hands of our chem-
ists, specialists in research, our
products are prepared with the
utmost care, skill and acumen.
Their purity challenges com-
parison.
Formulae of our specialties,
reprints of interesting articles
and price lists cheerfully fur-
nished to physicians on re-
(frphi
EN DOARSAN
•sJBSSW
I WiVhuMMrn*^-
GUIOLEUM
(Oqnorrha'l
^E/tttr-Attl W~m ta Pit
, GLYCO- ASEPTIC
MravenousProducts Go. of America, mc.
121 Madison Avenue, NeViorkCity
Pttriffi
Safety
Mentioning The American Pkyrician Insurrt Prompt, Careful Service
The American Physician
[Pbila.. March, 1922
iff
A LAXATIV
NATUKE S OWN PHARMALY
Out in California's sun-swept orchards
Nature has provided a tasteful, healthful
laxative that should find proper place in
every physician's Materia Medica. Made
into prune juice, Sunsweet Prunes offer a
fine, fruity laxative-drink that may be dis-
pensed to young and old alike.
Even aside from their traditional laxa-
ative value, clinical tests have proved the
body-regulating qualities of prunes. For
example: prunes are rich in benzoic acid
-the natural fruit benzoic acid. This ben-
zoic acid is eliminated as hippuric acid—
the acid that is normal to the urine and
always ought to be there. Where the
urine is alkaline, prunes possess actual
medicinal value in restoring the normal
acidity . This applies to both children and
adults— and more especially to the aged
who are so prone to alkalinity of the urine.
As one eminent clinician puts it:
"Prunes should be used freely and can do
only good." To any physician or nurse in-
terested in the dietetic and medicinal
value of prunes we shall be glad to send
our brochure, "For the good that's in
them." Also— the new Sunsweet Recipe
Packet containing recipes tested for their
nutritive and palate-pleasing qualities.
Both are free! Address California Prune
and Apricot Growers Inc., 380 Market
Street, San Jose, California. A coopera-
tive association oi 11,000 growers.
snuitivr- stomached
ei-reguUiur
pattern? Better
to tint — and better
for him— than
the average purge.
prune juice may be
fortified in the
process of' tooting by
the addition °f
tenna Leaves, bed
in. small bag.
prune whip, prune
•oufflr, prune
pudding, etc The
SUNSWEET „ -YljCS
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Mercurosal—
Companion of Arsphenamine
T^HE discovery of Mercurosal, a new synthetic mercurial
1 bearing the same relation to inorganic mercury that ars-
phenamine bears to inorganic arsenic, signalizes a distinct
advance in the mercurial treatment of syphilis.
Every doctor knows that arsenic per se has very little effect
on the course of syphilis, but arsenic in the form of arsphena-
mine, the synthetic compound, is a powerful antiluetic.
And now there is this synthetic mercurial— Mercurosal —
that seems already to have established itself as the therapeutic
companion of arsphenamine.
Clinical inveetlgatoi
Tcuroaal hat hlfh iplrochcticJda] vmluc-
.th that of bichloride of nwrturv- Thiaehowtoi
uprnw It, " * * * thla drug doca not Irritate tht veins, however mall the ve
Repealed Injection! (17 to one cue, to a aectlon of a vein onlf S inch louj) hw
obliteration or other apparent Injury to the veaacl wall.
ravenou*lv or fcricrami
jntrol of the pliTiiclan.
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Mentioning The American Physician Insures Prompt, Careful Service
The American Physician
bila., March. 1922
NEURASTHENIA
The tumultuous life entails its penalties — among them neu
rasthenia.
The storm and stress of modern civilization exhaust the reserve
force of the organism just as the suffering and hardships of war
did. Organotherapy is effective in overcoming the nervous
exhaustion induced more subtly, but just as surely, by the high
speed conditions of the Twentieth Century.
Hormotone
tends to restore the per-
fect hormone balance es-
sential to the maintenance
of health and to the resto-
ration of it in a run down
condition.
In neurasthenic cases as-
sociated with a high blood
pressure use
Hormotone Without
Post-Pituitary
Dose of either prepara-
tion : One or two tablets
three times daily before
meals.
G. W. CARNRICK CO.
419 Canal Street New York, U. S. A.
You can buy with Confidence— See "Service Guarantee to Readers" on page 240
The Am
Vol 27
encan
Physici
iaan
March, 1922
Ab. 3
A Reaction Against
The Allen Starvation Treatment of Diabetes
TO BE EXPECTED BECAUSE SO MANY PHYSICIANS ARE INCLINED TO OUT-ALLEN ALLEN
FOR SOME TIME we have been looking for a
reaction against the so-called "starvation treat-
ment" of diabetes introduced by Dr. F. M. Allen, of
the Rockefeller Institute Hospital, and this largely
because many physicians are inclined to out-Allen
Allen, carrying the treatment too far. For it must
be noted that Hill and Cabot, in the Massachusetts
General Hospital, who helped to place this treatment
on a elinieal basis, keep the patient, for forty-eight
hours after admission, on ordinary diet in order to
determine the percentage of sugar in the urine and
to prepare the patient; then the patient is starved,
except for Whiskey, coffee and water, until he is
sugar-free, which is never over four days and com-
monly only two days, when the patient is allowed a
diet containing about 15 grams of carbohydrate, which
amount is gradually increased to the limit of toler-
ance— usually 50 grams of proteid, 50 of carbohy-
drate and 200 of fat, or 1800 to 2000 calories. This
amounts in a day to about the following: 3 slices
of bacon, 1 eggf 4 slices of parsnip, 12 heaping table-
spoonfuls of 5% vegetables (thrice boiled), a small
slice of chicken, 6 slices of salt pork, 4 squares of
butter, 6 ounces of cream, coffee or tea without
sugar. It is seen that both proteid and carbohydrate
intake is restricted, while considerable fat is allowed.
This treatment is entirely practicable in a hospital,
bat in private practice it takes considerable attention
to be given by the physician, really almost daily at-
tention, with constantly followed-up laboratory find-
ings and weighing every scrap of food, which must
be especially prepared.
Omr Owm Experience
We have seen very marked benefit from this treat-
ment in competent hands ; then the patient is returned
to the care of his physician, and commonly has to
go to work, when 2000 calories a day will not sustain
him. The physician is "up against it" in the case,
runs the calories too high, usually from allowing too
much meat, and finally the patient experiences an
intolerable appetite for carbohydrates and, yielding,
rapidly slips back. Then another physician is con-
sulted who starts starvation treatment again and
usually prolongs the treatment far beyond four days,
acetonuria and coma supervene, and sometimes the
patient dies prematurely. In our own experience, 50
grams of carbohydrate will not for long sustain a
patient; hence we allow a little fruit and one slice of
toast a day, at the same time administering a little
codeine when necessary. This may not be according
to the modern idea, but the patient does well and may
live and work for years. Sometimes a little pure
grape sugar is allowed, or even some levulose, but,
heretical as it may sound, we believe that a little
fruit sugar (levulose) in the form of a very little
cured fruits, or, preferably, fresh fruits, rarely hurts
a well-managed case of diabetes when sugar hunger
becomes urgent. Understand, very little and not over
once a day. It is remarkable how a little fruit will
satisfy a patient. Apples contain 14% of carbohy-
drates and must be used with care, but peaches have
only 9%, strawberries 7%, and melons 7 to 9%. Cured
fruits, such as figs, prunes and raisins, contain about
75% in the dry state, but when cooked without any
sugar, may, in the absence of fresh fruit, be allowed
in very small amount, say, three prunes for breakfast.
Bananas are too starchy to be allowed at all.
After starvation has accomplished its purpose, and
the patient has attained a fair sugar balance and is
at work again, this latitude, we believe, is perfectly
allowable and even advisable. At all events, our
patients do well on it, and we do not believe that
natural fruit sugars are nearly so deleterious in dia-
betes as is cane sugar.
The Heme ei Stern
Heinrich Stern, M.D., LL.D., has recently written
a book entitled "Fasting and Undernutrition in the
Treatment of Diabetes/' in which he takes sharp issue
with Allen, perhaps going a little too far in the other
direction, but Stern is an able and experienced man
188
Quinidine Sulphate and Auricular Fibrillation
[The American PhyaicUn
and his ideas are entitled to respect. He does not
approve of starvation at all, but does believe in fast-
ing when indicated, as in advanced and severe forms
of diabetes, though in the majority of cases he
adheres to the older methods of dieting. Stern has
created a bit of a sensation, but hosts of physicians
will agree with him. Allen would almost make a
specialty of treating diabetes, taking the cases out of
the hands of the general practitioner, thought he does
not openly so declare.
The Blood Smgar
Henry J. John, M.D. (J. A. M. A., January 14,
1922), reports a case of starvation treatment which
did not remove the sugar from the urine, although
the patient was reduced to a mere framework. In
this case he found blood sugar normal, and it re-
mained so after full carbohydrate diet was allowed
for some time. He contends that there are cases of
ready permeability of the kidney to sugar, which con-
stantly appears in the urine, and yet the patient does
not have diabetes. He has raised a very valid point.
Read his article.
There is quite a reaction against the starvation
treatment of diabetes, but we fear that some anti-
tendencies, including this one, may go too far. Allen
has done good work, and we are inclined to the view
that it has permanent value. The trouble has been
that some physicians have made a fad of starvation
and carried it too far. — T. S. B.
Quinidine Sulphate and Auricular Fibrillation
QUINIDINE TREATMENT SOMEWHAT OVERRATED
QUININE is C»H*0,N,+3H,0, while quinidine
is the same thing' minus the three molecules of
water; it is isomeric with quinine, differing from it
in that it crystallizes in prisms and turns the plane
of polarization to the right; yet the sulphate of
quinidine has recently been credited with an action
very different from that of quinine sulphate, as for-
merly understood. In view of the chemical composi-
tion of the two alkaloids we fail to see wherein quini-
dine should differ in action from quinine. These
remarks will serve to take away the mystery from
some recent discussion in the journals.
Quinine has been empirically used in the treatment
of certain cardiac conditions for many years, and in
1914 Wenckebach recommended it as useful in re-
storing the normal rhythm in paroxysms of auricular
fibrillation, which is a condition marked by an irreg-
ularly irregular pulse. Frey, of Germany, and Levy,
of the United States, later investigated these claims,
verifying the action in one-half of the cases treated,
using from 2 to 4 grains at a dose, quinidine being
supposedly preferable to quinine, in each case the
sulphate being employed and given by mouth three
times a day. Drury and Iliescue, of England, re-
ported similar findings, believing that the action is
upon the auricle alone, reducing the rate at which
it beats through a slowing of conduction of the never-
ending wave that is supposed to encircle the auricle
in fibrillation.
Seme Wmnumg$
Lewis and Drury, of England, warn against the
indiscriminate use of this remedy, since there is often
a rise in the ventricular rate during treatment and
depression of the vagi in some cases.
Mackenzie, a noted specialist in cardiac affections,
expresses himself very conservatively, for he fears
that the small clots that sometimes form in the fibril-
lating auricle may be detached and enter the circula-
tion if by action of quinidine the auricle resumes its
normal contraction too quickly, as it is not so apt to
do under digitalis, though it sometimes happens.
Furthermore, he discounts the danger of auricular
fibrillation in and of itself; it is the effect upon the
ventricle that he fears. On the whole, he prefers
digitalis, using quinidine only when digitalis fails in
slowing the ventricle.
Some Sensible Obtervati
Samways put the whole matter very sensibly when
he said, in The British Medical Journal, October 22,
1921, "When a horse falls under a heavy load, and
begins to struggle to regain its feet, the usual treat-
ment is to sit on its head, or otherwise hold it down,
to prevent its damaging itself. This treatment does
nothing towards pulling the cart. In the same way
the treatment of auricular fibrillation or flutter, per se,
probably does nothing toward recovery from cardiac
breakdown, though it may be very useful in prevent-
ing the auricle embarrassing the ventricle." Samways
might have added that while the horse's head is held
down the harness is removed, and that, sixty years
ago, the patient with auricular fibrillation would have
been bled to reduce the load. Sometimes we ought
to bleed the patient today in such conditions, espe-
Pfafli., Much, 1922]
His Work Will Lire After Him
dally when the auricle is dilated, manifested by
fibrillation.
Doctor, don't count too much on quinidine sulphate
curing your heart eases, for if the auricle is dilated,
which is the real lesion back of serious fibrillation,
neither quinidine nor digitalis will remove that lesion.
But the good old treatment of giving mere tonic doses
of quinine in heart nutter ought to come in again,
for quinine in two-grain doses will probably do all
the real good in such conditions that the vaunted qui-
nidine treatment will accomplish.
St. Louis and the A. M. A. Meeting
NEXT MAT the American Medical Association
holds its annual session in St. Louis, and
already hotel reservations are being made. An active
loesl committee of arrangements is making every
effort to make the meeting a success and to secure
a full attendance. The principal hotels are as fol-
lows: American, Beers, Brevort, Cabanne, Cliridge,
Hamilton, JKETEBSON, Lecledc, Majestic, Marion Roe,
JliBQCETTEj Maryland, Planters , Plata, Rose] I e,
St Francis, Statleh, Stratford, Terminal, Warwick
and Westgate. Ones having 400 rooms and over are
printed in small capitals; those having from 200 to
350 rooms are set in italics, and the smaller ones in
ordinary type. The American has an annex with
225 rooms. The usual rates prevail. The meeting
is from May 22 to 26, but there is an advantage in
securing a room for the full week beginning May 21.
Secure reservations from the hotels, and if not ac-
commodated, write to Dr. Louis H. Behrens, 3525
Pine Street, St. Louis. The time to secure reserva-
tions is NOW.
The May session promises to be most interesting,
and many subjects will come up that are agitating
the profession. Doctor, if yon are not satisfied with
the present professional and economic position of the
profession, instead of letting it ferment inside and
getting yourself fussed up from an arm-chair point
of view, go to the meeting and talk it over with the
good fellows you will meet there; it will broaden you
and help to a solution. Needless to say, the sessions
will be most instinctive and helpful, and many ques-
tions of A. M. A. policy will be worked over. We
hope they will be constructively solved. The very
worst way to meet them and thus to induce confusion
and trouble in the profession is to stay at home and
fume over these problems. So go to the meeting,
have your say, hear the other fellow, and you will
come home the gainer in every way.
A Real Mc
Dr. Jcxtph MacDonald, 1870-1922
Mm*nf E*tH and ^WlW*r . Th, Amnion Jwrnal of Sur**
Only those who knew Dr. Joseph MacDonald will
realize just how much he will be missed by his friends.
Death is the everyday experience of mankind. As
we grow older we become conscious that here and there
friends are dropping from the ranks. Others step into
their place and the eternal plan goes on. We know
that sometime we in our turn will drop out, but the
eternal plan goes on.
The great thing of it all is to live so when our turn
comes to drop from the ranks we may leave behind
—good work well done— a remembrance in the minds
of those who knew us that will make it perhaps a
little easier for them to live and work, so in turn
they will leave behind, good work well done, a good
fight well fought, a worth-while life well lived.
Full all of this Dr. MacDonald leaves behind him.
While the sorrow is sharp in my heart that I will
never see him again, never hear his cheery "Mac-
Donald" laugh, never feel his hearty handclasp again,
there is also in my heart a certain cry of victory for
him— "Well done, 'Joe' MacDonald."
When the going is hard, when the temptation to
slow up is strong, to give way to pessimistic fore-
boding, to lag in indecision instead of goin«; forward
190
Announcement*
[The American Physician
with confident courage, I know if then the thought
of MacDonald comes into my mind it will be just
a little easier to "hit the line hard without flinching
or fouling." I venture to say this will be true of
a great many men who knew Dr. MacDonald. When
we leave such a remembrance we have not lived in
vain.
Dr. MacDonald's death might be said to be the re-
sult of his very virtues, always extremely energetic
and the hardest kind of hard worker in anything to
which he gave himself, the arterial hypertension from
which he died was largely a sacrifice to his overzeal.
But just what does it matter whether a man's span
is fifty years or seventy years or eighty years. It
is a man's quality ;.nd achievement that count. Better
to use up than rust out. Far better to live fifty years
as MacDonald lived them than to live eighty years
that mean nothing.
Dr. MacDonald died suddenly in his office January
7th of cerebral hemorrhage. He had suffered a cere-
bral hemorrhage in 1919, causing a hemiplegia. His
splendid fight these past two years in recovering his
old-time energy and fitness is. an inspiration to those
who know of it.
He was born in Branchville, Sussex County, New
Jersey, in 1870. Through sheer hard work and untir-
ing energy he rose from office boy to manager in the
office of the International Journal of Surgery, at the
tame time securing his medical education. In 1905 he
established the Surgery Publishing Company and the
American Journal of Surgery (formerly American Jour-
nal of Surgery and Gynecology). Dr. Walter M. Brick-
ner, a New York surgeon, has been associated with him
from the outset as editor-in-chief. The journal early
acquired well-merited esteem through the high standard
of literary critique it has maintained.
It will be a most fitting monument to his memory. It
is often true that the larger success of a man's work
comes after his death on the foundations he has builded.
MacDonald was the type of man whose work lives after
him and continues to grow.
He was co-publisher with Dr. Sol. Martin, of St.
Louis, of Medical Pickwick, a most entertaining, unique
monthly magazine of medical wit, humor, verse, history
and biography. He was an ex-president of the Ameri-
can Medical Editors' Association and for many years
as secretary invaluable to its success. An officer in the
Medical Reserve Corp after our entrance into the war,
he was given the rank of Major. He rendered valuable
service, first in stimulating physicians through the coun-
try to enter the military service by vigorous propaganda
in his own and member journals of the American Medi-
cal Editors1 Association, and later as chairman of the
New Jersey Army Medical Examining Board and then
as a member of the General Medical Board at Washing-
ton. He was very active in Masonry, a Past Grand
Commander of Knights Templar of New Jersey.
He is survived by a widow and a sister, Mrs. W. C.
McKeeby, wife of Dr. McKeeby, of Syracuse, New
York.
Quite apart from the important positions he filled and
the signal success of his work, the spirit of Dr. Mac-
Donald will linger in the hearts of his friends for the
man he was. Anyone who knew the host of those
friends, knew the kind of men to whom he appealed,
knew what he meant to them, would need to know
nothing more to understand the rare quality of "Joe"
MacDonald, as he was affectionately called by so many.
He was above all else — a real man among men.
C. C. Taylor.
Coming in Next Issue
Prognosis and Choice of Operations in Cancer of the
Stomach, by A. Wiese Hammer, M.D.
Cancer of the stomach means death. A very early
operation — seldom possible because the condition
is usually discovered when it is well developed —
offers a dubious chance for a radical cure, but
operation at any time often prolongs life and
mitigates suffering. The various phases of the
question involved, the medical and surgical aspects
of this all-vital problem are deftly and compre-
hensively discussed by Dr. Hammer in this scien-
tific but practical paper.
The Acute Abdomen — The Medical Version, by
Samuel Floersheim, M.D.
An acute abdomen has sent many a patient to
the grave. An acute abdomen requires immediate
attention. You have no time to study an acute
abdomen — you cannot wait, you most act. To
know what to expect, what to anticipate, what
to look for when called upon to treat this condi-
tion, read Dr. Floersheim's paper, which aptly
reviews this vital subject.
Is Cancer of Parasitic Origin? The Arguments, Pro
and Con, by Albert Schneider, M.D.
The etiology of cancer is still unsettled, its rav-
ages are still raging, while some minds still cling-
to the parasitic theory of the origin of malignant
growths. Just as every man is entitled to his
opinion, so is every physician entitled to the light
shed by such opinion. The paper of Dr. Schneider
has aptly presented the pros and cons on the sub-
ject under consideration. Read it and draw your
own conclusions.
Habits Which Lead to Constipation, by A. W. Herr,
M.D.
Ever since the human quadruped became a biped,
constipation became a product and a problem of
civilization. Whether this abnormality is due to
the superimposition upon one another of the body
viscera, "originally" intended to be hanging freely
from the posterior aspect of the body, as we be-
lieve, or is due to the several factors enumerated
in this splendid and instructive paper, or both, is
a question worthy of the physician's consideration.
At any rate, Dr. Herr presents a delightful paper,,
which we are sure you will enjoy.
Acidum Acetyl Salicylicum— Acetyl Salicylic Acid.
Trade Mark Name— Aspirin, by A. D. Heine-
mann, M.D.
Acetyl salicylic acid, aspirin, is the universally
abused drug. Of this the layman is woefully
guilty, though the physician as well contributes
his share to the promiscuity with which this
drug— excellent in its place — is so carelessly em-
ployed. A drug of such extensive utilization is
certainly worth knowing, hence Dr. Heinemann's
paper, we are confident, will be widely read. Do
not miss it
The following papers
are contributed exclu-
sively to this journal.
Republication is per-
mitted if credited as
follow: AMERICAN
PHYSICIAN, Phila-
delphia,
Original Articles
Sntmn, III suktss, tan insist utai Mtt essJmri
We are not respon-
sible for the views ex-
pressed by contribu-
tors; but every effort
is made to eliminate
errors by careful edit-
ing, thus helping the
reader.
Some Pediatric Don'ts
A Practical Survey of Every-Day Pediatric Problems *
DONTS THAT WILL HELP THE GENERAL PRACTITIONER BOTH IN DIAGNOSIS AND TREATMENT
By H. Bbookeb Mills, M.D., F.A.C.P.
1734 Spruce St., Philadelphia, Pa.
Professor of Pediatrics, Medical Department, Temple
University; Podiatrist to the Samaritan and
Oarretson Hospitals, and Consulting Pedi-
atric to the Hebrew Sheltering
Home and Day Nursery.
From his wide experience, the author gives
practical points which wiU help the physi-
cian both in diagnosis and treatment, with
his small patients; interestingly written in
the shape of brief, pertinent reminders, on
the more frequently met pediatric prob-
lems.— Editors.
Ckickem-Pax ami Herpet Zaater
DO NOT forget that these two conditions, accord-
ing to a recent author, Kraus, are believed to be
due to one and the same germ, entering the system in
each case by way of the nose and throat, and, in
the one case, going direct to the central nervous
system, resulting in herpes zoster, and, in the other
case, entering the circulation and going to the surface
direct, resulting in chicken-pox.
Physical Exmmumatiom W InlmmU
In making an examination of an infant, do not
forget the thinness of the chest walls; the presence
of the thymus gland; the fact that the second pul-
monic sound is normally accentuated; the advisa-
bility of examining the ears, nose and throat last,
because the crying that will result will prevent further
examination, and the advantage of turning the child
face downward over the examiner's hand to make
an abdominal examination.
Obscure Cmmsts W High Temper aire im Children
Where no apparent cause exists for a continued
high temperature, remember it is often due to one of
• Read before the Associated Physicians of Haileton, Novem-
ber 14th. 1921.
four conditions, (l)otitis media, (£) mastoiditis,
(3) pyelitis, or (4) the unstable equilibrium of the
child's nervous system. I would remind you that
the otitis media may be present without pain, and
that it is claimed 90 per cent, of the cases of otitis
media are influenzal in origin.
Caewkai Adenitis
It is well to bear in mind that this condition is
so frequently the result of diseased tonsils and de-
cayed teeth, and that a cure cannot be effected until
these two conditions have been removed, if present.
So many cases of lobar pneumonia have been
diagnosed as, and have been operated upon for,
appendicitis, that it is well to remind you of the
fact that, during the first 24 hours of an attack of
lobar pneumonia in the child, the symptoms are
largely abdominal; in fact, there are so many of the
symptoms of lobar pneumonia and appendicitis pres-
ent during this time, e. g., the sudden onset with high
temperature, the abdominal pain and distention, the
vomiting, the leucocytosis, the rapid pulse, etc, that
there is really only one symptom on which the dif-
ferential diagnosis can at least provisionally be made,
and that is the greater increase in the respiratory
rate in lobar pneumonia. The chest symptoms in
this disease often do not materialize until 24 hours
after the onset of the illness.
I would also remind you that death in this condi-
tion is a cardiac death, and not a pulmonary one,
and therefore you should be guided accordingly in
the class of stimulants employed.
Delayed Talking im m Chili
Before deciding that a child's lateness in talking
is probably due to mental deficiency, make sure that
it is not tongue-tied, and that its hearing is normal.
The Uses W Orange Juice
A recent author, Gerstenberger, claims to have
proven that instead of orange juice tending to loosen
the bowels, it acts rather in the opposite direction;
that its action is really that of a diuretic, and, by
192
Some Pediatric Reminders — Mills
[The American Physician
acting on the kidneys, thus increasing the flow of
urine, the fluid contents of the intestinal canal are
diminished, thus tending toward rather a diminution
than an increase in bowel action.
Excoriated Buttechs
An interesting contribution on this subject by
Brennemann recently showed that, not only this
condition, but also an actual inflammation, even
ulceration, of the head of the penis, frequently re-
sulted from an ammoniacal diaper, which was not
remedied until the mother was instructed to boil every
diaper removed from the baby, never mind even if
it be only slightly dampened by urine.
Another interesting article on this subject recently
appeared, in which the author (Cooke) claims that
he has isolated from the stools of these patients
a gram-positive bacillus which he calls Bacillus
Ammoniagenes. He states it is a saprophyte, and
has the property of fermenting urea with the pro-
duction of ammonia.
He shows that the growth of this organism is in-
hibited in acid medium, but is abundant in neutral
or alkaline medium, and suggests the following
directions for the use of the three antiseptics that
he has found to produce the best results in relieving
the trouble: —
Mercuric chlorid (1:5,000). — Dissolve one 7%
grains tablet in two quarts of water and use this
solution for the final rinsing of the diapers. Wring
thoroughly and dry.
Boracic acid (1:20). — Dissolve one heaping tea-
spoonful in six ounces of water by warming. Pour
this over a dry napkin, wring thoroughly, and allow
to dry.
Mercuric iodid (1:5,000). — An aqueous solution ot
5 per cent, each of mercuric iodid and potassium
iodid is prescribed. One teaspoonful is to be added
to a quart of water and used for the final rinsing
of the diapers.
Diphther'w
Do not forget the proven value of the Shick test,
which consists of the intra-cutaneous injection of
toxin-antitoxin, or undiluted diphtheria toxin in the
dose of l/50th of the minimum lethal dose for a
guinea-pig, a positive reaction indicating the need
for diphtheria anti-toxin.
Tongue-Tie
Remember that the act of nursing is performed
largely by the tongue and not by the lips, and, there-
fore, an examination for the existence of tongue-
tie should be the first thing done in the case of diffi-
cult nursing.
Bhod Examinations
Before rendering a decision as to the meaning
of a differential leucocyte count, bear in mind that,
at the age of 8 years, a child's blood is said to assume
adult characteristics, in other words, previous to this
age the polymorphonuclear leucocyte count is nor-
mally from 25 per cent, to 50 per cent, and the
lymphocyte count is from 50 per cent, to 75 per cent.,
whereas, after this 'age, conditions are reversed,
the polymorphonuclear leucocyte count being from
50 per cent, to 75 per cent., and the lymphocyte
count from 25 per cent, to 30 per cent
Diseased Adenoids, Tonsils ami Decayed Teeth
Always have in mind the many infections that
have been traced to one or both of these conditions,
and have failed to respond to treatment until the
causative factor was removed, among others cervical
adenitis, pyelocystitis, appendicitis, tuberculosis, car-
diac disease, etc.
InMuenxat Pntumsnia
Do not forget that the leucocytosis normally pres-
ent in broncho-pneumonia and lobar pneumonia is
absent in influenzal pneumonia, a leucopenia being
the rule.
Tuberculin Tests
The failure of the von Pirquet and Moro tests,
the two most commonly used in children, as the Cal-
mette is considered too irritating for the delicate
mucous membrane of the child's eye, to give a posi-
tive reaction should not be considered as final until
the test has been repeated two or three tunes
with several days intervening, and the dosage used
increased each time.
It is also well to remember that the reaction is
frequently negative in cases of pertussis and pneu-
monia.
Tuberculin Injections
This treatment has proven so valuable in children
that it is well to have in mind at least one method
(that of Miller) of its use that has been found
satisfactory. Thus, starting with l/1000th of a mg.
of Koch's Old Tuberculin, then giving l/900th of
a mg., then l/800th of a mg., etc., and so on, giving
an injection at least once a week, and increasing
to the amount desired to accomplish results.
Tabes Mesentericm
As you all know, the glands of the mesentery are
not normally palpable, and, when they are, the diag-
nosis of tabes mesenterica is usually a safe one. Even
then, as you all also know, these enlarged glands
will not show on an X-ray plate unless some calcifi-
cation is present, and, therefore, as the determination
of the existence of this condition is frequently one of
the first things possible in making a diagnosis of
tuberculosis in a child, one should train themselves
to be able to elicit its existence.
Enlargement or the Bronchial and Mediastinal Glands
As Eustace Smith, of London, claims that in 8
out of 10 cases showing this condition, tuberculosis
is the cause, one should bear in mind the sign named
after him, which is a venous hum caused by the com-
pression of the left innominate vein between the
PhiU., March, 1922]
Some Pediatric Reminders — Mills
193
enlarged glands and the trachea, elicited by placing
the stetheseope at the supra-sternal notch.
Do not forget that the path from the intestinal
tract to the thoracic duct and lungs is a direct one,
so that tuberculosis of the bronchial glands or lung
infection may be by way of the intestines, and in
this way it may be explained why some of these
cases are due to the bovine type, i. e., they are pri-
marily intestinal infections, becoming thoracio sec-
ondarily. It is also important to remember that
these intestinal infections are not only due to food,
especially milk, but that they may also be due to
infected material carried thru the mouth from dirty
fingers, especially where the dirt is obtained from
crawling on the floor.
f— fif W Gmm*
You may all have noticed how little, if any, relief
you have obtained at times by lancing the gums for
presumed difficult dentition, but perhaps it has not
occurred to you the reason therefor. I believe this
to be due to the fact that most of the pain is caused
by the squeezing of the gum between the erupting
teeth rather than to the soreness in the swollen gums
over the points of the teeth, and, if this be so, of
course the lancing does not reach the seat of the pain.
Then, too, there is the risk of the gum re-forming over
the points of the on-coming teeth, and, if this does
occur, it will be more tough and fibrous than was the
gum removed, thus increasing the difficulty the teeth
would have in forcing themselves to the surface.
Umdescemdtd Te*icU
Having seen a number of trusses being worn to
hold up a supposed hernia, which proved to be an
undescended testicle, I would remind you to always
nave in mind the not infrequent existence of this
condition in children, as, not only may much harm
be done by the application of a truss to an unde-
scended testicle, but a large amount of valuable
time may be lost in giving the proper treatment
to a real hernia,
Epiiemuc Ccrebr+Spkmi MemmgkU
■ I would remind you of the great diagnostic and
therapeutic value of lumbar puncture in this con-
dition, and also of the importance of McEwen's
sign in determining the need for the puncture
and for its repetition. McEwen's sign, as you know,
consists of a tympanitic note obtained by percussion
over the frontal and parietal lobes, preferably with
the patient in the upright position with the head
inclined to one side. The thinner the skull the
greater the vibration, and the greater the fluid and
intracranial tension the clearer, the percussion note.
The sound produced may be well represented with
the hands. If, for any reason, it be undesirable to
sit the patient up, then the head should be turned
to one side, and the percussing done on the lower
side, i. e., the side nearer the bed. The sound is
reduced in intensity after a lumbar puncture, and
is, therefore, a guide for its repetition. As you, of
course, know, it is due to an accumulation of fluid
in the ventricles.
You may also have noticed that the spinal fluid
in some of these cases is of a yellowish color, which
condition is called xanthochromia, and these cases,
which are almost alwayB fatal, are divided into two
main groups: (1) those fluids that give a positive
reaction for haemoglobin, which probably causes the
yellow color, and do not coagulate spontaneously;
and (2) those that do not give a positive reaction for
haemoglobin, but do coagulate spontaneously. The
yellow color in cases" in Group I is due to dissolved
haemoglobin, or its derivatives, while the yellow color
in cases in Group II is due to the fluid in the lower
portion of the canal being shut off from communi-
cation with the fluid in the ventricles by an obstruc-
tion of the sub-arachnoid space, such as by a tumor,
or adhesions following a previous inflammatory proc-
ess, or a tubercle.
It is also well to bear in mind that eases have
been observed where the first puncture yielded a clear
fluid, whereas subsequent punctures revealed speci-
mens of a decidedly purulent nature. This condition
is explained in one of three ways: (1) that the in-
flammatory process has only just begun in the men-
inges, and therefore the cloudy fluid that will eventu-
ally result therefrom has not yet flowed down the
spinal canal to the point of puncture; (2) as the
choroid plexus is believed to be responsible for the
secretion of the spinal fluid, it is possible that the
drainage of the fluid from the sub-arachnoid space
into the spinal canal is being temporarily blocked
by the inflammatory exudate; or (3) the obstruction
may be mechanical, the pressure from below being
greater than that from above downward ; in this case,
the relief of the pressure from below by the first
puncture will permit of the flow of fluid from above.
One, therefore, is not justified in dismissing the diag-
nosis of cerebro-spinal meningitis, based on the
appearance of a clear fluid at the first puncture.
I would suggest three rules be observed in admin-
istering the serum in these cases, in order to avoid
the serum sickness and thermal reaction that some-
times follows : —
1. When large doses of intravenous or intra-
spinal serum are given the serum must be introduced
slowly. At least ten minutes should be taken
to run the serum into a vein. The slowness of
intravenous administration is essential to the safety
of the patient. As the larger the amount of fluid
that is used the greater and easier is the control of
the rapidity of the flow, the serum may be diluted with
salt solution merely to increase the bulk.
194
Some Pediatric Reminders — Mills
[The American Physician
2. The temperature of the serum should never
be below the temperature of the circulation. Indeed,
it is better that it should be slightly above that of
the patient.
3. It is very important that the serum should
be clear, and, if any sediment is present, to be sure
to avoid its introduction.
The three points therefore, (1) rapid administra-
tion, (2) cold serum, and (3) cloudy serum, either
singly or collectively, may be responsible for either
of these unpleasant reactions. Should the serum
sickness develop anyway, a 5 per cent, solution of
phenol works well in affording relief.
The U*e of Urotrop'm
As it is claimed this drug "only acts in an acid
media, it is wise to add acid sodium phosphate aa
to the urotropin when using this drug.
The Use W Castor Oil
Because of the constipating after-effects of castor
oil, it is usually considered wise to use it only in
diarrhoea rather than in constipation.
Rickets and Breast-Feeding
Every once in a while you have probably encoun-
tered patients who persisted in keeping their infants
at the breast far into the second year, and I would
suggest you bear in mind that prolonged nursing
is the most common cause of rickets in breast-fed
babies, the reason being the deficiency of the milk
in nutritive value.
Some points that it is important to remember in
connection with breast-feeding are that there is said
to be less milk in the breasts in the afternoon, i. e.,
after 3 p. m. ; that the percentage of fat is highest in
the middle of the day; that there is more sugar in
the milk at the beginning of a nursing, and more
fat at the end of a nursing; that the percentage of
fat present varies all the way from 1 per cent,
to 10 per cent.; that there is no relation between
the stage of lactation and the amount of fat present;
that the proteid per cent, varies but little during a
nursing; that the greatest variation in the milk from
the two breasts, taken at the same time, is in the fat,
and that the great difference in the percentage pres-
ent of the various ingredients of the milk from the
two breasts makes it absolutely necessary, when
testing the milk, to do so from each breast separately,
and not mix the two together previous to examina-
tion.
Typhoid Paver
Because of the fact that the rose red spots so
common in typhoid fever in the adult are only present
in about 20 per cent, of the cases in children, it is
well to bear in mind that their diagnostic value is
only in that proportion.
Vomiting in Infancy
A recent author states that, where no reason can
be found for persistent vomiting, in a certain num-
ber of cases atropine solution in the strength of
1/1000 is beneficial, especially in bottle-fed babies,
one drop of this solution being added to every feeding
for 48 hours, then two drops to every feeding for
48 hours, and so on, going as high as five drops or
more, to each bottle, if necessary.
Hat chiton** Teeth
The question is often asked as to whether or not
this condition occurs in the first teeth, and I would
remind you that, as these teeth have their beginning
at the 17th or 18th week of intra-uterine life, the
occurrence of syphilis at that early date in suffici-
ently severe form to affect the teeth would cause the
death of the foetus; therefore, it is not likely that
this condition occurs, but very rarely, if ever.
Kernig's Sign end BahinM* Phenomenon
Do not attach too much importance to these tests,
partly because of their occurrence in so many forms
of meningitis and cerebral lesions, and partly be-
cause they may be normally present, at least up to
the age of 18 months.
I might also remind you that, whereas a positive
adult Babinski consists merely of a dorsi-flexion ot
the great toe when the plantar surface of the foot
is stroked with the finger, pediatric Babinski con-
sists, in addition, of plantar flexion and separation
of the remaining toes.
Itching in Contagion*' Diseases
I have found that the use of warm baths, followed
by inunctions of cocoa-butter, without first drying
the skin, to be a most agreeable, as well as beneficial,
method of handling this troublesome condition, the
heat of the body from the fever that is present and
the moisture on the skin from the bath, causing
a thin film of cocoa-butter to adhere to the skin.
A good method of preventing scratching is the use
of "Hand-I-Hold" Mits.
Protection of the Eye* in Measles
You all know how important this is, and are also
aware of the unpleasantness and discomfort that
has frequently resulted to the nurse and the patient
from the darkening of the room for this purpose,
and I would suggest the placing of the patient in
bed in such a way that the back of the head faces
the window, instead of the child facing the window;
in this way the curtain at that particular window
may be raised all the way, and plenty of light allowed
in the room, the only curtains to be drawn being
those at the remaining windows, if there be any.
Phfla., March, 1922]
Complications Following Gastric Operation — Hammer
195
Complications Following Gastric Operation
POSSIBLE COMPLICATIONS MUST BE CONSIDERED BEFORE OPERATION
By A. Wiesb Hammer, M.D., F.A.C.S.,
218 South Fifteenth St., Philadelphia
f# Kmow What to TtU the Pmtiemt
Complications and sequelae of gastric sur-
gery are frequent and important. To know
the probabilities and possibilities of the pro-
cedure under consideration is to know what
to tell the suffering patient in quest of vital
advice. This paper of Dr. Hammer is ex-
cellently presented and covers its ground
admirably well. We hope our readers will
benefit by it. — Editors.
THERE ARE MANY COMPLICATIONS— im-
mediate and remote — following in the wake of
gastric operations, and as death, too often in a large
percentage of these cases, is recorded as a part of
statistics, it becomes an instructive study to examine,
with critical attention, the likelihood of a fatal ter-
mination following such operations as well as the
complications and sequela? that may lead to such a
termination.
The causes of death after operation on the stom-
ach include: Shock, peritonitis and pneumonia.
There is also the possibility of the so-called "vicious
circle," after gastrojejunostomy, and the possibility,
in other instances, of peptic ulcer, internal hernia,
gastric or duodenal fistula and subphrenic abscess.
All sorts of statistics are available, and at first view
such data must appear as misleading and confusing.
But the thoughts incorporated in this paper deal with
the more recent advances in gastric surgery with
improved technic and in the hands of the skilled oper-
ator. One factor that every student of statistics need
reckon with is the effect upon the individual's health
brought about by the original disease, rather than as
the result of any operation.
Shock
When the patient, having been under watchful care
before operation, is brought to the operating table
properly protected, so as to avoid loss of bodily heat,
the inference usually is that such an individual, if
he become a victim of shock, does so through some
fault of his surgeon. Shock, therefore, often results
from a bungling in the operation such as a too pro-
longed procedure in the weak and sickly, operation
upon some other part or organ in addition to the
original operation and in not selecting the very best
operation for the case under consideration. Hemor-
rhage may antedate shock. With dense adhesions and
in the presence of certain malignant conditions, copi-
ous hemorrhage is at times hardly avoidable. But it
is almost criminal for a surgeon to be taken unawares
for lack of instruments or for the proper ones, when
the patient lies exposed and time is lost in the selec-
tion and preparation of the paraphernalia necessary
for the operation.
rtntoMftf
Because of improvements in technic, this complica-
tion is quite exceptional, and is to be found mostly
in ulcerations and perforations of the abdominal
organs. Although the peritoneal infection is second-
ary to the lesion under consideration, it may become
primary in importance. Per contra, we may en-
counter extremely mild perotonitio evidences in the
most serious malignant lesions of the stomach and
its adjacent viscera. The employment of the Murphy
button and the occasional leakage resulting from
anastomosis, has not infrequently led to peritonitis.
Complicated technic, the perforation of gastric or
duodenal ulcers, and prolonged and clumsy handling
of the parts all contribute their share to the develop-
ment of this complication.
There is a variety of causes alleged to bring about
pneumonia in operation upon the stomach. Many of
these are problematic. Thus, local anesthesia is
said to be more likely to produce pneumonia than
when a general anesthetic is employed. This later
statement is energetically defended by Mikulicz.
Others are skeptical concerning" the assertion.
The view entertained by Kelling finds favor with
many of the best surgeons, namely, that these pneu-
monias are the direct result of inhalation or through
diaphragmatic infection. Or, again, that the breath-
ing, which is of a purely restricted costal type because
of the seat of the operation, favors hypostatic con-
gestion. Such interferences and accidents are antag-
onized in a large measure through the more modern
post-operative treatment of stomachic operations, of
having the patient assume the sitting posture in bed
soon after the operation. The true explanation for
the development of these pneumonias seems to lie in
the recent pronouncement of Cutler and Hunt (1920),
that mobility of the part and sepsis, favor the forma-
tion of emboli that are carried to the pulmonary tis-
1
196
Complications Following Gastric Operation — Hammer
[The American Physicka
sues through the blood stream and the lymphatic
channels. The percentage of pneumonias following
upon surgery of the stomach varies between 1 and 5
per cent.
Virion* Circle Afar Gastro-jejumtttmy
All sorts of explanations and a variety of theories
have been advanced to clarify a chain of post-opera-
tive symptoms as applied to persistent vomiting after
this operation, and which was believed until about
fifteen or sixteen years ago to be the expression of
the escape of ' the stomachic contents through the
pylorus and the regurgitation from the duodenum
back into the stomach, by way of the afferent loop
of the gastrointestinal anastomosis.
It is essentially caused by obstruction to the on-
ward passage of the duodenal contents, due to much
handling of the intestine resulting in a paretic condi-
tion or to the faulty use of clamps; it may likewise
be caused by a kinking of the bowel at the point of
anastomosis, or to some obstruction beyond the
gastrojejunal opening.
The presence of bile or pancreatic fluid in the
stomach cannot be held responsible for the persistent
and pernicious vomiting; for as early as 1890 Dastre
published an exhaustive study (Archiv. fur Physi-
olog.) in which he absolutely exploded the erroneous
theory. J. B. Deaver asserts, in speaking of gastro-
jejunostomy as quite the ideal treatment of gastric
ulcer, especially the pyloric ulcer with pyloric ob-
struction, that
"If the anastomosis is made* in the pyloric
portion, not in the body of the stomach, the
anastomotic opening will functionate even where
the pylorus is patulous; and even if the gastric
contents do not leave the stomach by the new
opening, but still are discharged by the pylorus,
the gastrojejunostomy aids in healing the ulcer
by permitting admixture of bile and pancreatic
juices with the stomach contents, thus diminish-
ing hyperacidity.'*
Nor are the following factors at all convincing to
account for the vicious circle: The presence of a
loop on the proximal side of the opening into the
stomach, which is disproved by the large number of
anterior gastroenterostomies which necessarily must
have such a loop ; by the situation of the opening not
being at a dependent part of the stomach, because
what was not dependent before operation, becomes
dependent after operation. Then, again, the stom-
ach does not empty its contents by gravity but by
contractions into the bowel. Also, so very many of
the operations, not at the most dependent part have
been so thoroughly successful.
The following are some other causes advanced to
account for the development of a vicious circle:
Acute angulation of the jejunum beyond the anas-
tomotic opening; avoided by one or two sutures be-
yond the opening.
Pouting valves of the mucous membrane; avoided
by proper application of the marginal suture, secur-
ing apposition of the intestinal to the gastric mucous
membrane.
Compression of the colon, as asserted by Doyen,
by the jejunal loop in the anterior* operation.
Mayo Robson, in speaking of the vicious circle as a
sequel to gastrojejunostomy, reports that in one of
his cases adhesions formed subsequent to the opera-
tion leading to constriction of the distal arm of
jejunum, upon which he performed a subsequent
operation six months later, and cured the condition
by the division of a band crossing the distal jejunal
loop.
The profession seems well in accord with Robson's
conclusion: "That the causes of vicious circle are
avoidable and the complication should, therefore, sel-
dom if ever occur and, in fact, since recognizing the
cause in 1901, "I have never seen," he says, "a case
of regurgitant vomiting."
Peptic Ulcer ei the Jejmtmm
Peptic ulcer of the jejunum is an extremely inter-
esting one and has given rise to much speculation and
to many theories. It would be impossible in a brief
space even to attempt to name the conditions that
would predispose to this complication, although the
dictum of Robson that the condition is in all likeli-
hood an expression of a mild form of sepsis leading
to gastritis and an excess of free hydrochloric acid in
the gastric juice, is believed by many very excellent
surgeons. The Mayos blame this complication upon
faulty technic. Deaver is of the opinion that as the
stomach is diseased, and whatever be the real cause
of the ulcer, it cannot be absolutely and completely
eradicated by the operation alone and that the devel-
opment of an ulcer at the site of the anastomosis or
in the vicinity may be regarded as a manifestation of
the underlying disease.
Internal Bermm After Gmtre-jejmmtemy
Internal hernia after gastrojejunostomy is of rare
occurrence. Deaver observes the reports of ten cases
of different operators, and notes that in four of these
instances the complication occurred after a posterior
short-loop or no-loop operation. It occurred in two
instances after anterior gastrojejunostomy and in
two after a posterior long-loop operation ; in one case
the nature of the gastrojejunostomy is not described.
He asserts 'that even without an actual hernia, the
long loop has been responsible for death in a small
number of cases by producing obstruction through
volvulus of the anastomosed loop, or by drawing the
mesentery so taut as to strangle the lower bowel
beneath it.
PhiU., March, 1922]
Complications Following Gastric Operation—Hammer
197
In 1902, W. J. Mayo reported the passage of the
small intestine through the loop formed above the
junction of the jejunum and the stomach. This con-
dition is only likely to occur after the anterior oper-
ation, and its occurrence was the signal for operation
one year following the primary operation, i. e., ante-
rior gastroenterostomy.
Later, Moynihan reported such a case of internal
hernia, the patient dying on the tenth day following
operation, the result of acute intestinal obstruction;
when a part of the small intestine was found in the
lesser peritoneal cavity. But, at best, this complica-
tion is of infrequent occurrence.
ufltnric IM UMttttH rtfUMtf
These are serious complications that may follow
in the wake of operations upon the stomach. Peptic
nicer of the jejunum as a sequel to the operation of
gastrojejunostomy (vide supra), has been suffi-
ciently referred to in this paper. It is interesting,
however, to note that Leiblein has critically studied
seventy-nine cases of jejunal ulcer, and announces in
twenty-four cases perforation into the peritoneal
cavity, while the remaining fifty-five ran a chronic
course.
In thirteen instances an internal fistula resulted; in
ten cases, a jejuno-colic fistula; in one, a gastro-colic
fistula; and in two, jejuno-gastro-colic fistulfe. In
1905 Kauffman reported the occurrence of a gastro-
jejuno-eolic fistula, following the operation of pos-
terior gastro-entero-anastomosis, done four years
previously.
SttkpkftMC Aw9C€M3
The subject embraced under this caption is a large
and important one, but it is only necessary to point
out in this brief exposition, that this complication
after operations upon the stomach may arise from a
variety of ulcers — gastric, duodenal or jejunal, many
of such ulcers resulting after operations upon the
stomach; the condition is also, at times, liable to
arise from gastric or duodenal fistulae, already suffi-
ciently dwelt upon.
In order to offer a clear classification, the above
complications are those embraced in the prefatory
words to this paper. But there remain three other
complications that at times may appear and are sub-
joined in order to make the epitome complete.
The first of these is perforation, owing to a want
of union at the point of anastomosis. This is an
extremely grave complication and in the cases re-
ported has always resulted fatally. It occurred in all
these cases where the Murphy button was used. In
none of these cases was union by suture. Robson
has reported one of these eases; W. J. Mayo two
such cases, and the late J. B. Murphy, one instance.
In one of the two cases reported by Mayo, the acci-
dent followed an epileptic seizure on the ninth day; "
in the other on the seventh day after gastroenteros-
tomy for malignancy of the pylorus.
Whether due to faulty technie or some error in
asepsis, the occurrence of adhesions subsequent to
gastroenterostomy may at times appear as a compli-
cation, although it is the consensus of opinion that
perigastritis or adhesive peritonitis, at a distance
from the site of operation, while rarely encoun-
tered, must have its explanation in the employment
of antiseptics too powerful and at the same time too
irritating. Adhesions, the result of cancer, and ulcer
are quite common and Mayo Robson found these so
extensive in one case that it was almost impossible to
locate any healthy portion of the stomach to which
the jejunum might be applied.
DttA Fnm AtAmm
Death from asthenia although still encountered, is
to be regarded rather as a surgical rarity after oper-
ations upon the stomach. Twenty-five or thirty years
ago it was considered a part of treatment for the
patient to abstain from food by the mouth, in other
words, major surgical operation upon the stomach
was the signal for starvation. Today asthenic deaths
in these classes of cases is the exception, for, with
the administration of liquid and semi-liquid nourish-
ment, and this supplemented by nutrient enemata,
these dangers are greatly minimized.
Of course, in any of the large series of statistical
tables at one's command, he is likely to find that
death supervened in many cases of gastric operation
from uremia, anemia, myocarditis, cerebral embolism,
etc. But these complications arise in one with these
complaints already existing to some degree, and are
merely aggravated or brought to a fatal issue through
the gravity of the operation that has been performed.
But they can in no way be considered as complica-
tions or sequela) of gastric operations, or is their
development at all probable as post-operative events.
For this reason, mention of all such causes of death
have been studiously avoided as being irrelevant to
the subject.
Trttmt* W TwbtcdnU hy Mmtd Im-MdUm MrftW
J. P. Israel, Houston, Tex. (N. Y. Med. Jour., January
4, 1922), says:
1. It is of the utmost importance that all anomalies
of the nose be corrected so that nasal respiration may
be correctly established as soon as possible.
2. The insufflation method in the use of tuberculin
is of great advantage in the treatment of tuberculosis
and can easily be given by any physician.
3. In most cases uniform results are produced. It
can be employed in hospital or office alike. The period
of treatment should extend over six to eight weeks at
least, and where tuberculins are to be used over a long
period, it is the ideal method, as it is not painful and
causes very little discomfort to the patient, and the
results are the same as the subcutaneous method.
In my opinion it is the method par excellence for
the treatment of ocular tuberculosis.
198
Intravenous and Intramuscular Therapy — Saverese
[Phita., March, 1922
A Clinical Comparison
of
Intravenous and Intramuscular Therapy, Using Iron and Arsenic
CERTAIN DEFINITE RESULTS MAY BE EXPECTED WHEN INJECTED DlRECrLY INTO THE CIRCULATION
By Melchior F. R. Saverese, M.D.,.
209 Washington Park, Brooklyn, N. Y.
THE THERAPEUTIC advantages of intrave-
nous medication are that certain definite results
may be expected from the dose given. As the drug
enters directly into the circulation, it is not liable
to the change or decomposition it undergoes if given
by mouth or intramuscularly. Physiologic results
are often obtained much more quickly. Particularly
is this true in anemias and many types of malnu-
trition. When the whole system is surcharged with the
poisons of these low-grade diseased conditions the
absorption of food is greatly impaired. Many medi-
cines when given per os are changed before the final
absorption and cannot, therefore, have the same effect
as when administered hypodermically. The place
of injection is important. It has been shown that
absorption from intramuscular injection is faster
than from subcutaneous, and often injection directly
into the circulation is the most prompt, and therefore
the method of choice.
The use of some form of iron and arsenic, alone
or combined, has for many years been the practice
in the treatment of anemia. Although improvement
and even cures have been reported when the prepara-
tion was given by mouth, digestive disturbances of
varying degree were almost always accompanying
phenomena. Moreover, improvement could not be
predicted with any assurance. The comparative
results of intramuscular with oral administration of
iron alone, or iron and arsenic preparations, show
the intramuscular method to be much more certain;
but, irritation may result if the preparation is too
concentrated.
Intramuscular injections of iron have been given
by Italian physicians for some years.1 In this
country intramuscular injections of arsenic and iron
have been used with good results in severe anemias
and pulmonary tuberculosis; but the use of iron and
arsenic together has been neglected. In an attempt
to duplicate as nearly as possible the work of the
Italians, many physicians here used the preparation
which has been standardized in Italy. With this
solution sixty to eighty intramuscular injections
were required to effect a cure. The number is de-
termined by the reaction of the patient. Moreover,
it has been found1 that unfavorable symptoms are
mitigated by alternating the injections, toward the
end of the course, with administration per os of
arsenico-ferruginous preparations with nux vomica,
strychnine and other drugs. If these are continued
for some time after injections the therapeutic effect
is better and more lasting.
5mm Rettmrck
It has also been noticed by careful investigation1
that under the stimulus of the intramuscularly in-
jected Italian solution the hemopoietic organs pro-
duce red blood cells which are immature and do not
last, hence there are many recurrences.
In 1907, Dawes and Jackson* reported the results
of several years' experimentation and intramuscular
treatment with sodium cacodylate. The reason for
using this form of arsenic was that the sodium held
the inorganic arsenic in such a stable combination
that only a partial decomposition could be affected,
thus avoiding the toxic symptoms reported by others.
Hence large doses and long continued treatment were
necessary. The dose consisted of about 0.1 gm. of
the salt dissolved in a syringeful of boiling water,
injected through a long needle deep into the gluteal
muscle. A course of ten daily treatments was fol-
lowed by a similar interval of non-treatment. There
was always an increase in the hemoglobin but usually
only a small increase in the red blood cell count
Thirty injections extending over a two months' period
cured eight patients with simple anemia.
Of the three cases of splenic anemia, one died
after a period of temporary improvement; the other
two were cured by 0.15 gm. doses after five ten-day
courses with ten-day intervals (100 days).
Of Dawes' forty-five cases treated intramuscularly
with sodium cacodylate, thirty-four patients were
either entirely cured or much benefited, eleven showed
no change and two were made worse. The results
were not recorded in a form which can be incorpor-
ated in Table I of this paper but comparison of the
final results shows the limitations of this treatment
The results were uncertain and the treatment was
long (two or three months).
Although many other physicians in this country
have obtained satisfactory cures of anemia by in-
jecting some form of iron and arsenic intramuscularly,
practically without exception they report that pain
is felt at the point of puncture for about twenty-
four hours, and occasionally an abscess develops.
Phfla., March, 1922]
Intravenous and Intramuscular Therapy — Saverese
199
The induration may heal of itself or may require
local treatment by massage and hot applications.
Since the introduction of the intravenous injection
of these two drugs no such ill effects are encountered.
The preparation is supplied directly to the blood,
where the immediate need is, and the effect is prompt.
The blood stream carries the solution through the
body in a few seconds and the therapeutic function
is accomplished before any extraneous tissue or
digestive secretion has an opportunity to nullify its
effect. It is entirely logical to expect better results
from the more direct method.
I had for a number of years used the intramus-
cular method, but when I realized the possibilities of
getting the solution into direct contact with the part
most in need of it, I decided to make a study of the
comparative value of the intramuscular and intra-
venous methods.
it. All instruments must be carefully and thoroughly
sterilized. Draw the fluid into the barrel of an
all-glass syringe, which is equipped with a twenty-
three gauge hypodermic needle, and insert the needle
parallel with the vein. As soon as dark blood
appears in the syringe, one may be certain that the
vein has been penetrated and care must be exercised
to avoid going beyond into the muscular tissue. Re-
lease the pressure on the vein and inject the fluid
slowly.
The solution used for the intravenous injection
as 5 c.c. solution of iron and arsenic prepared
according to a method approved by conservative
authorities.4 The iron in this solution is in a col-
loidal state and the amount used contains 64 mg.
(1 grain) of iron cacodylate. The patients were
treated every fifth day. For those receiving intra-
muscular treatment 1 c.c. containing 32 mg. (0.5
TABLE No. 1
Method
Intramuscular
Preparation
Iron, arsenic
glycerophosphate!
Iron eacodylatef
(Italian soluble iron
arsenate)}
Hemoglobin
Before After
65% 95%
** t*
Intravenous 5cc American iron
cacodylate solutiont
60%
37%
40%
30%
68%
60%
90%
57%
55%
52%
Red Blood Count
Before After
3460,000 5,010.000
3.625.000 3.865,000
2.220.000 2.220.000
8.248,000 4,888.000
3,500,000 4,350,000
<o 8,700,000 5,400.000
95% 3.500.000 4.500,000
Time
108 days
(3 times a week)
38 days
(daily).
35 days
(daily)
60 days
(daily with 4-5 day
rest after 20th
injection)
2-3 months
(daily with 4-5 day
rest after 20th
injection)
30 days
(6 injections)
30 days
(6 injections)
Results
no irritating
qualities
no improvement
after 13th
injection
no bad effect*
TABLE No. 2— PRESENT SERIES
Method
Intramuscular
Intravenous
Preparation
1 cc Italian solution
iron arsenate
Hemoglobin
Before After
73% 80%
73%
73.5%
87%
88%
5cc American
solution of iron
cacodylate
The Author's Experience
For the most part my patients are of Italian birth.
A series of cases covering a period of five years
serves as the basis for the present conclusions.
The technic is practically the same in both methods
except that for the intravenous injection the needle
is directed into the median basilic or median cephalic
vein at the bend of the elbow. Alcohol is used to
sterilize the surface at the point of the puncture.
Adjust the band, for taking blood pressure, firmly
about the upper arm so that the vein stands out
enough to allow the fingers of the left hand to grasp
Red Blood Count
Before After
3.600.000 3,900,000
3.600.000 4.650.000
3,610,000 4.850,000
Time
40 days
(13 injections)
3 months
(30 injections)
40 days
(8 injections)
Results
Occasional
Toxic
symptoms
•«
No toxic
symptoms
grain) of iron arsenate was used and the injection
was repeated every third day.
During 1919, eighty patients were treated, repre-
senting secondary anemias, some post-operative, some
post-febrile. Alternating these patients as they
appeared for treatment, half were given intramus-
cular, and half intravenous injections. The red blood
cell count and hemoglobin were taken at the beginning
of treatment, at the end of forty days, and, in the
case of the intramuscular series, at the end of three
months.
Pain and an occasional abscess followed the intra-
muscular injection, but no untoward symptoms were
200
Intravenous and Intramuscular Therapy — Saverese
[The American Physician
noted in the intravenous method. I have made over
2,000 intravenous injections with no sign of abscess
formation and in no case was there any alarming
reaction. Occasionally a needle-shy patient appeared,
who showed some indications of fainting.
I found that I was able to obtain at the end of
forty days with an average of eight intravenous
injections results which required three to four months
by the intramuscular method. The average figures are
included in Table 1, showing the comparisons of the
two methods. The results given in this table are
typical records from the literature for intravenous
and intramuscular therapy. Each entry indicates
a case.
My figures (Table No. 2) are averages of eighty
cases, forty each treated intravenously and intra-
muscularly.
My results show that one intramuscular injection
raises the red blood count about 23,000, while each
intravenous injection raises it about 100,000 to
150,000. The improvement in the hemoglobin is in
the same relation.
Comparative Costs e4 the Tw Methods
As it is the custom for physicians to charge more
for an intravenous injection than for an intramus-
cular one, the patient is likely to prefer the latter.
It is evident, however, that six to eight injections at
five dollars, for example, is somewhat less expensive
than thirty or more injections at a dollar and a half,
the usual price charged. This economical aspect is
very important to the patient. It is manifested in
society by the increased efficiency of the laborer or
housewife in a comparatively short time. We are
now able to assure a patient who cannot afford to
be ill that in five or six weeks his blood condition
and consequently his general health will be as nearly
-normal as it would be in twice that length of time by
the older method. At the same time the cost is less
and the possibility of unpleasant accompanying
symptoms is reduced to practically nil. The saving
in time to the busy physician is, moreover, no mean
consideration.
Be Smra of Your Solatia*
To insure positive results in this treatment one
must not experiment with extemporaneous solutions.
In attempts to avoid the unpleasant results of others,
many physicians here and in Italy have devised solu-
tions of widely varying formula. The results are
just as diverse. Attempts at commercializing a few
of these have met with indifferent success as they
could not be depended upon. It is unfortunate that
a method which is basically sound is in danger of
acquiring a bad reputation because the solution used
is unsuitable.
It is due to careful research and pharmaceutical
work that standardized, animal tested solutions are
now available. Our sontributions to intravenous ther-
apy mean that the United States has advanced an-
other step ahead of other countries. With the im-
provement of the solutions, as well as the mode of
application, the full therapeutic value of old, well-
known drugs is assured. The technie as outlined in
recent literature is a safe and practical office pro-
cedure such as any careful practitioner can employ
with safety.
References
1Fedele, N., Gas*, d. egii osped., 24:143, 1903.
•Flore. G.. Gas*, med. Sicilian*, 7:83. 1904.
* Dawes, S. L., and Jackson, H. C., J.A.MJL, 48:2090, 1907.
4 Loeser, a new field for pharmacological and therapeutic
research, N. Y. Medical Journal, October 19, 1921.
fMusser, J H., Boston Md. and S. J., 166:775, 1912.
$Vanffeon, H.: Contribution to the study of iron caeodylate
in the study of anemia, Paris thesis, 1901-1902.
SFedelea Gas*, d. egli osped., 24:143, 1903.
t Geyser, A. C.: N.Y.MJ., 109:274, 1919.
Imfectwm Mot ImMmwmatiom
T. J. Watkins (Chicago Med. Recorder, January,
1922) says disease produced by invasion of the body
by pathogenic bacteria is infection and not inflam-
mation, or "itis," and it should be so designated.
The terms "inflammation0 and "itis" originated
when the inflammatory reaction was considered the
disease. The nomenclature should be changed to in-
fection because infection is the disease and inflam-
mation the result of the infection. Why continue to
confuse cause and effect? Why continue to call in-
flammation a disease when we know that it is not
essentially destructive, but protective?
Aside from right, the old terminology handicaps
teaching and confuses in literature the relation of in-
fection to inflammation. #
For some time I have used the term infection in-
stead of inflammation or "itis" in teaching gynecol-
ogy to medical students and nurses and have been
much gratified with the result. Infection has a defi-
nite meaning which is readily comprehended. In-
flammation has an uncertain vague meaning as it is
associated with some of the changes in organs such
as nephritis, hepetitis, etc., which include a variety
of causes. For example: infection of the fallopian
tubes has a definite meaning. The term salpingitis
confuses cause and effect, and salpingitis may include
pathology not due to infection. Even in case of
nephritis, it would be a delight to hear infection of
the kidney discussed by itself. The discussion of any
other variety of nephritis could be made under its
own name, or considered under unknowns.
Why not be progressive, honest and frank and
"play the game?"
Treatment e4 TmbercwUsU
The most important factors in the management
of the average case of tuberculosis may be sum-
marized as follows:
1. The importance of an accurate diagnosis as
affecting the prognosis and therefore the management
of the case.
2. The value of frankness and truthfulness in
gaining the patient's co-operation, which is indis-
pensable if we are to help him back to health.
3. The blessing of rest, good food and fresh air
and the danger of indiscreet exercise in treating tu-
berculosis, and
4. The far-reaching importance of reducing future
tuberculosis by properly instructing each individual
case in the simple measures of prevention.— J. J.
Lloyd in Southern Medical Journal.
Phila., March, 1922]
Rectal Fiatala— Drueck
201
Rectal Fistula
Symptoms Which Lead to a Diagnosis
THOROUGH DIGITAL EXPLORATION IMPERATIVE TO DETERMINE STRICTURE, NEOPLASM OR OTHER PATHOLOGY
Charles J. Drueck, M.D.,
30 N. Michigan Ave., Chicago, 111.
Professor of Rectal Diseases, Poet-Graduate Medical
School and Hospital.
Kmomimg UuU W Am lt*pmtmi C—ikmm
The general practitioner knows little of
rectal fistulae and usually "bothers with it"
as much. That it is real, obstinate, and
worthy of serious attention those who have
suffered with it will tell you in no uncertain
terms. Dr. Drueck's paper presents this
rather neglected but important subject in
dear, concise and practical form. He dis-
cusses all the phases of this disease in a
way that the reader cannot help benefiting
by it. Don't miss tt— Editors.
T'HE SYMPTOMS vary greatly with the extent
and variety of the fistula. The first symptom
which attracts the patient's attention is the local
abscess, manifested by redness, swelling, pain and
fever. The untreated abscess points either externally
on the skin, internally into the rectum, or both
ways. The abscess ruptures and discharges its
contents, thereby relieving the local distention.
The tissues are then soft and tend to retract
and contract, leaving only sufficient opening to
permit the exit of subsequent discharges, which
may continue indefinitely. The character of the
discharge suggests somewhat the age of the fistula.
The excretions of a recent abscess are thick, abun-
dant and constant, but as the lining membranes
grow old and are covered with pale, grayish granu-
lations, the discharges become thin, watery and less
in amount After the abscess has emptied itself
the patient suffers no discomfort except the puru-
lent discharge, which is always fetid and sometimes
contains intestinal gas and feces which make it
difficult to keep the parts clean. As the retained
pus burrows, forming new abscesses and sinuses,
the discharge gradually increases. When the dis-
charge of a given sinus is small in amount and ir-
regular in outflow the opening tends to become
aeeluded and retention occurs. Thus a new abscess
is produced which ruptures through the old sinus
or forms a new outlet In this way two or more
fistulae often connect with a common abscess. In
any ease, if the discharge ceases or becomes irregular
always suspect a new abscess.
The patient may sometimes help in establishing
a diagnosis of fistula if he reports having had re-
peated "boils" or pimples on the skin near the anus.
Where we meet this history the search for a fistu-
lous opening should be very persistent and thorough.
A history of pruritis and much moisture should also
be sufficient reason for a careful examination, for,
while it may not always be due to a fistula, it often is.
Constipation is often induced from fear of pain
during defecation and the sufferer goes on in this
condition for years before he seeks surgical relief.
Painful or difficult urination sometimes occurs, but
rather a perineal burning or pruritis due to the
irritating discharge which may be hardly sufficient
to soil the linen. Gradually the tract of the abscess
becomes thickened and fibrous.
Pain is not an important symptom of a fistula,
seldom being more than a dragging sensation or
one of discomfort There may be tenderness on
sitting down.
In blind internal fistula the symptoms are fre-
quently intermittent in character, the attacks being
due to the lodgment of feces in the opening of the
sinus or the accumulation of pus due to partial
closure. Relief is accompanied by a more or less
copious discharge of pus, which may escape from
the anus during the act of defecation.
fi—i JMfim W the F'utmlm
When the patient presents himself for examina-
tion the diagnosis of fistula has usually been made
because any discharge of pus from about the
anus has that meaning to the layman. Much val-
uable information is learned from the patient's
description but it remains for the surgeon to de-
termine the existence of the fistula and also its
character, origin, extent and pathological nature.
The history of injury or abscess antedating the
symptoms which have been mentioned above can be
brought out by questioning. The duration of these
symptoms will determine in a measure whether an
abscess or fistula exists. All abscesses in this region
which have existed for several weeks after being well
drained are to be considered as fistulae; but if
drainage has been insufficient the condition may be
202
Rectal Fistula — Drueck
[The American Physician
one of abscess which may heal if properly drained
and treated. An abscess recently ruptured and
leaving a free discharge of a small amount of pus
indicates a small fistula with openings near the
external sphincter. Even if one fistula is found, a
thorough search must be made for others or for
other rectal troubles.
Position of Patient for Examination
No one position of the patient is suitable for ex-
amining all rectal fistulae and even during the
examination of a given case it may be of consider-
able advantage to change the position to explore
the entire field. I usually begin the examination
with the patient in the left lateral prone position,
and then change as needed to the opposite side or
to the exaggerated lithotomy, with the hips raised.
By a careful examination the diagnosis is not
difficult except in the internal incomplete or in
the horseshoe varieties. Separate the buttocks by
grasping the glutei on either side with the fingers
reaching toward the anus, when by gentle traction
the external fistulous opening, if near the anus,
will be seen in a little depression or in the center
of a mass of granulations in the radiating folds of
the anus.
The number and location of the fistulous openings
is variable. The external opening may be, however,
quite a distance from the anus, even out on the
thighs or legs and perhaps so small as to admit
only a fine probe. It may escape a cursory examina-
tion unless a drop of pus be expressed during the
manipulations. The whole region must be carefully
scrutinized.
Appearance of External Opening — Detection of F'utmloa* Tract
The appearance of the external opening varies.
It may be in a pouting tubercle or in a depression
in some scar on the skin, or resemble an anal fissure
in the mucous membrane folds at the anus where
it may be seen only after forcibly separating the
buttocks, or, especially in a tubercular fistula, it
may be in the base of an ulcer. If the opening
happens to be closed over at the moment of examina-
tion, the covering will be thin, pinkish white, and
easily ruptured by stretching the edges, or it may
be punctured with the end of a probe. As soon as
this fragile membrane is broken a drop or two of
pus flows out.
By palpating about the anus the tracts may be
detected suboutaneously by their hardness. A finger
within the rectum follows the sinus inward to its
internal opening, and by pressing on the induration
a drop of pus will usually appear at the external
opening. Sometimes a bidigital examination, one
finger within the rectum and a finger of the other
hand palpating outside, will better follow the tract
and determine whether it is direct or circuitous.
This is an important point to determine, as the
sinus may even surround the anus. Also the tract
may not be of even caliber through its entire length,
but may have pockets of pus along its course.
Sometimes the tract is very circuitous and the pus
may burrow under the glutei muscles and open in
the groin or on the thigh, even as low as the pop-
liteal space. Sir Astley Cooper mentions an autopsy
where the fistula opened in the groin, but he traced
it back along the spermatic cord and found it ended
in an apparently ordinary fistula in the rectum. In
a recent straight fistula the external opening is
large, with edges thin and well marked. There
is not necessarily a sinus just because pus is dis-
charged on the skin near the anus; the abscess may
open directly on the skin.
the Internal Opening
Finding the internal opening of the fistula is one
of the most important steps in the treatment of
our case. It is this opening which constantly re-
infects the sinus, and unless it is eradicated our cure
cannot be permanent. The external opening may
be on one side of the anus, and, owing to branching
and twisting of the tract, the internal opening may
be anywhere within the rectum, even on the oppo-
site side. The internal opening is often found in
the posterior commissure, although it may be in the
anterior. Generally it is above the external sphincter
and below the internal sphincter. The opening may
be in an indurated spot, perhaps somewhat raised,
or in an ulcer with wide and gaping rough edges,
or it may be in the base of a crypt. All ulcerated
and even congested spots must be carefully examined
for a possible internal opening of a complete fistula
or the opening of an internal incomplete fistula.
Palpation alone will usually locate the internal open-
ing. When necessary, however, a conical speculum
with a sliding window may be introduced and a
careful inspection made of the whole canal by gently
turning the instrument and by searching every sus-
picious point with a fine bent probe. In case the
internal opening is not readily found, many differ-
ent methods have been suggested for following the
sinus inward to its terminus, but all are liable to
error.
Injecting the Su
Where there are several ramifications of the fis-
tulous tract, some of which are so fine or bend
at such sharp angles that not even a fine probe
can pass, injecting the sinus with a colored stain-
ing solution, such as methylene blue or perman-
ganate of potassium is of advantage, and may assist
in finding the internal opening as the fluid escapes
into the rectum. A mixture of one part saturated
PhUa., March, 1922 J
Rectal Fistula— Drueck
203
solution methylene blue to two parts hydrogen
peroxide is forced into the fistula with a hypo-
dermic syringe, having a short, thick, blunt needle.
The sinus is filled slowly and carefully, using only
slight pressure. As the solution oxidizes, the gas-
eous disintegration dilates all parts of the sinus
and bubbles through every internal and external
opening. The rectum should be dilated enough to
inspect the mucous membrane carefully and note
the fluid's appearance through the internal opening.
This little technic is especially valuable where sev-
eral tracts exist and where a small or unusual
sinus might be overlooked. The solution marks all
of these sinuses as the peroxide of hydrogen car-
ries the coloring matter into the finest passage.
When the internal opening cannot be otherwise
found, the solution will bubble out of even the
smallest opening.
The great value of bismuth paste injected, not
for therapeutic but for diagnostic purposes, ought
also be considered. The paste should be thin to
reach easily the limits of all side tracts, and the
main tract should contain simultaneously a probe
passed to its limit. The picture shown by roent-
genograms, provided they are taken in stereoscopic
form, is often graphic indeed, a bismuth finger
pointing directly at the primary focus of trouble,
particularly if that be osseous. Flat, nonstereo-
scopic pictures have no such value. By reinjecting
bismuth paste just before operating on- a patient,
the contrast of the yellow bismuth and the red flesh
is far more definite and much more satisfactory than
a stain of methylene blue solution or black per-
manganate solution. Even while operating the
watery solution runs out while the bismuth remains
in situ and may point out something overlooked.
As I have said above, no technic is infallible, and
a fistula may have a valve-like flap at the internal
opening or along its course which will close and
hold the fluid within the fistula, thus giving a false
impression of an incomplete fistula. If this little
technic is slowly and carefully carried out there is
no danger of carrying infection into new and
healthy tissues. The internal opening is not neces-
sarily the upper limit of the fistula. The mucous
membrane may be undermined for several inches
above this opening. When the internal opening
has been found and the tract traced to it from the
outside, it is positive proof of a complete fistula.
Several fistulous openings on the skin may be
branches of one sinus, but multiple openings into
the rectum signify several distinct fistulae. When
the internal opening is at the base of a crypt the
probe or injection is necessary becauses it cannot
be felt or seen from within.
Smbmmt* Uw—Tfbmt ike F'uhdm
Salmon's law is valuable in all cases: "A line
connecting the tuberosities of the ischium bisects
the anus. If the external opening of the fistula is
in front of this bisecting line and within one and
one-half inches from the anal margin, the internal
opening will be radially in from the external open-
ing, but the external opening is farther from the anus
than one and one-half inches or posterior to this bi-
secting line, then the internal opening will usually
be found in the posterior commissure."
Probing a fistula except when operating is ob-
jectionable and dangerous, because it is painful and
may produce new channels, and it affords no in-
formation that may not be gained from careful
inspection and palpation. If the probe is forced
out of the sinus and into the tissues it may mislead
the examiner as to the condition of the fistula, be-
sides carrying infection into new fields, thus forming
new sinuses. I never probe a fistula, other than
the internal variety, except when operating; nor
do I hunt unnecessarily for the internal opening.
It matters little whether you find the internal open-
ing before the operation, because when you operate
you will find it much easier than is possible when
the patient is conscious.
Spasmodic contractures occur during examination
if the patient is awake, which make the examination
painful, but when he is anesthetized and quiet, you
have no trouble in tracing out any or all sinuses.
If probes are needed, a large variety are essential,
from a fine silver probe to a large, soft uterine
sound. The probe must be introduced carefully and
without force until it has gone as far as it will,
when, with the index finger of the left hand in the
rectum, one may find the probe projecting through
the internal opening, or, in some instances, covered
only with the mucous membrane, or it may have
passed away from the rectum and cannot be felt at
all. Where a tortuous tract exists which the probe
cannot follow, the sinus must be dissected step by
step. In the examination of internal fistulae, blind
or complete, the probe is of advantage in determin-
ing the depth and direction of pockets or sinuses.
Where the external opening is remote from the
anus, a probe may be of value, because often the
tract is so deep and covered with so many other
structures that it cannot be traced by palpation,
even though the internal opening is found.
Crmmdatiom mmd Other Foulh'ditiet
Lardaceous granulations, the result of chronic in-
flammation, line the tract of the fistula and contain
many new formed blood vessels. The granulations
prevent the healing of the sinus by keeping the
walls apart. A recent fistula is, however, sometimes
lined with healthy granulations, which form new
tissue, and such a fistula may heal spontaneously.
A thorough digital exploration of the rectum is
imperative in all cases to determine any possible
stricture, neoplasm or other pathology.
Doctor Mackenzie Forbes' Pott-Graduate Diagnostic Clinics
A Series of Thirty Clinic* Emphasizing Diagnosis thai Should he Most Helpful to the General Practitioner
By A. Mackenzie Forbes, M.D., 615 University St., Montreal, Canada
Twenty-fourth Clinic
Jl Case of Acute Osteomyelitis
J. F., age 12 years, No. 929/20, Children's Me-
morial Hospital, was admitted to this hospital com-
plaining of swelling of the left leg.
The following history was taken by Dr. Morrison,
the superintendent of that hospital.
This boy has always been in good health until six
weeks ago when, while playing in a swing, he dropped
off and fell about ten feet, landing on his feet. He
was not injured and at the time felt no bad effects.
Two days later he complained to his parents of
pain in his left knee and also of a sore throat.
Since that time he has been under treatment in
bed by his family physician, who described the con-
dition by telephone very much as follows:
I have been attending this boy for five weeks, vis-
iting him about three times a week and treating him
with the ordinary remedies for acute rheumatic fever.
He has been running a temperature and has been
quite ill. His leg has increased in size in the last
few days and the swelling has led me to believe that
the condition may be due to an osteomyelitis of the
femur. Will you take him into the hospital?
Examination made by Dr. Morrison.
Patient is acutely ill.
He lies quietly in the bed, at times makes irregular
movements with his body and hands. He talks ir-
rationally and complains bitterly of the pain in his
left leg. He is very much emaciated and extremely
pale.
His tongue is coated, his throat reddened and his
breath offensive.
There is a peculiarity in his respirations, in that
he takes frequent long inspirations, more particu-
larly after waking from sleep. It would seem that
he has air hunger.
Examination of the Chest and Ahdsmtn Are Negative
His left leg is enormously swollen from the thigh
to the knee. It is flexed to an angle of 20° at the
thigh and almost to a right angle at the knee.
Examination of the knee shows the presence of
some fluid in the joint, but there is no tenderness nor
any special deformity.
Only slight movement is possible at the knee. He
complains of pain in his thigh when the knee is
moved. A reddened area is noticed on the lower
third of the inner side of the thigh. This is found
on examination to be tender, tense and fluctuating.
The middle and lower thirds of the leg also show
evidence of deep seated fluctuation. Indeed this con-
dition seems to be due to a large abscess which has
burrowed under the muscles of the thigh.
Acute Osteomyelitis of ike Femur
The boy was dangerously ill and he was accord-
ingly given a light anesthetic and an incision was
made down to the bone, over the site of the abscess
and about 1500 c.c. of thick, odorless, free pus evac-
uated. The lower third of the posterior surface of
the femur was stripped of its periosteum. It felt
rough and ridged. No bony sinus was detected. A
counter opening was made on the external surface
of the thigh and two rubber drainage tubes were
inserted to the bone.
The next day the boy's condition was very much
improved. He was still somewhat feverish but did
not look nearly so ill.
There was not very much discharge on the dress-
ings, but upon irrigating with Dakdn solution con-
siderable pus was obtained.
The day after he seemed very well. His tempera-
ture had come down to normal. His general appear-
ance had improved. He complained of no pain what-
ever.
The boy whose history has been read was suffering
from an acute osteomyelitis of the femur. During
six weeks he was said to have been suffering from
acute rheumatic fever.
This is one of the most distressing mistakes which
can be made. Acute osteomyelitis in children should
not be confused with anything except it be acute
cellulitis.
Acute Osteomyelitis vs. Acute Rheumatic Fever
Gentlemen, if I impress only one thing upon you
today, let it be that acute osteomyelitis should not
be confounded with acute rheumatic fever. Rheu-
matic fever is a disease with a characteristic history.
It is an acute affection. In this affection the tem-
perature and pulse rate are high. An arthritis ap-
pears in one joint It soon appears in a second
joint, a third, a fourth or even more joints. It is to
be particularly noted that as the lesion in the second
PhUa., March, 1922]
\
A Cam of Acute Osteomyelitis— Forbes
205
joint appears the lesion in the first joint tends to
disappear. One does not see a number of joints all
equally affected at the same time. One does not see
any tendency to chronicity. Let me express this in
other words. Rheumatic fever is an acute affection.
It never becomes a chronic affection. There is no
such thing as chronic rheumatic fever. There are
rheumatoid diseases, but these have nothing to do
with rheumatic fever. They should never be con-
fused with it. Acute rheumatic fever is a specific
complaint. It has a well recognized history and
course. It is comparable in this with such infections
as pneumonia. It is characterized also by being pro-
foundly influenced by the use of salicylic acid and
the salicylates. On the other hand these do not influ-
ence the course of the so-called rheumatoid diseases,
osteomyelitis or other arthritic affections.
Again, rheumatic fever is very likely to have as a
complication such cardiac lesion as endocarditis,
whereas, this complication is rare in the rheumatoid
affections.
Acute osteomyelitis in children shows a different
picture than rheumatic fever. It always, or nearly
always, affects the diaphysis close to its epiphysis
of one bone and one bone only. It is most fre-
quently seen in the first decade. The patient prob-
ably suffers greater prostration than in rheumatic
fever. A high leucocyte count is characteristic of
this condition, whereas, a low leucocyte count char-
acterizes rheumatic fever. In acute osteomyelitis the
patient has marked pain near one joint which is
neither swollen nor reddened until about the second
or third day.
Let us now make a careful study of this affection :
The upper end of the tibia, the lower end of the
tibia and the upper end of the humerus are almost
as frequently the seat of acute osteomyelitis as the
lower end of the femur. To study this condition in
any long bone, let us take as an example this disease
as seen in the lower end of the femur. In studying
this condition in any bone it is necessary to remember
two anatomical facts:
The periosteum of the diaphysis is not continuous
with that over the epiphysis, but ends and is inserted
into the diaphysis at the epiphyseal line, thus the
periosteum tends to limit the knee joint. The
medullary cavity of the femur ends about 2-3 inches
above the lower extremity of the diaphysis.
Et'mUgy
The etiological factor is probably an extraneous
focus of infection in the tonsil or some other part
far removed from the seat of the osteomyelitis. Some
consider that trauma at least predisposes to this af-
fection, by rendering the area traumatized less re-
sistent to infection.
fsffttltgy
The infection starts in the diaphyseal side of the
epiphyseal line. The infection is first close to the
cortex, but in the cancellous tissue (not cavity of the
lower end of the diaphysis). The infection later
spreads through the cortex towards the periosteum
and detaching this raises it from the bone. Almost
immediately the formation of new bone begins on the
cortical layer of the periosteum. Here and by this
the involucrum is formed which latter will, in extreme
cases, constitute the whole shaft of the femur or
uniting with that part of the femur which is still
viable will form this.
Under the involucrum, now under process of forma-
tion, that part of the original femur which suffers
death or necrosis will become separated as a se-
questrum.
The cloaca, which is a term used in the description
of the pathology of osteomyelitis, is the opening
which remains in the newly formed involucrum or
viable bone and which leads to the sequestrum or
dead, dying and probably still infected bone.
Age Imciicmct
It occurs oftenest in childhood, rarely in adults.
It is not uncommon in infants of two years or up-
wards and is most frequent in the first decade. It
develops only during the period in which the bone
is still quite vascular and is growing.
Acute osteomyelitis in infants and children is char-
acterized by a sudden onset. The patient is severely
ill. He has a high temperature. He has a high
leucocyte count. He suffers marked pain in the
neighborhood of a joint, the skin over which is
slightly swollen and may be reddened, the swelling
and redness appears only on the second or third day.
It is exquisitely tender to pressure and the area of
infection is localized by this means.
The prognosis depends entirely upon the virulence.
In virulent cases death may occur in three to four
days.
One case of Dr. Clarence Starr's, namely, an
infant of two years old, who was taken to the Hos-
pital for Sick Children in Toronto, died in forty-
eight hours. The autopsy showed a general septi-
caemia. The periosteum was stripped from the whole
shaft of the tibia which bone evidently had been
the seat of the infection.
I remember many years ago being hailed when
passing a farm-house near a small hamlet on the
lower St. Lawrence and asked to see a child who had
been suffering from this condition for less than three
days. The child was already in extremis when I saw
him and although the duration had not been more
than 70 hours, every attempt to save him proved
206
I
A Case of Acute Osteomyelitis — Forbes
[The American Physician
futile. In cases such as that which we have just
described in this clinic, where the virulence is much
less or the resistance greater, the life of the patient,
although he may be extremely ill, may be saved by
a spontaneous rupture of the abscess, but the saving
of the bone is only accomplished by early surgical
interference.
Diagno$U
I remember hearing Dr. Clarence Starr, of Toronto,
to whom I owe a debt of gratitude for increasing
my knowledge of acute osteomyelitis in children,
make the statement at a meeting of the American
Orthopaedic Association, that an acute osteomyelitis
should be confounded with nothing else except an
acute cellulitis. I think that perhaps this is true
in as far as some surgeons are concerned, but,
of course, we see it confused with other lesions in
many cases. We have already shown in this clinic
that one patient was treated for rheumatic fever
before osteomyelitis was suspected.
The aim of treatment should be to relieve tension
and to prevent the infection spreading into the can-
cellous tissue. Find the localized point of tenderness
then relieve tension by a simple incision through the
periosteum to the bone. This will probably reveal
the presence of pus. Drain through this incision.
If no pus is found drill a few holes towards but
not to the epiphysis, thus preparing a line of least
resistance through which pus collecting in the can-
cellous bone may escape to the surface. Do not
attempt to chisel into the medullary canal.
If the infection progresses without treatment for
four to five days a large amount of pus will prob-
ably collect under the periosteum. If you have an
extensive stripping of the periosteum do not attempt
to interfere with the bone until a sequestrum has
formed. While a sequestrum is forming, an involu-
crum is synchronously forming on the outside by the
osteogenetic power of the inflamed periosteum.
When the original infection is in the lower end of
the femur the medullary cavity does not usually be-
come infected for two to three weeks.
When the sequestrum is detached or easily detach-
able and ready to come away it may be removed and
the cavity wiped out and allowed to heal.
If there is complete stripping of the periosteum
from the shaft of the bone, this latter should be
left alone to act as a splint until the involucrum is
formed of sufficiently strong bone to form a new
shaft.
Radmm in Non-MoJtignamt Gynecological Coniitk
Dr. C. J. Broeman has found radium beneficial in
the treatment of menorrhagia occurring in women
under thirty-five having no gross pathological condi-
tions ; in chronic endometritis and endocervicitis, when
these conditions have become chronic and refuse to
yield to the customary curative measures. In uterine
fibroids when they occur in women over thirty-five,
do not extend above the umbilicus, and are not pro-
ducing severe pressure symptoms, radium is the treat-
ment of choice.
If surgery is contra-indicated for any reason, ra-
dium should be tried upon fibroids of any size.
He does not advise the use of radium upon tumors
extending above the umbilicus, or those causing severe
pressure symptoms or accompanied by inflammatory
lesions in the surrounding tissues.
Radium should be applied with extreme caution
to patients still within the child-bearing period, less
too large a dose might produce a permanent meno-
pause.— Author's abstract from the West Virginia
Medical Association Journal, p. 110.
Dr. Herman Goodman says watch for the physio-
logical systemic effects when prescribing thyroid for
affections of the skin. In some individuals, even
small doses may give toxic symptoms.
Arte* of AmricmUr Fihrillation hy tk* U*t of QmmUint
Arthur W. M. Ellis and A. E. Clark-Kennedy (The
Lancet, October 29, 1921) give a preliminary report of
their results in the treatment of seven cases of auricular
fibrillation, in five of which the administration of
quinidine by the mouth has been associated with return
to the normal cardiac rhythm. In all these five cases the
change has been demonstrated by polygraph tracings, and
in two of them by the appearance of a crescendo pre-
systolic murmur at the apex. In one of these five
relapse occurred soon after the drug was stopped, and
again a second time when the tlosage was reduced. In
two the dosage was only decreased and there was no
relapse into auricular fibrillation. In two of the five
cases, shortly after the onset of normal cardiac rhythm,
embolic infarction of internal organs occurred. The
formation of clots in the appendix of a fibri Hating
auricle is not uncommon, and the loosening of these by
restored auricular contraction and their projection into
the general circulation is easily understood. The phar-
macological action of quinidine is still undetermined.
Electrocardiographic study shows that, under quinidine,
alteration in both shape and size of the auricular and
ventricular waves occur and are accompanied by a
prolongation of the P. R. interval. It seems reasonable
to suppose that quinidine abolishes fibrillation either
by increasing the conductivity or by prolonging the re-
fractory period of heart muscle, with the result that the
gap is bridged and circus movement ceases. The use
of quinidine is not without danger, the risk of embolism
being a real one. In the writers' cases the improvement
in the general condition was not striking and much less
marked than might have been anticipated, and perhaps
little more than might be attributed to prolonged rest
in bed. That quinidine will take a place in the treat-
ment of cardiac disease seems altogether probable, but
the authors show a commendable caution and are ready
to admit that the nature of its action and the limita-
tions of its therapeutic value remain to be determined.
PluJa., March, 1922]
Value of Hydrotherapy in General Practice — Hayward
207
The Value of Hydrotherapy in General Practice
Elaborate Equipment Not Necessary
By 0. M. Hayward, M.D.,
316 McCallie Avenue, Chattanooga, Term.
Emrich foor Thcrapemtic
The effect of hydrotherapy is often re-
markable, even in its most humble form.
The washing of the face with cold water
removes "sleepy feeling" and sensation of
fatigue as if by magic. The exhilarating
or soothing action of the cold or hot bath,
as the case may be, and its beneficial in-
ftuences in both health and disease cannot
be denied by even the so-called opponents
of this form of treatment. Combine
these simple truths with the facts so clearly
elucidated by Dr. Hayward in this paper
and you will enrich your therapeutic arma-
mentarium with a series of "simple proced-
ures which will serve any physician well
if he will only make use of them." — Editors.
MOST OF US have grown up, professionally,
with the idea that hydrotherapy belongs to
the hydropathic institute, hence have not considered
whether it might be helpful in the homes of our
patients. While it is true that institutional hydro-
therapy' occupies an important field in the system-
atic treatment of chronic invalids, there are also
procedures that can be carried out in the home,
without elaborate equipment and with great benefit
both to patient and physician.
Therapeutic applications of water are made chiefly
for the purpose of awakening, strengthening, main-
taining or diminishing visceral reflexes by the ab-
straction or addition of heat— for which purpose
water is the most facile 'agent we possess. To this
may be added percutient or other effects due to
the mode of application. In some instances the
addition or substruction of heat is the primary object
sought, in which case it may be desirable to in-
fluence the reflexes as little as possible.
Then, there are more homely and common — if
more important — uses of water which are too often
overlooked by physicians, especially by those who
seem to have the idea that science in medicine means
the substitution of art for physiology.
We may mention the immense importance of water
in the removal of body wastes through the alimentary
tract, the skin and the kidneys; its influence upon
the digestive functions, and the indispensable physi-
ological importance of water in the general economy
of the body. A clear conception of these uses of
water should influence the management of patients
to a far greater extent than is now the rule.
Allowing the foregoing brief mention to suffice
for this phase of. the subject, and without wishing
to introduce any argument in regard to a more ex-
tended use of water in family practice, I will attempt
to describe a few simple procedures which will serve
any physician well if he will make use of them.
This is a local application of both intense and
moist heat. It is prepared by wringing a cloth
of proper size and thickness out of boiling water,
wrapping it immediately in a warm, dry cloth and
applying it to the part. The best material is that
from a heavy blanket having cotton warp and woof
of wool. A convenient size is thirty-six inches long
by twenty-four inches wide. The outer or dry part
of this fomentation should be spread on a smooth
surface after being warmed; or, in the private home,
it may be warmed and spread smoothly upon the
part to be treated.
The wet cloth is folded to the desired width, then
made into a snug roll, grasped by the two ends,
twisted a little and dipped into boiling water, to
remain until the water in its meshes has reached the
boiling point. It is then wrung quite dry by the
process of twisting and stretching, quickly untwisted
and spread smoothly upon the dry cloth, which is
then folded over it. Because of the dry outer cloth
and the absence of wrinkles, and the uniform satura-
tion of the wet cloth, the fomentation may be ap-
plied close to the skin at a temperature which pro-
duces an immediate and very marked effect upon
the circulation of the part thus treated, and often
upon the capillary areas associated therewith.
The fomentation is chiefly useful in relief of pain,
in reducing passive congestions and early acute in-
flammations, and in softening superficial inflammatory
208
Value of Hydrotherapy in General Practice— Hayward tTl»« American Physfciaa
indurations, and hastening suppurative processes
which have not received, or have not been checked
by, early treatment. It is usual to apply three or
four fomentations in succession, each one to remain
on the part only until it has lost the intensity of
its heat. The relief from pain, the relaxation, the
improvement in impeded circulation, is often magical,
and thus it has a salutory effect upon the patient's
mental attitude.
The word "early," in connection with inflamma-
tions, is emphasized because fomentations may do
no good and may do harm if used too late — for
example, in inflammations of the lungs when the
stage of hepatization is imminent.
The size and material of the fomentation may be
altered to meet the requirements of a suitable ap-
plication for any part of the body. It will be
found most useful in acute inflammatory congestions,
and in a more prolonged treatment of so-called
"chronic" inflammations; e.g., hepatitis. In the
latter conditions, it is more effective if a very cold
compress or cold friction is interspersed between
the applications of the fomentation.
The Moist Cotmpreu or Pack
This consists of an old linen or cotton cloth wet
or well moistened in the coldest water obtainable,
applied directly to the skin, covered snugly with dry
flannel and left in place for several hours. The
thickness of the flannel depends upon the degree
of evaporation desired — a point which must be gained
by experience.
The moist compress is useful in the simple, acute
anginas, and should the case later prove to be com-
plicated, no harm will have been done. A folded
handkerchief wet in ice-cold water, applied to the
sub-maxillary and the anterior cervical regions, made
to fit well up around the angle of the jaw, and covered
snugly with a wool stocking, piece of underwear,
or any woolen material that happens to be at hand,
will often cure acute «ore throat the first night.
The best form of throat compress is a four-tailed
piece cut to fit, one tail from each side being brought
up over the head, while the other passes around
the back of the neck. The thickness of the wet
cloth, the amount of water to be left in it, and
the thickness of the outer covering, are to be regu-
lated in accordance with the degree of inflammatory
heat and congestion present, with some regard also
to the age and general condition of the patient.
A similar moist compress or pack to the chest
will often abort an acute bronchitis or pulmonary
congestion which, if left untreated, might, by the
next day, develop into a serious illness.
There are two forms of chest pack, one being a
four-tailed affair like the throat pack, having a
wide flap to go beneath the shoulder, and a nar-
rower one to go over the shoulder. The outer part
is of blanket flannel ; the inner, or wet part, of linen
or cotton, cut a little narrower than the flannel, as
it is important in all these compresses to leave no
wet edges exposed.
The other is the "roller chest pack," which is
merely a five to eight-inch roller bandage of sufficient
length, of the blanket flannel ; the wet linen or cot-
ton part to be of any form that can be conveniently
and smoothly applied. This form of pack may be
adapted to any part of the body where is located an
acute congestion, and is very useful, if early ap-
plied, in preventing capillary stasis, thus exerting
an inhibitory influence upon the subsequent inflam-
matory processes.
Before the compress becomes dry, it should be
removed and the parts rubbed vigorously with cold
water or alcohol, and well dried. The compress may
then be re-applied, or, it may simply be renewed.
Th* Evaporatmg Compress ami Ice Compress
The evaporating compress is simply a wet cloth
with little or no cover, closely related to the moist
pack, and which is useful where a more pronounced
cooling, rather than the cooling-poultice effect is
desired. Evaporation may be increased by accel-
erating the circulation of air over the part. (Fan-
ning, window draught.)
Applied to the trunk and thighs, it aids in con-
trolling temperature in fever cases in which there
is a hot, flushed skin; e. g., certain cases of typhoid.
Applied to the abdomen, it is useful in enteric and
peritoneal inflammations; to the spine and scalp in
meningitis; to the precordium in pericarditis — all
of fulminating types of inflammation. It may also
be used with advantage instead of the ice compress
in certain cases of dermatitis, and, in fact, wherever
the more marked refrigerating effect of the massive
ice compress or the rubifacient effect of the light ice
compress is not desired. Of the two latter, the ap-
plication of the first must be prolonged, care being
taken to avoid sloughing of the skin in states of
lowered vitality. The last is of briefer duration,
deep refrigeration not being desired.
The Moist Abdem'mmi Bmmimge or "UmscHmge"
This is a moist pack applied around the trunk
to cover the liver, kidneys and all abdominal organs.
It is used in chronic rather than acute conditions,
and is therefore usually made so as to render evap-
oration much less rapid than is usual in the moist
pack. This may be done by the use of more thick-
nesses of flannel, or a layer of oiled muslin or silk
may be used between layers of flannel. It is applied
snugly at night and removed with cold friction be-
fore the patient gets out of bed in the morning. In
the case of bed patients, it may be worn night and
day, and changed from two to six times in twenty-
four hours.
PUU., March, 1922]
Value of Hydrotherapy in General Practice — Hayward
209
Sinee the moist abdominal bandage is, as a rule,
used for days or weeks, it is important to have the
inner or wet part well laundered daily in order to
avoid troublesome skin eruptions.
The H**mg C— yrm
This consists of a towel, muslin or gauze folded
to fit, wrung well out of cold water (ice water best),
applied to the part, covered with flannel or oil cloth
and changed as often as it becomes warm.
When it becomes fully warmed by the body heat,
a considerable degree of relaxation of the parts be-
neath it has been accomplished. Then, the appli-
cation of extreme cold causes a certain degree of
contraction, and with the gradual heating there
comes another period of relaxation, so we have a
gentle, revulsive effect combined with the abstraction
of heat. It is desirable to apply the compress very
cold, and with as much suddenness as the nervous
state of the patient will permit, and it is important
to allow the compress to become sufficiently warm
before changing. Its use must be modified, if used
at all, in asthenic conditions; and where there is
much fever with vigorous circulation, it may be used
wetter, thicker, and with more frequent changes.
The heating compress is simple, but it is a very
effective therapeutic measure. Its greatest useful-
ness is in acute or sub-acute inflammations within
the abdomen and pelvis, but it is also of much value
in many other deep-seated inflammatory conditions.
(Joints, muscles.) It is helpful in pericarditis
(precordium), gastritis, enteritis, acute pelvic in-
flammations, etc.
If its use is begun early in typhoid fever, the
course of that disease is favorably influenced. The
splanchnic circulation will be better maintained, re-
sulting in better functional activity, and lessening
the liability to deep ulceration and hemorrhage.
Temperature and toxemia are kept within lesser
degrees, which is a benefit to nervous system, heart
and kidneys.
Indeed, if one institutes the early morning daily
sweat within one to four days after the onset of
typhoid fever, and uses the large heating compress
to the abdomen from early morning till about mid-
night daily, changing it every ten to forty-five min-
utes, according to the case, and uses common sense
about water-drinking, diet, evacuations of the bowels,
etc, the disease is so changed as to be scarcely
recognizable, and the patient's convalescence is
usually prompt and without sequellae.
There are none of the measures outlined above
which cannot be carried out by a moderately intelli-
gent home nurse, under the physician's direction.
If it is difficult to get the trained nurse to faithfully
carry out such methods of treatment, it is probably
because she has been well-trained to something else,
and does not take kindly to procedures which she
may regard as belonging to a sphere beneath that
of her profession.
But if any of these measures seem complicated,
we will mention one that is simple, namely, the
immediate immersion of a sprained wrist or ankle
in a bucket of cold water, or if the sprain is in a
part not easily immersed, continuous applications
of large, very wet, cold compresses. The effect is
instantaneous and magical, yet how few employ it
in cases of sprain. The cold application should be
continued until the patient experiences a marked
increase of pain ; it should then be discontinued and
alternate hot and cold applications employed along
with other appropriate measures, among which the
heating compress days, and the most pack nights,
are often useful.
LmemgCM mmi /rrtf «ti
Of these, brief mention may be made of but few.
The enema and the vaginal douche are quite well
known among the laity — certain manufacturers hav-
ing done much through skillful advertising to popu-
larize colon washing — and they have made the public
pay a handsome tuition. The public is satisfied,
however, because of the remarkable relief expe-
rienced after the thorough rinsing out of a pestifer-
ous cesspool in the colon.
Doctors should take some interest in these humble
"treatments" and they, with trained nurses, should
be the teachers of the public rather than leave so
much teaching to the manufacturers of enema
outfits.
It would be well for the physician to exercise
more controlling influence over the use of these
measures, for he knows that not all patients are
benefited and some are injured by their use.
It is the patient with unwholesome intestinal flora
and colonic stasis who benefits most, and only the
physician is prepared to determine the cause of the
stasis and to institute measures to overcome it, and
to correct the intestinal flora so that the enema does
not have to be repeated ad infinitum.
The EmemaU
There are many forms of the enema, but two prin-
cipal types are used for cleansing purposes. These
have come, quite widely, to be spoken of as the
"low" and the "high" enema. Hydrotherapists speak
of them as the enema and the Colon Clyster.
The enema consists of one-half pint to one quart
of hot, warm, cool or cold water, plain or medicated,
introduced into the rectum for the purpose of ex-
citing peristalsis and otherwise aiding the rectum
and lower sigmoid to discharge its contents. It should
be taken sitting or lying on the left side. In in-
flammatory, tenesmic conditions it should be used
hot. In ordinary, spastic or hypertonic conditions,
warm. In atonic conditions, cool or cold. It is
210
Value of Hydrotherapy in General Practice — Hayward
[The American Physician
sometimes well to order a graduated course from
hot to cold, making at the same time use of dietetic
and other measures to overcome the conditions calling
for the enema.
The colon clyster should signify a thorough cleans-
ing of the colon. From one to three quarts of fluid
should be introduced at each flushing, and one to
three repetitions may be necessary. The tempera-
tures should be — warm, neutral, cool — ordinarily.
The standard position is dorsal, moderately in-
clined to the right side, though in some instances it
is well to give the first injection in the genu-pectoral
position.
It is well to add a small teaspoonful of salt or
soda to each quart of water used in the colon
clyster. If the rectum is loaded with hard feces,
a small, hot soapsuds enema should be first admin-
istered.
The partial (not extreme) Trendelenburg position
is desirable for the giving of procto-clysis and medi-
cated and nutrient enemata.
In administering any of the above, with the ex-
ception of the small evacuating enema, the fluid
should be allowed to flow into the bowel slowly.
The fountain syringe with four or five feet of
tubing and a glass nozzle sufficiently long to reach
well through the sphincters, is the best outfit to use.
It will be a relief when doctors and nurses get away
from the idea that a few inches of soft rubber tube
coiled up in a patient's rectum constitutes a "high
enema!"
Tka Colon Lavage
This is the most thorough-going means of com-
pletely cleansing the colon. Its use often requires
time and skill and it is reserved for special cases
The patient is marked over the tip of the eleventh
thoracic spine and moderate pressure or light con
cussion applied to this point for fifteen or twenty
seconds. He is then comfortably placed in dorsal
position, legs flexed, and hips slightly elevated. The
bed or table is protected by a Kelly pad or some
sort of substitute. A large-size, rather stiff colon
tube is connected with a large fountain syringe
having tubing twice the size of that of the ordinary
"enema can," and an elevation of two feet. The
water, which should be slightly alkalinized and of
neutral temperature (100°) is started and the well-
greased tube passed through the sphincter. With
great care, and by the aid of the flow of water,
one may often pass the tube through the roomy
ampulla and beyond the valves, which is desirable.
In some instances the tip of the tube may be
guided over the promontory by rectal or vaginal
touch. If, however, the sphincters are stretched or
manipulated much, peristalsis will oppose the prog-
ress of the tube.
Failing to pass into the sigmoid, it is better to
withdraw the tube sufficiently to allow its inner ex-
tremity to rest just within the internal sphincter.
Water is allowed to flow in through the tube until
the colon is quite well filled. Then the stopcock is
closed, the colon tube disconnected from the tubing
of the syringe, and the fluid in the colon allowed
to siphon out into a receptacle.
During this process the nurse stands at the
patient's side, controlling the tube with one hand,
while with the other, gentle, soothing, vibratory move-
ments are imparted to all parts of the colon through
the abdominal walls. In executing these movements
the warm palm of the hand only is in contact with
the abdomen, and the movements must be gentle
and rhythmical.
When the colon is quite well drained it is re-
filled, and this process is repeated as long as there
is evidence in the washings of fecal matter that
has been some time in the colon. Sometimes fresh
material from the ileum comes down during the
treatment, and it is easy to distinguish this from
the original contents of the colon.
After the colon lavage, one may introduce cultures
of bacillus Bulgaricus or any other medicated or
nutrient enema desired.
This colon lavage is somewhat difficult, but a very
effective treatment in cases in which it is indicated.
It may be given to bed patients, even those who are
very sick, if it is carefully done.
The Hot Rectal Irrigation
This may be made continuous by means of a re-
turn-flow irrigating tube, or intermittent; the fluid
passing in and then out through a single tube. Its
principal use is to overcome severe chronic inflam-
mations of the rectum, and to aid in eradicating
gonorrhoeal infections and removing the results
of gonorrhoeal inflammations anterior to the rectum.
In some of these later cases, and also for a stimulat-
ing effect upon the bowel, the alternate hot and
cold irrigation may be used.
In order to accomplish what is desired with the
hot rectal irrigation, the temperature must reach
the extreme limit of tolerance. In prostatic condi-
tions this irrigation has been used at a temperature
of 140°, but many patients will not bear that de-
gree of heat, and one must use caution. If an ice-
cold cloth is wrapped round the tube close to the
anus to avoid over-heating of the same, a higher
temperature can be used than would be tolerated
without this precaution, for the heat pain arises
from the outer portion of the anus and adjacent
skin and not from the rectum. The sitting posture
is suitable for administering the rectal irrigation.
Vagtmai Irrigatiom
Aside from the ordinary cleansing douche, the
principal therapeutic results of the vaginal irriga-
Phila., March, 1922]
Rectal Etiology of Gastroenteroptosis — demons
211
tion are obtained by the use of from one to four
quarts of very hot water (117° to 125°), or the
use of a relatively larger amount of water — two to
five gallons — at about 105°. The very hot vaginal
irrigation is more useful in fairly acute inflamma-
tory conditions and in recent cervieo-vaginal in-
fections. It should be followed immediately by the
revulsive Sitz for three to five minutes, repeated two
or more times, or by large fomentations or hot
pack to the pelvis, alternating with cold friction.
This combination is often of great value in relieving
pelvic pain.
The more copious irrigation of milder temperature
is used more in later stages of pelvic inflammations
and in post-inflammatory conditions. The dorsal
position is best for therapeutic vaginal irrigations,
and it is sometimes an advantage to have the hips
elevated. The elevation of the fountain should be
from one to three feet, according to the conditions.
An intelligent and faithful use of these irrigations,
combined with the revulsive Sitz bath, the revulsive
hot and cold alternating compresses and heating
compress, together with rest and other indicated
measures, effects a remarkably beneficial change in
many cases which might otherwise be too hurriedly
sent to the operating table.
It is true in hydrotherapy, as it is in all other
therapeutic measures, that he who uses it success-
fully must familiarize himself with its principles
and technic, and must use it with some degree of
confidence and enthusiasm.
Rectal Etiology of Gastroenteroptosis
Permanent Results Can Only Be Achieved by Elevating the Anorectal Line
By E. Jay Clemons, M.D.,
605 Hollingsworth Building, Los Angeles.
ExctUert Logic mmi Worthy Review
The paper of Dr. C lemons is well written
and well compiled. It is based on excellent
logic of cause and effect. It furthermore
reviews briefly but clearly a series of em-
bryologic, anatomic and physiologic facts
which the general physician has a tendency
to forget. They are all subjects of import-
ance and are well worth reviewing. — Edi-
tors.
D«£utfM
GASTROENTEROPTOSIS is downward dis-
placement of stomach and transverse colon.
This abnormal state of affairs is the result of faulty
distribution of intravisceral pressure causing the
hollow viscera to become dependent, for support,
upon their fixed portions.
Redd Etmkgf
Rectal etiology of gastroenteroptosis is due to dis-
placement of anatomical structures in such a man-
ner as to cause spastic anorectal sphincter muscles.
The specific rectal pathology associated with spastic
anorectal sphincter muscles is found in cases of
hypertrophied anal papillae, anal cryptitis, compli-
cated anal fissures, so-called "sentinel pile," pro-
lapsed polypi, infiltrated rectums, and hemorrhoids.
For one to clearly associate spastic anorectal
sphincter muscles with gastroenteroptosis it becomes
necessary to recall certain facts relating to embry-
ology, anatomy and physiology.
EmkryeUfy
At the beginning of embryonic life the alimentary
canal is a simple bag, containing the yolk. As the
fetus grows, it closes around this yolk-sac, constrict-
ing its middle in such a manner as to enclose a
portion within the body. This portion within the
body develops into the intestinal canal As the
fetus increases in size so does this canal, first elon-
gating, later bending, and eventually con vol u ting.
It is covered with peritoneum, which, being mobile,
is easily drawn from one point to another and is
capable of considerable adjustment. It does not,
however, continue to grow at the same rate as the
viscera. For this reason the viscera, except at the
two fixed portions, have mesenteric attachments.
The two fixed portions are the duodenum and hepatic
flexure. Because the duodenum and hepatic flexure
are fixed they retain their relative positions, as in
embryo, so any transposition of viscera that can
take place does so in such a manner as not to alter
their position.
The alimentary canal is derived from the inner-
most layer of the blastoderm, the entoderm. The
membranes of the body are derived from the outer
and middle layers of the blastoderm, the ectoderm
and the mesoderm. Toward either extremity the
intestinal canal of the fetus terminates in cul de
sacs. At the mouth and anus depressions occui
forming short channels leading into the body,
212
Rectal Etiology of Gastroenteroptosis — demons
[The American Physician
terminating in cul de sacs. The cul de sac of the
anus comes in contact with the blind termination
of the rectum and by absorption of the two inter-
vening layers the communication between the rectum
and the anus is established. The line of junction
is the anorectal line. Above this line the alimentary
canal is supplied by the vegetative nervous system:
below, the anus is supplied by the systemic nervous
8ystem- nnUo„
Intravisceral pressure is to some extent produced
and maintained through the activities of the intes-
tinal bacterial flora. Distribution of intravisceral
pressure is by peristalsis. Peristalsis is vermicular
motion of the alimentary canal. This physiological
process is due to alternate contractions and relaxa-
tions of the muscular coats of the intestinal wall.
Innervation of peristalsis is by the vegetative nerv-
ous system, whereby the sympathetic division acts
in opposition to the autonomic or parasympathetic
division of the vegetative nervous system.
Mtchtmtm of GoMtroeoitropioou
Spastic anorectal sphincter muscles are the result
of downward displacement of rectal tissue, which is
supplied by vegetative nerves in such a manner as
to remain within grasp of the anal sphincter muscle,
which is supplied by systemic nerves. This brings
about reflex interference with peristalsis whereby
those portions of the alimentary canal with thickest
muscular coats become markedly spastic, while those
with thinner walls dilate, resulting in so-called
"iliac stasis" and gastric dilatation. "Iliac stasis"
and gastric dilatation causes abnormal distribution
of intravisceral pressure resulting in the hollow
viscera becoming dependent for support upon the
fixed duodenum and hepatic flexure.
EiecU of GastroenUroptotU
Patients thus afflicted suffer from the effects of
bodily derangement which varies from a slight indis-
position to a most profound autointoxication be-
cause of faulty digestion, assimilation, elimination,
and oxygenation resulting in dyspepsia, malnutri-
tion, and overloading of the tissues with waste
products.
Trotdmemt of GastroemUroptosu
Dietary, mechanical, medicinal and surgical meas-
ures may be employed in the management of a case
of gastroenteroptosis, but in order to achieve per-
manent satisfactory results it becomes necessary to
drain the rectal mucosa and elevate the anorectal
line, reconstructing the region so that this line can-
not be again forced down, preventing tissue supplied
by vegetative nerves from again coming within
grasp of the external sphincter muscle. This pro-
cedure is best accomplished by a minor surgical oper-
ation under local anesthesia, thus insuring the mini-
mum risk and the mA-rimum satisfaction to both
patient and operator.
Symptomatic Trombmtmt of Ft
The factors that may cause dyspnoea are discussed by
Means and Barach (Journ. Amer. Med. Asso., October
15, 1921). Dyspnoea will arise whenever the pulmonary
ventilation called for by the life processes at the moment
exceeds the quantity of air that the pulmonary bellows
is mechanically capable of delivering with ease. The
respiratory centre wishes to maintain a constant alveolar
carbon dioxide tension. To do this, ventilation must
increase in like proportion to the carbon dioxide output.
In pneumonia the metabolism will, as in the normal, be
one of the factors determining the volume of the pul-
monary ventilation; an increase in metabolism due to
the disease will call for an increase in ventilation, ex-
actly as the elevated metabolism of muscular work did
in the normal person. The metabolism of the pneu-
monia patient may be expected to be higher, even while
he is at complete rest, than it would be under the same
conditions when he was well. He will, in other words,
have a metabolic need for increased breathing. If in
a portion of the lungs a proper gas exchange cannot
take place, in order to maintain blood carbon dioxide
tension at a normal level the normal portion of the
lungs must be overventilated. Impairment, then, in the
respiratory function of any portion of the lungs, if it
leads to a mixture of aerated and unaerated blood, will
be a factor demanding hyperpnoea. Other causes are
an insufficient circulation rate of blood flow and anox-
aemia. The lower the vital capacity the more will a
patient have to increase his ventilation by an increase in
rate at the expense of depth. That the vital capacity is
reduced in pneumonia is certain. Whatever the cause, it
will have the effect of necessitating a rapid, shallow rype
of breathing. In the treatment of these conditions the
authors suggest that the possible lines to pursue are
to decrease demand or increase supply of ventilation.
Two procedures which may be expected to diminish the
need for ventilation are the giving of alkali and the
therapeutic administration of oxygen. Bicarbonate
should be given only in amounts sufficient to turn the
urine alkaline to litmus; if pushed farther than this
it may do harm by producing alkalosis. Oxygen should
be given with one of the modern types of apparatus
and often nearly continuously by a specially instructed
nurse; its continuation is to be governed by the effect
on the cyanosis and the comfort of the patient Thest
measures ase supplementary to specific therapy. When
used, however, they may be expected to spare the
patient several avoidable burdens and leave him free
to devote his entire energy to the fighting of his infec-
tion, thus theoretically, at least, improving his chance of
recovery.
FtmM Scats
J. F. Corbett, Minneapolis (Minn. Medicine, Decem-
ber, 1921), conclusions are:
1. Surgeons should pay more attention to nerve sup-
ply and conserve nerves when possible.
2. Blood vessel ligatures should not include nerves.
3. In amputation cases or whenever a nerve must be
cut the proximal part of the nerve should be injected
with alcohol with purpose of preventing a neuroma,
4. In all operations upon nerves associated with pain,
watch must be kept for neromata in small unimportant
nerves.
5. Neurological examination may reveal nerve lesions
in cases presenting themselves for reoperation for "ad-
hesions."
6. After alcohol injection of a nerve the nerve stump
should be so planned that it will not be subject to irri-
tation.
Efficient Organization of Medical Practice
THE GENERAL PRACTITIONER IS THE FUNDAMENTAL FACTOR IN EFFICIENT MEDICAL SERVICE
Wmle surgery the specialties, hospitals, people are to be served, the primary im- ordinated in constructive co-operation with
institutional medicine, public health work, portance of the function of the General the essential service of the Family Physician,
industrial medicine, etc., have their definite Practitioner must be recognised. Other divi- This is an integral purpose of The American
functions, if the best health interests of the sions of medical service must be properly co- Physician.
Half Way Through
The Plight of the Middle-Aged Doctoi
HALF-WAY THROUGH his term of office, when
his second legislature has adjourned, the enact-
ments approved or vetoed, the appointments all
made, and the slate-makers begin to arrange to wax
the slide, a governor feels like the umpire in the fifth
inning with a heavy score on one side and a goose-
egg score on the other. But in a close game the
umpire has a chance for a bit of excitement; so has
a governor, if he keeps his nerve and refuses to feel
that he is going down the shady side of political life.
If four years of office-holding is like the proverbial
month of March, coming in like a lion and going out
like a lamb; or if forty years of medical practice is
estimated the same way, the doctor letting down when
half-way through, it would seem a better plan to
have March come in like a lamb and go out like a
lion.
Ordinarily the trouble with the lion business is that
it is mostly roar, especially with a young lion, or a
young doctor, and after he has tired of roaring and
is content to den up the people "get his number"
and begin to count him a "has been'7 because he lets
them think so and does nothing to change their esti-
mate of him.
It is largely a matter of psychology, for a governor
can flunk out after only two years, when it may
take a doctor twenty years to do so; the principle
is the same in both instances, and the cure is to stop
watching the clock and be so interested in one's work
that one is utterly amazed when the whistle blows
with a splendid job not yet done that no one else can
do so well and that the boss of the shop realizes he
cannot afford to place in other hands.
The TromUe With ike Ui
We have just been reading an article in a Western
medical journal and entitled "Do Our Leaders Lead J"
and as we know the author to be only forty years
old, capable, holding good appointments, etc., the note
of pessimism, unjust criticism and carping slams
throughout the paper remind us of a certain governor
who in the middle of his term was on his job a day
or two each month of the remainder of his governor-
ship, which went out in an orgy of mud-slinging —
and to this day a lot of the mud is still sticking to him,
while his opponents are still "lily white" in politics.
And it all came from going into the governor business
with the lion idea but a sore throat.
When a young cockerel whose spurs are only be-
ginning to sprout begins to strut and do alleged
crowing, it is well for him to keep out of the way of
the old roosters, for they are apt to do him up or run
him off the lot, after which he becomes misanthropic,
loses out with the ladies, slams the leaders, and fi-
nally gets his head chopped off because he is a no-
good rooster, fit only to be roasted.
If a lion has the judicial temperament, keeps his
mouth shut until he has something worth while to
roar about, refrains from cultivating a nasty dis-
position, and reaches middle age with good wind and
staying qualities, he is "king among the beasts;" but
few lions do this, and as a consequence most of them
are chewed up by the tigers before they are old
enough to put up a good fight.
The Mental Attitude of Middle Age
One can excuse a young fellow for losing his tem-
per, exaggerating, slamming his opponents or saying
unwise and unjust things, provided he does not do
too much of it and gradually learns better than to
do these things at all; but the middle-aged man who
cannot control himself is apt, some day, to wake up
to the fact that his fellows who really count in the
scheme of things regard him as a pest.
Successful living is just one compromise after an-
other; not a compromise as between right and wrong,
but between forces and opinions, and the middle-aged
doctor is persona grata, or is not, largely on the
basis of his mental attitude, his ability to view mat-
ters straight, get along with people as they are, realize
that he is just as apt to be wrong as is the other
chap, be a good loser or a modest winner. What-
ever we may think of the leaders in this world, the
214
The Plight of the Middle- Aged Doctor
[Phila., March, 1922
fact remains that they have certain qualities, else
they would not be leaders.
The two greatest handicaps a middle-aged doctor
can have are lack of enthusiasm and an overplus of
obsessions. Half-way through is the time to get a
well-tempered enthusiasm over something worth while
and to "start something." The average old chap has
an intolerable itching to start something backwards,
forgetting that every generation establishes its own
standards; but the blessed young chap of fifty goes
along with the new generation but adds his tempered
wisdom to the elaboration of something acceptable
to the times, always courteously listening to younger
men and keeping cheerful, even when fighting. This
world is full of big men; cultivate their acquaintance,
and you will soon be big yourself, be placed in posi-
tion of responsibility where you have to work like the
deuce, be consulted in affairs, learn how to do team
work and really get there; and then you can smile
indulgently at the carpers who attribute all of your
success to having a "pull." An advertisement that
"pulls" is a good advertisement, and he is a pretty
poor yap of a doctor who can't organize his own
"pull" on the basis of merit and being worth while.
The Cane oi the Oheauiam
The Bible tells of many persons and critters of
various sorts that were possessed of an evil spirit,
but the outstanding instances were old chaps and
hogs, and the latter "ran down a steep place into the
sea and were drowned," which would have been a good
ending for the humans who were possessed. Now,
being obsessed is just one step short of being pos-
sessed, and an obsession is alway dangerous. Every
editor has a lot of contributions come to his desk
which are written by persons who are obsessed, un-
reasonable, one-sided and cranky; and most of them
are written by men and women who are over fifty
years of age. Look out, doctor! Don't allow your-
self to become obsessed. Sometimes whole groups of
people are obsessed. An instance appeared in the
newspapers recently, for at a certain church confer-
ence a resolution was passed calling upon the United
States Government to sever diplomatic relations with
every nation that refuses to adopt prohibition as the
national policy. Think of itt
Being Unhappy
We all have middle-aged patients come to us whose
countenances look like three rainy days. They whine,
complain of a multitude of nebulous symptoms, are
touchy, grouchy, critical, fussy and have thoroughly
nasty dispositions. If they would just buck up and
swear a little bit, even get drunk once in a while,
or come in with a black eye achieved in a fight, we
would like them a whole lot better; but they are
afflicted with a certain brand of ingrowing righteous-
ness and their motto is "I am holier than thou."
Yet careful examination reveals absolutely no physical
disease and, in addition, no real reason for being un-
happy. The psychologitis of middle-age is one of
the worst and most intractable of diseases, readily
prevented by the free use of a club in the premonitory
stages, but not budged by an earthquake in a fully
developed case.
The half-way-through doctor is apt to contract
psychologitis, unless he gets out of the rut; and after
that he is just as useless as an elephant's tail or an
appendix on a strike for union hours. So, doctor,
get out of that rut and thus avoid psychologitis.
What Do Yam Know?
Not that anybody cares particularly if you don't
know a bloomin' thing; that's your lookout. Peo-
ple will pass you cigars, pat you on the back and
even solicit you for insurance when they know that
you could not make twenty per cent, on Edison's
questions. Pretty nearly all that's left to some mid-
dle-aged doctors is to run for the legislature. Oh,
no, not quite all; your office is a handy place and
you are a good chap and cheaper than the other
doctors, so you are valuable to the community in
small medical routine work.
Say, doctor, the above does not fit you; but you
know it fits only too many middle-aged physicians,
who are half-way through and are letting down, ceas-
ing to study, read the journals, buy books and read
them, attend medical society meetings and take post-
graduate courses.
Now'* Yomr Tame
Some governors buck up in the middle of their
terms; some league games are most full of pep after
the fifth inning; some lions are kings among beasts
as long as their teeth last and some doctors make a
tremendous stir after they are sixty years old. The
"plight" of the middle-aged doctor is principally of
his own making; he regards himself as half-way
through, at the top of the hill and the coasting down
will be easy. Of course it is easy to coast down;
but what was the use in climbing to the top unless
you mean to stay there t There's nothing but oblivion
and a long sleep at the bottom, where you are "un-
honored and unsung." Doctor, put on brakes, main-
tain your ground, and you will be a middle-aged
doctor while your fellows around you grow old and
slide, slide, SLIDE. You are as young as you feel.
T. S. B.
Pratt* Against Cornell Univenity EstmblUhing a Pay Clime
Editor American Physician.
The -Bronx County Medical Society at a meeting
held on November 16, 1921, unanimously adopted the
following resolutions and recommendations:
Resolved: That we protest against the abolition
of the Poor Clinic by Cornell University and against
(Continued one leaf over)
The America Physician] Atl Hottest M^Ct PldCt 215
After Abdominal Operations
bowel paresis — intestinal atony — is frequent from the effects
of the anesthetic, the shock of the operation, or the handling of the
intestines.
To relieve this dangerous condition
For Post-Opera-
tive Atony — Two
or three days af-
ter operation give
two teaspoonfuls
every three hours
until the desired
effects are ob-
tained. Then ad-
just the dose and
frequency to
meet the patient's
condition.
Send for useful
and interesting
booklet.
INTEROL
has proven of exceptional value. Used systematic-
ally it softens the feces, lubricates the canal and
assures easy evacuation without discomfort or
straining at stool.
Interol thus robs abdominal operations of one of
their most dangerous sequels.
ALLIED DRUG AND CHEMICAL CORPORATION
2413 THIRD AVE. NEW YORK CITY
Post-Scarlatinal Nephritis
is always a condition that demands prompt and efficient treatment.
There is no time for temporizing.
ANASARCIN TABLETS promptly and efficiently meet the indi-
cations, because ANASARCIN strengthens the heart, overcomes
circulatory stasis, brings about absorption of effused fluid and elimina-
tion via the kidneys of both urinary solids and fluid.
Such action renders ANASARCIN TABLETS invaluable also in
the Albuminuria of Pregnancy as well as in the dropsy of Chronic
Bright'* Disease and Anasarca resulting from cardiac valvular lesions
with loss of compensation.
ANASARCIN is safe, reliable, perfectly tolerated, non-irritating. The dose
is easily adjustable to each individual case and can
be continued indefinitely.
Sample and literature to physicians on request.
THE ANASARCIN CHEMICAL CO. Winchester, Tenn.
Mentioning The American Physician Insures Prompt, Careful Service
216
Internationalizing Sera Standards
[Phila., March, 1922
the entrance of the University into commercial medi-
cine for a profit;
That the establishment of Pay Clinic by a Univer-
sity is inimical to the best interests of the public at
large and of the medical profession in particular,
because such clinics are in direct competition with
the physicians who practise in the immediate and
remote vicinity.
That the offer of co-operation by the University
with the general practitioner is a blind to beguile
the latter to refer cases to them.
That we condemn the conduct of the physicians who
permitted their names and their positions to be used
for such crass newspaper publicity as the advance
announcements contained.
That such advertisement is distinctly adverse to
the best actions of medical men and to the code of
ethics as established by the American Medical Asso-
ciation.
That we recognize that these very men will not
and cannot offer their services to the patient, but will
merely act in an advisory capacity far from the
clinic rooms.
That for all the above reasons we recommend that
the respective County Societies to which these men
belong, and under whose jurisdiction Cornell Univer-
sity Medical School exists, shall take proper and
fitting action to reprimand these men and the Uni-
versity, and furthermore, shall recommend to its
members that they not accept positions in a dis-
pensary that works to the economic detriment of
their brethren.
Yours fraternally,
I. J. Landsman, M.D., Secretary.
391 East 149th Street, New York Citv.
We publish the above without comment and will
be equally ready to give space to the other side. —
Editors.
Imtermmttomoliiimg Sera Simmdmri*
Co-operation of the foremost laboratories of the
world, including the United States, for the unification
of international standards of anti-toxic sera has been
begun on a large scale by the League of Nations
Health Committee, according to detailed plans re-
.ceived here today. Already two preparatory confer-
ences have been held, the work divided amongst the
various national laboratories, and the individual
studies been begun.
The United States has agreed to co-operate in this
work through the United States Public Health Serv-
ice at Washington, and through the presence at the
conference of Dr. Rupert Blue, Assistant Surgeon
General, stationed at Paris. German scientists will
also take part, as well as Japanese, and representa-
tives of all the greater European medical services.
The work involved is considered of great impor-
tance to the medical world. Up to now there has
been as much confusion in the various national
standards of measuring the strength of anti-toxic
sera for diseases such as dysentery, tetanus, diph-
theria, syphilis, meningococcus and pneumococcus
as there has been in the different currency systems
in the world.
This has had two serious effects. First, the Amer-
ican scientist, for instance, is handicapped in study-
ing methods of treatment of various vital diseases
abroad, because of the different standards of measur-
ing the strength of the anti-toxic sera employed;
secondly, as international trade in sera is increasing,
it represents not only an inconvenience, but a pos-
itive danger to have their strengths listed at varying
standards.
In order to obviate these difficulties, the Health
Committee of the League of Nations began a series
of studies last October, which resulted in an inter-
national conference at London in December, when
some of the foremost scientists of the world came
together to prepare plans for the first joint experi-
mental inquiry of the sort ever attempted. A pro-
gram was adopted whereby the study of the effects
of the various standards was divided according to
diseases amongst the various laboratories represented.
To the Hygienic Laboratory at Washington, for
instance, it was proposed to allocate the study of
tetanus and diphtheria. As soon as these studies
have been completed, they will be co-ordinated
through the State Serum Institute at Copenhagen.
Other bodies which will co-operate in the work are
the Medical Research Council of Great Britain,
Pasteur Institute of France, State Institute of Italy,
State Institute of Warsaw, Hygienic Institute of
Basle, Pasteur Institute of Brussels, Kitasato In-
stitute of Japan, as well as Austrian and German
organizations.
League of Nations News Bureau,
Raymond B. Fosdick, Director.
2702 Woolworth Bldg., New York City.
More Light on Argyria
Editor American Physician.
I notice on page 48 of the January issue, an article
by Dr. Hyman I. Goldstein, in which he reports a
case of argyria by Lochte following the use of Silver-
Salvarsan.
For your information, I beg to say that the Journal
of the A. M. A., of October 23, 1920, contained a
report of a case of argyria, so-called, from Silver-
Salvarsan (the only one reported after more than
500,000 injections of the drug in Europe).
Immediately after the publication of the report,
Colonel Metz communicated with the Farbwerke of
Hoechst by cable and received the following answer:
continued one leaf over)
Physician]
An Honest Market Place
217
•a*.
Doctor, do you know
the distinctive characteristics
of Grape-Nuts?
The cereal food, Grape-Nuts, is made from a mixture of
malted barley, whole wheat flour, salt and water; raised by
yeast, baked in loaves, sliced, again baked and finally crushed
into granules. More than 20 hours are consumed in the various
baking processes.
Thus prepared, this unique food is characterized by:
1 . A distinctive flavor, satisfying to the taste and appetite.
2. A physical condition whereby the Grape-Nuts does not
form a pasty bolus inaccessible to the digestive fluids, but
retains in a softened condition its granular form throughout
the digestive tract so that even at the beginning of digestion
all portions come into intimate contact with the digestive
juice.
3. Nutrient ingredients, some partially digested, all acces-
sible for digestion.
4. Natural ingredients in sufficient amounts that resist
ion and give bulk to the intestinal contents.
1
S
The results obtained by its use are: I
a. Well balanced, satisfying nutrition. J§
b. Passage through the alimentary tract without physio- ||
logical stasis, thus avoiding excessive fermentation and s
putrefaction of the food, with consequent auto-intoxication. S
c Bulk and moisture to the contents of the sigmoid and =
rectum, thereby inducing normal peristaltic action and §
avoiding stasis in the bowels. §
These are some of the reasons why Grape-Nuts is of such 1
great value in maintaining health and is particularly indicated |
for the correction of auto-intoxication and the nervous diseases I
that are exacerbated, if not caused by this condition. s
Samples of Grape-Nuts, for individual and clinical test, will be I
sent on request to any physician who has not received them. 1
Postum Cereal Company, Inc. |
Battle Creek, Michigan, U. S. A. 5
dnWIIIIITO
Mentioning The American Physician Insures Prompt, Careful Service
218
More Light on Argyria— Baketel
[Phil*., March, 1922
"The only two references we have ever seen to
argyria following injections of Silver-Salvarsan, refer
to the same case and were based upon a report enti-
tled: 'Argyria After Twelve Silver-Salvarsan Injec-
tions/ Therap. Hdtbmonatsh., June 15, 1920, by Dr.
Lochte, and 'Supposed Argyria After Silver-Salvar-
san on the Strength of the Diagnosis of a Natu-
ropathist and not Controlled/ by Dr. Schlossberger.
These references are based on the same case.
"Lochte denies expressly the authorship of the
sensational heading and states that the case report
as sent to him bore this heading. Lochte states that
he did not see the case himself, although he requested
that the patient call upon him. Therefore, he says
he was not in a position to confirm the diagnosis of
the naturopathist, and he himself suggests the pos-
sibility of an arsenical melanosis.
"If we can believe Tweedy (Dublin Med. Jour.,
July, 1895), silver must be taken for a period of
about three years in order to produce argyria."
The letter continues that despite the administration
of more than half a million Silver-Salvarsan injec-
tions, no case of argyria has been observed by com-
petent authorities. In rabbits which were injected
intravenously with from 0.02 to 0.04 gram Silver-
Salvarsan per kilo body weight, every third or fourth
day for a period of from nine to twelve months, no
argyria of the skin could be demonstrated, although
they had between three and four grams of silver.
The silver was deposited in the otherwise normal
intestinal tract, according to Fischer (Frankfurt-on-
Main), Kolle, W., D. M. W., 1918, Nr. 43, U. 44,
especially Kupffer's starcells of the liver and to a
lesser degree in the kidneys. No functional disturb-
ances could be observed in the rabbits; their weight
increased constantly.
Another thing to be considered in this Lochte re-
port is that this naturopathist gave the injections
intramuscularly, although the manufacturers insisted
that it be given intravenously. It is not difficult to
imagine that a hypersensitive patient might have an
argyria following the intramuscular injection of
silver, as it would likely be more easily deposited
when injected this way.
Personally, I have looked into the matter very care-
fully and I find that according to the best authorities,
it takes fifteen grams of silver to cause argyria, and
if we were to give a course of twelve injections,
using a maximum dose of three decigrams, which is
more than is recommended, the patient would only
get 3.6 grams in a course, leaving a very wide mar-
gin between the amount taken and the minimum for
the causing of argyria. As a matter of fact, I be-
lieve the danger from argyria is exceedingly small.
Very truly yours,
H. Sheridan Baketel, M.D., F.A.C.P.
New York City.
"Book %eUews
Nmt Growing
By Robert T. Morris, M.D., New York City. Cloth,
illustrated, 236 pages. The Macmillan Company, New
York. Price, $2.50.
Dr. Morris is always original, and what he says is
always worth while, whether in his specialty, surgery,
or in the fad he has taken up to the point of profession-
alism, nut growing. This book is the outgrowth of his
many years' interest in nuts and their future in this
country.
The book opens with a most interesting presentation
of the sociologic phases of the subject, discussing the
world's future food supply and the apaedion index to
the decline of nations, as based on the cultural limita-
tions of man and the impossibility, as Dr. Morris views
it, of the world ever becoming over-populated, though
it may become hungry. This latter menace he would
help to meet by using great wasted areas of rough land
for the cultivation of food- and lumber-producing nut-
bearing trees. If marketing and financial matters make
progress as fast as the author wishes to see nut cultiva-
tion promoted, there is certainly a future for nuts; but
their cultivation must be made to pay.
As a contribution to agricultural literature the book
possesses marked value, being dependable in statement
and a safe field guide. Perhaps the most valuable and
original feature of this work is the section on grafting
and budding. In this matter surgical principles have
been applied to a subject that has made little progress
for generations and the author is entitled to much credit
for his painstaking investigation of the subject.
Doctors who wish to pursue a side line full of charm,
and perhaps of profit in dollars and cents, should buy
and study this very excellent and inspiring work.
T I* Oxtwi
By various authors. Edited by Henry A. Christian,
A.M., M.D. Hersey Professor of the Theory and
Practice of Physic, Harvard University; Physician-in-
Chief to the Peter Bent Brigham Hospital, Boston,
Mass., and Sir James Mackenzie, M.D., F.R.C.P.. LL.D.,
F.R.S. ; Consulting Physician to the London Hospital,
and Director of the Clinical Institute, St. Andrew's,
Scotland. In six volumes. Illustrated. Volume IV —
Diseases of Lymphatic Tissue, Metabolism, Locomotary
Apparatus, Industrial Disease and Infection Diseases.
Oxford University Press. American Branch, 35 West
Thirty-second Street, New York. $15.00 per vol., or
$90.00 set of 6.
This volume is fully worthy of the splendid com-
ment already awarded those of the three preceding
ones. The book is still a text par excellence.
Vic* mmi Health
By John Clarence Funk, M.A., LL.B., Director,
Bureau of Protective Social Measures, Pennsylvania
Department of Health ; Scientific Assistant, U. S. Public
Health Service; formerly U. S. Navy Law Enforce-
ment Representative and Vice-Agent U. S. Department
of Justice. Cloth, J. B. Lippincott Company, Philadel-
phia.
This work of 175 pages presents in semi-popular
form the problems of vice and prostitution in con-
(Book Reviews continued one leaf over)
The American Physician
X
An Analysis of
Ktllogg'm BRAN
:noked and Itruiublad
Aside from ill regulatory
MINERAL SALTS
C«rbo-hydr»tts
Inducing
better peristaltic action
by the regular
use of BRAN
Medical authorities now generally agree that old
age and sickness have their inception in the intes-
tinal tract and that the most effective way to ward
off these enemies of mankind is to rid the patient's
system, at the earliest possible moment, of waste
materials.
Kellogg's Bran, cooked and krumbled, through
its mineral salts and its ability to absorb water,
giving bulk and moisture, is nature's way to assist
in perfect elimination. The intestine is thus dis-
tended and better peristaltic action secured.
Kellogg's Bran, cooked and krumbled, forms no
habit; besides, unlike common bran, Kellogg's is
not irksome for the patient to eat. Kellogg's has
a delicious nut-like flavor, and in its attractive,
krumbled form is most appetizing. Kellogg's is
served the patient as a cereal, or sprinkled on other
hot or cold cereals. It also makes delightful bak-
ery batches. We particularly recommend bran
griddle cakes, muffins, raisin bread, gems and
macaroons, etc. Recipes appear on every package.
Kellogg's Bran is sold by all grocers.
We will appreciate your person*! and professional
interest in Kellogg's Bran. If yon will drop us a
card we will promptly mail yon a full-sized pack-
age without tbe slightest obligation on your part
die original &RAN ~ cooked and krumbled
Mentioning The American Physician Insures Prompt, Careful Service
220
Helpful Points
[Phik., March, 1922
tained and constructive language far from sensational;
and the suggestions for solution of the vice menace to
health are founded on practical experience and ob-
servation over a wide area both in times of peace and
war.
The author is an attorney and student of sociology,
and he brings to the preparation of this work a tempered
enthusiasm that discounts much of mere propaganda,
the result being a volume well worth while and de-
signed to aid the lay and professional reader to the
attainment of sane opinion concerning vice and the
health problems it precipitates.
in each instance. Rhinol is one of my standbys in my
practice and now that I have realized its great thera-
peutic value in the treatment of the above-named con-
ditions, I could not do without it"
Complete outfit, $3.00; refilled packages, $2.50. For
further information address: Rhinol Company, Inc.,
1416 Broadway, New York.
The Diagnosis smi TreotastM •/ Iwtassnsctptitn
By Charles P. B. Clubbe, L.R.C.P., M.R.C.S., Con-
sulting Surgeon to the Royal Prince Alfred Hospital,
Consulting Surgeon to the Coast Hospital, Sydney;
Hon. Surgeon to the Royal Alexandra Hospital for
Children, late lecturer in Clinical Surgery, University
of Sydney, New South Wales. Second edition. Henry
Frowde, Hodder & Stoughton, Oxford University
Press, London. Price, $2.50.
This is an excellent discourse of practical value,
"based entirely on experience of intussusception during
the last thirteen years."
Results Evident the First Night
If you knew, as many physicians have learned from
experience, the excellent results from Creo-Tussin in
whooping cough, you would not be without it The
good results are evident the first night
It is made very easy for you to try this excellent
product, with no expense and the least possible
trouble to you. Sample and literature will be sent
gladly. Just turn to page 229 and send in the coupon.
Affections of Nose and Throat
One New York physician writes: "During the last
year I have treated a large number of patients suffer-
ing from coryza, chronic rhinitis, pharyngitis, laryngitis
and hayfever with Rhinol, and it gives me great pleas-
ure to state that the results have been very satisfactory
A Standard Synthetic Improved
Atophan has been manufactured for quite some
time past in the manufacturing plant of Schering
& Glatz, Inc., at Bloomfield, N. J.
The product is made by a special process which
entirely eliminates the possibility of unpleasant em-
pyreumatic admixtures, and thus still further im-
proves this standard synthetic in the treatment of
rheumatism, gout, neuralgia, neuritis, sciatica, mi-
graine and "retention" headaches.
Schering & Glatz, Inc., 150-152 Maiden Lane, New
York City, will be glad to send a trial box of
Atophan Tablets to American Physician readers on
request.
(Helpful Points continued one leaf over)
ACTIVE CATHARTICS OR PURGATIVES THAT PRODUCE A WATERY
STOOL DO NOT GlVE GOOD RESULTS IN
Habitual Constipation
as the digestive secretions are carried off and a period of constipation follows
until the secretions again accumulate and the natural process of digestion and
assimilation is resumed.
A mild tonic laxative, gives the best result and you can obtain this with Cascarm
Comp. Tablets (Killgore's), as they stimulate the secretions, give an easy natural
movement without griping and do not become ineffective by continued use.
Dose: One or two tablets at night.
Liberal Sample and Formula Sent to Physicians on Request
CHARLES KILLGORE
Manufacturing Chemist
82 FULTON STREET
Established 1874
NEW YORK
You can buy with Confidence — See "Service Guarantee to Readers*' on page 240
An Honest Market Place
SAVE 30% ON
Intravenous Specialties
This firm, pioneer of yesterday and leader in the field today,
now offers many intravenous specialties to the physician at a
»aving of 30c on the dollar.
These products, made in our large laboratories from the
newest and best proved formulae, are recognized by the medical
profession as the highest quality known.
We have always set the standard of quality — now we are
establishing a price that is of further advantage to the physician.
Write for our latest price lists today.
GEORGE A. BREON CO.
Coca Cola Bldg. DepL 102 Kanui City, Mo.
H The Management of an Infant's Diet
Infants' Stools
irity in bowel movements contributes much toward
althful progress, and a knowledge of the number
ter of the stools during each twenty-four hours is
nt part of the general management of early life and
h in properly adjusting the diet.
stions for the regulation of infants' stools by slight
the make-up of the diet and particularly in re-
mstipated Movements
1 our book, "Formulas for Infant Feeding," and in a
evoted especially to this subject. This literature will
physicians who are interested in the matter.
dj Mellin's Food Company, Boston, Mass. I
Mentioning The American Physician Insures Prompt, Careful Service
222
An Honest Market Place
[Phik., March, 1922
Effective Remedy for Hemorrhages
The following cases illustrate the clinical value of
Styptysate as the remedy for hemorrhages:
Mrs. E. M., age 30. Menorrhagia of five years, with
menses of ten days' duration, at times more profuse
than at others, some dysmenorrhea which caused her
to go to bed. January 10, 1921, 8 A. M., patient un-
able to sit up. Prescribed Styptysate in dose, 15 gtts.,
t.i.d. 9 P. M., better, less pain, less discharge. Janu-
ary 11, 1921, improving. January 12, 1921, feeling
O. K. Menses four days instead of ten as hereto-
fore. Expect to see less trouble next time, as action
in this case was remarkable in the light of previous
experience.
Mrs. A. S'., aged 39. Uterine hemorrhage following
miscarriage at five months. Called January 11, 1921,
2 A. M.; administered Styptysate as indicated hemo-
static. Result very satisfactory. I believe from
clinical observation thus far made you have in Styp-
tysate a meritorious hemostatic. — B. H. M., M.D.,
Kansas City, Mo.
The manufacturers of this effective product, Ernst
Bischoff Co., Inc., 85 W. Broadway, New York, are
making a very special introductory offer; turn to
page 175 and send in the coupon.
The Original Russian Oil
Usoline, the original Russian mineral oil, was the
first mineral oil put on the market in this country,
and physicians have been prescribing it for internal
use ever since with markedly satisfactory results.
A clinical test, six-ounce bottle of Usoline, will be
sent free to American Physician readers. Address:
Oil Products Co., Inc., 50 Union Square, New York.
Vaccine in Prophylaxis and Treatment
In the treatment of stubborn, sub-acute and chronic
sinus infections, middle-ear disease, chronic tonsillitis,
chronic bronchitis, asthma and such conditions, many
clinicians are not depending on drugs, but using in-
stead Mixed Vaccine — Ear, Nose and Throat
(National).
Begin with initial dose of 200 million bacteria. Re-
action slight, persisting not over twelve to twenty-
four hours. Subsequent doses at five to seven-day
intervals until the full treatment (four doses, 200, 500,
1000 and 2000 million bacteria) has been given.
This has also been found to be a very efficient
prophylactic against colds. Literature and price lists
will be sent gladly to American Physician readers.
Address: National Vaccine and Antitoxin Institute,
Washington, D. C.
For Prostatic and Gonadal Dysfunction
Prosto-Orchoid Compound (Mayson) contains
prostate gland, orchic and lymph glands, with nuclein
in suitable proportions. Physicians are obtaining
gratifying results by the use of Prosto-Orchoid Com-
pound in impotence, sexual neurasthenia, prostatic
disorders and hypertrophy of the prostate with irri-
tation of the bladder. Prosto-Orchoid Compound
(Mayson) is used with marked success in senility,
chronic prostatitis, prostatorrhea and after prosta-
tectomy, and is a most valuable genito-urinary tonic
Booklet containing list of perfected pluriglandular
formulas, therapeutic uses, etc., will be sent gladly
to American Physician readers. Address The May-
son Laboratory, 5 S. Wabash Avenue, Chicago, 111.
(Helpful Points continued one leaf over)
IIIIIIIOIIIIIM^
CHLORYLEN
itiiiiiiiiiiuiuiiiiiiuiiuiiniiniiuniiiiiiiiiiEiiiiiHiiiiiiiifiia^Bi^
A New Treatment for Trigeminal Neuralgia
Chlorylen is used with marked success in the treatment of tri-facial neuralgia.
It has a specific action on the sensitive Trigeminus, gives immediate relief and the
pain disappears after a few treatments.
Chlorylen is applied by inhalation. 20 to 30 drops are placed on cotton or
the handkerchief and inhaled through the nostrils, until the odor disappears. It
is a volatile liquid with a pleasing odor and is obtainable in bottles of 25 grams each.
NEUTRALON
A substitute for the Bismuth salts,
Sodium Bicarbonate, Silver Nitrate,
etc., in the treatment of Hyperchlor-
hydria, Hypersecretion, Ulcus Ven-
triculi, etc. A white, tasteless, odorless
powder; supplied in packages of 100
grams each. The dose is one teaspoon-
ful in a glass of water before food.
VALAMIN
A sedative and soporific for use in
the treatment of Neurasthenia, In-
somnia, Hysteria, Palpitation of the
Heart, etc. It is a Valerian and Amy-
lene combination, is easily absorbed
and acts promptly. Valamin is mar-
keted in packages containing 25 cap-
sules of 4 grains each. The dose is
one or two capsules after meals. In
nervous insomnia, two to four capsules
should be taken before retiring.
For further information and literature address:
KIRBACH, Inc., General Agents, 227-229 Fulton St.,
NEW YORK
minimi!
[fiuiinmiimiiinifinninniiiim!iii!Ti!!inniniii!ififniinnintnfRnnniniiintifiHiffmi!
You can buy with Confidence — See "Service Guarantee to Readers'' on page 240
The American Physician]
An Honest Market Place
223
ssa,
r--
Success in Desperate Cases
Makes a Doctor's Reputation
Hie physician who uses the Philo Burt Method of Spinal correction invariably accomplishes
more and in a shorter space of time than is possible with other methods.
This Doctor proved it — and he says: —
"Absat tw# years ago I was trset-
lac the Uttls 4aa*hter af Mrs.
C. W. R — for Potts Dissase of the
spine; the last dorsal ana1 first two
hussar vertebrae belas; inrol red-
She was pot into a plaster cast,
and improTtd sossewaat, bat
•wins; to the low location of the
kyphosis it was impossible to ret
a satisfactory result and after
two or three applications, the child
refeeed to have another cast ap-
plied. A rifid brace was oat of
the ejaestlon and I knew of no
non-riald one. Luckily Mrs. E.
knew of yours, and we applied it.
Yesterday (April 13, 1911) she
to my oflce aad I was
Always Made to
on
prtoed and deliffhted at the won-
derfal chaace in the child's condi-
tion. She' had frown fire laches,
and gained 89 poena*. AJthoaf h
the kyphosis remained and there
were scars from the sinuses, the
spine was straight and almost as
iexible as normal, aad she looked
the picture of health. I examined
the appliance with treat interest
and was pleased with H. I shall
ase H in my practice, which is
Orthopedic Sarrery, as it is more
comfortable than a plaster or
celluloid Jacket and can be taken
eft* at any time and re-applied. I
canaratalate yea anon the work-
manship and perfect fit."
30 Days' Trial
A Typical Case
We are glad to receive the m«
arements from any physician for
any of his casps and co-operate
with him, and allow 30 days' trial
with money back if not satisfac-
tory. We have done this for over
20 years in more than 45,000 cases.
We will send oar Physicians' Port-
folio which contains facsimile let-
ters from reputable physicians and
surgeons throughout the U. S.
We co-operate with family phy-
sicians or specialists. We guar-
antee perfect fitting of the ap-
pliance and refer to any bank in
Jamestown as to our financial re-
sponsibility and business integrity.
Write for our literature.
THE PHILO BURT CO., 115-15 Odd Fellow* Temple, Jamestown, N. Y.
Pioneers in a New Field
Every thinking Physician appreciates Research work, Experimental
Chemistry and Therapeutics.
He recognizes the self-sacrifice and courage required to broaden
any field of medicine.
Such American Workers as Osborne, Mendel, McCollum and Hess
Have contributed vast new knowledge relating to foods. The concep-
tion of the Vitamines clears a great new field in nutrition.
The Harris Laboratories introduced to the medical
profession the first and original preparation known
to the civilized world of carefully standardized water-
sohible-B Vitamine.
There is still no other product of this character, this power, this concentration
Vrith standard U. S. Government tests of its activity — available for therapeutic
practice.
Yeast Vitamine-Harris Tablets have shown their clinical value in thousands
of cases of:
Suppressed Growth Low Vitality Subnormal Hunger
Delayed Convalescence
PREPARED BY
THE HARRIS LABORATORIES
Tuckahoe, N. Y.
IV rile for charts and clinical suggestions
Mentioning The American Physician Insures Prompt, Careful Service
224
Helpful Points
[Phil*., March, 1922
Still the Scourge of Mankind
An extremely interesting and helpful booklet "Pul-
monary Tuberculosis; Its Diagnosis and Treatment, will
be sent to Amzrican Physician readers on request.
Address: Fellows' Medical Manufacturing Co., Inc., 26
Christopher Street, Now York.
As Osier said: "Tuberculosis is the most universal
scourge of the human race." Despite the war science
is waging against it, tuberculosis still causes more deaths
than any other disease.
The physician will find this booklet scientifically de-
pendable, interesting and helpful in handling his own
cases. Write for it today, it will be sent gladly on
request.
Doctor, Write for This
Many physicians are finding that the treatment of
fractures with the Ambulatory Pneumatic Splint, either
in or out of bed, secures good bone union, comfort,
strength and health in the least possible time.
Write for measurement blanks and illustrated circu-
lars, and information on ambumatic washable abdomi-
nal supporters. Address: Ambulatory Pneumatic Splint
Mfg. Co., 30 (C) E. Randolph Street, Chicago.
Dietary Deficiencies
The constant need for a sufficient supply of water-
soluble vitamine in the diet is now well known. Phy-
sicians are aware that general debility and sus-
ceptibility to miscellaneous infections follow the con-
tinued ingestion of food containing too little of
this dietary factor.
Yeast has been found to be richer in water-soluble
B vitamines than any other known substance.
The success of experiments made by various ex-
perts with yeast has given impetus to the study
of this source of vitamine. Physicians are now
prescribing it for certain dietetic troubles, and the
yeast treatment, both in hospitals and in private
practice, has been attended with marked success.
Fleischmann's Compressed Yeast offers an easily
obtainable, economical and scientifically standard-
ized source of vitamine.
For further information, address The Fleischmann
Company, Dept. S3, 701 Washington Street, New
York.
Has Proved Its Dependability
Many able members of the medical profession have
found Pluto Water excellent for the counter-action
of those drugs which suppress secretions. In pre-
scribing this valuable water in small doses the
action is to flush the intestinal canal and stimulate
the liver to remove from the ducts the accumulated
secretions. And many practitioners direct con-
valescent patients to the spring for rest and com-
plete treatment.
A Pure Cereal Beverage
Physicians have found that Instant Postum helps
in the gen real sedative and reconstructive treatment
of neurasthenic cases. Postum is an absolutely pure
cereal beverage, scientifically prepared in the larg-
est, most modern and sanitary plant of its kind
in the world. It serves every purpose of a hot
meal-time drink, and as it contains no harmful in-
gredients, no ill effects follow its use.
Samples of Instant Postum for individual and
clinical test will be sent to American Physician
readers who have not received them. Address: Pos-
tum Cereal Company, Inc., Battle Creek, Michigan.
TESTOGAN
THELYGAN
For Men For Women
Formula of Dr. Iwan Block
After seven years9 clinical experience these products stand as proven specifics.
INDICATED IN SEXUAL IMPOTENCE AND INSUFFICIENCY
OF THE SEXUAL HORMONES
They contain SEXUAL HORMONES, L c^ the hormones of
the reproductive glands and of the glands of internal secretion.
Special Indications for Testogan:
Sexual infantilism and eunuchoidism in the
■ale. Impotence and sexual weakness.
Climacterium virile. Neurasthenia, hypo-
Special Indications for Thelygau:
Infantile sterility. Underdeveloped mam-
mae, etc Frigidity. Sexual disturbances in
obesity and other metabolic disorders. Cli-
macteric symptoms, amenorrhea, neurasthe-
nia, hypochondria, dysmenorrhea.
Fmbkti to TABLETS for btonal at* mi to AMPOULES, for iatngbtnl fejecta.
Men: TaMita,4tmftWi,$Ltt;aBPMl«.2tiBftWi,$3.tt.
EXTENSIVE LITERATURE ON REQUEST.
CAVENDISH CHEMICAL CORPORATION
Sole Agents.
Pearl StrMt
Established 1905
H*w
You can buy with Confidence — See "Service Guarantee to Readers" on page 240
The American PhyricUn] All Honest Market PlaCC 225
:
NATIONAL BIOLOGICS
Diphtheria Antitoxin (National) is of the highest quality,
physiological activity and therapeutic dependability. Supplied
in our Special Ready-to-Use Syringe with needle already in end
rubber, thus eliminating all possibility of Infection.
1000 Unit Pkg. $1.25 5000 Unit Pkg $3.75
3000 Unit Pkg. 2.50 10,000 Unit Pkg. 6.50
For COLDS, use our MIXED VACCINE
(Ear, Nose & Throat)
An efficient prophylactic and an effective treatment in sinus infec-
tions, middle ear disease, chronic tonsillitis, bronchitis, etc. Dosage,
200, 500, 1000 and 2000 million bacteria.
4 Amp. Pkg... $1.50 5ce Vial. .$1.00 20cc Vial. .$3.00
NATIONAL VACCINE & ANTITOXIN INSTITUTE
Oldest in America
WASHINGTON, D. C.
High Blood Pressure— A Danger Signal
Its meaning should be carefully considered. Its reduc-
tion by safe methods is always a therapeutic necessity.
Pulvoids Natrium Compound
(High Tension Dr. M. C. THRUSH)
Sugar coated green color, dissolves in intestinal tract; it a safe, reliable, non-irritating,
non-toxic combination of potassium nitrate, sodium nitrate, sodium bicarbonate, nitro-
glycerin and Crataegus oxyacantha, prompt to act, prolonged in effect. Send for booklet
on High Blood Pressure; also for *'Drug Products," a periodical devoted to hypertension
and allied subjects.
If you dispense, ask for catalogue and price list of Pulvoids, Wafoids, Salvarpls, Vita-
Yeast, Organic products, etc.
Special Offer to Physicians and Hospitals Only
200 Pulvoids Natrium Comp., $1.00. One time only. 1000 Pulvoids
Natrium Comp., $5.00 on 60 days' trial; money back if not satisfied.
Mailed free for cash with order, or sent C. O. D.v mailing and collection
charges extra.
THE DRUG PRODUCTS CO., Inc.
150 Meadow Street Long bland City, New York
Mentioning The American Physician Insures Prompt, Careful Service
226
Helpful Points
[Phik.. March, 1922
Efficiency Requires It
Physicians are realizing more and more that efficiency
requires the use of a typewriter in writing prescriptions,
labels, directions, professional correspondence, etc. — no
question of mistaken directions and such a time-saver.
A very special offer is made this month to the physi-
cian who wants to get a good typewriter, with medical
keyboard, etc., at a moderate price. The typewriter is
sent before you pay anything, try it for five days and
if satisfactory you pay a small sum each month until
the price of the machine is paid. Turn to page 232 and
send in the coupon.
A Special Opportunity
A. S. Aloe Company is making two very special
offers: Rent a Tycos (1922, Dr. Rogers' model) sphyg-
momanometer for nine months and it is yours. Sold
on ten days' trial, money-back guarantee. And also a
bargain sale of army operating tables at less than half
price, and on monthly payments. Turn to pages 228
and 238 and see these special offers.
Efficient equipment goes a long way toward success-
ful results.
Of Real Aid in Pneumonia
Pneumonia is still the unconquered foe of medical
science, but clinical experience has discovered promis-
ing weapons to use against this disease. One of the
most promising measures in the treatment of pneu-
monia is the proper application of Pneumo-Phthysine.
Properly applied, not too hot. it will be found a very
real aid in controlling pain, temperature and generally
aiding in a successful outcome.
For full information address: Pneumo-Phthysine
Company, Chicago, 111.
Judge This Product Yourself
Lavoris combines with well-known antiseptics in
pleasing form, the therapeutic properties of zinc chlor-
ide. As a healing antiseptic it has unusual merit, and
for fifteen years it has a record of annual success as
evidence of its value.
A complimentary supply will be sent to American
Physician readers on request Address: Lavoris
Chemical Co., Minneapolis, Minn.
Effective Administration
It is unscientific and even dangerous to dispense cul-
ture media in bulk — the Franco-American Ferment
Company has therefore introduced the "small drink"
dose in individual one-dose bottles.
You will find that the administration of Bacillus
Bulgaricus cultures, as worked out by this company,
liberal dosage — minimum expense — effective results, will
be found to be the most satisfactory method.
Interesting literature and samples will be sent to
American Physician readers. Address: Franco-
American Ferment Company, 225-7 Sixth Avenue, New
York.
A Distinct Advance
Sodium Diarsenol has the therapeutic advantage of
arsphenamine with the solubility and convenience of
neoarsphenamine and gives clinical results that have
been found satisfactory in every way. Sodium Diar-
senol marks a distinct advance in syphilology.
Samples and interesting literature will be sent to
American Physician readers. Address: Diarsenol
Company, Inc., Buffalo, Boston, or Atlanta.
(Helpful Points continued one leaf over)
ANU
(Trade Mark)
_ •
Hemorrhoidal
SUPPOSITORIES
They break the
a
Vicious Circle
9f
in Hemorrhoids
Hemorrhoid sufferers are always inclined to become careless and dilatory
in their bowel movements, for fear of painful defecation.
And right there starts the "vicious circle"— constipation, local irritation,
aggravated Hemorrhoids, painful defecation, increased irregularity, and so
forth.
Anusol Suppositories remove the dreaded strain and the reassured patient
resumes his regular bowel function.
Then the excellent healing and tonic action of Anusol Suppositories can
set in and do its utmost without set-back-
And the utmost of Anusol Suppositories accomplishment is the utmost in
Hemorrhoidal therapy.
Ample Trial Quantity and Literature from
SCHER1NG & GLATZ, INC, ISO Maiden Lane, New York
You can buy with Confidence — See "Service Guarantee to Readers" on page 240
An Honest Market Place
"Clinical Medicine " says:
"The acute, severe and frequent pains for which you
have many emergency calls are spasmodic — never inflam-
matory. Therefore antiphlogistics are not indicated and
certainly not morphine. The pure benzyl benzoate, as in
Sharp & Dohme's Benzylets, gives you an ideal antispas-
modic agent in the colics — renal, hepatic, uterine, intestinal.
The anodyne value of Benzylets is well seen clinically in
asthma and neuritis.
"For results prescribe Benzylets S. & D."
"Benzylets"
in boxes of 24—5 mm gelatin glob-
ules, at all well-stocked drug stores
EVERY DAY doctors are advising a rest, a trip to a sanitarium, a visit to
a specialist, an operation — anything to get rid of their old, stubborn cases of
Prostatic Disease and Impotence
offer "thing hut prunlises and frequently give few,
YOU CAN GET RESULTS
in many of theie cases. If you will try SUPPOS. PROSTANS thoroughly in one or two cases you will aurely
convince yourself and will thereafter irep Ike bniinm you've bet* tuning may.
There ii nothing tecret about Sxppoi. Proliant— formula with each box.
If after a fair clinical test you feel that the results do not mnrt than m?et all your expectations, we hereby
"*" Remember, fjoctor, that your immediate order m:an, a clear saving of M to you. It seems a_ duty' to
'""pill "out" the' coupon now. Sincerely.
REGENT DRUG COMPANY.
This Coupon .Mranj Snecotl and Monty Saved ai Well, Fill II Out. Send Today
REGENT DRUG COMPANY. ■"» Burden of Proof R»t> Upon Ua.
3 1 52 Wooerwnrd Ave., Detroit. Mich.
I enclose $5.00. aend roe aut boxe* of Name — — - —
Suppoa. Proitana (worth $9.00) alio
ths above book and "Succeaaful Prosta-
tic Therapy"-
Address -
Mentioning The American Physician Insures Prompt, Careful Serviei
Helpful Points
[Phils.. Mjrcl.UH
Interesting Booklets Free
The Nujol Laboratories, Standard Oil Co. (N. J->,
Room 765, 44 Beaver Street, New York, are offer-
ing to send some very interesting booklets to phy-
sicians on request — "In General Practice," "A Sur-
gical Assistant" and "In Women and Children,"
also a sample of Nujol. Turn to page 231 and send
in the coupon.
Benzylcts Give Results
The oure benzyl benzoate, as in Sharp & Dohme's
Benzylets, gives you an ideal antispasmodic agent
in the colics, renal, hepatic, uterine and intestinal.
The anodyne value of Benzylets is well seen clinically
in asthma and neuritis.
Clinicians have found Benzylets effective in gall-
stone and other colics, in spasmodic dysmenorrhea,
in true asthma, neuritis, whooping cough — in short,
in most pathologic conditions where opium was
formerly used. For results, prescribe Benzylets
S. & D., manufactured by Sharp & Dohme and sold
in boxes of 24-5 min. gelatin globules at all well-
stocked drug stores.
A New Local Anesthetic
From time to time new anesthetics to take the place
of cocaine have been proposed, and to some extent used,
but without utterly supplanting the older and rather dan-
gerous drug. Now, however, the surgeon has a sub-
stitute that is a decided improvement. The new local
anesthetic is called Butyn (pronounced Bute-in, with the
accent on the first syllable). It is the discovery of
Professors Roger Adams and Oliver Kamm, of the
University of Illinois, and Dr. E. H. Volwiler, of The
Abbott Laboratories, Chicago.
The anesthetic has been passed by the Council on
Pharmacy and Chemistry, of the American Medical
Association. In his report, Dr. A. E. Bulson, Jr., for
the Committee on Local Anesthesia, Section of Ophthal-
mology, said that it acts more rapidly than cocaine and
its action is more prolonged. Less is required, and in
the quantity necessary it is less toxic than cocaine. It
has other advantages which make it highly useful, espe-
cially for eye work. A solution can be boiled without
impairing its efficiency.
The Abbott Laboratories is supplying Butyn, in tablets
(with and without Epinephrin) and 2% solutions, which
may be had without narcotic blanks.
Reprints reporting the clinical work done by the Com-
mittee will be sent to American Physician readers.
Address: The Abbott Laboratories, Dept. 49. 4739 Ra-
vens wood Avenue, Chicago.
Stronger Than Mercuric Chloride
An expert opinion on Chinosol: "A powerful anti-
septic, somewhat stronger in this respect than mer-
curic chloride and considerably stronger than phenol,"
has been borne out in practice by many clinicians
who depend on this excellent product.
For further information, address: Parmele Phar-
macal Company, 47-49 West Street, New York.
Starch-Free Bread for Diabetics
Diabetics do not have to forego the staff of life.
Tasty bread, muffins, pastry, etc., made from Lister's
Diabetic Flour (casein, strictly starch free) can be
given to these patients with good results — and no un-
toward effects. A month's supply of thirty boxes,
$4.85. For supplies or further information, address:
Lister Bros., 405 Lexington Ave., New York City.
(Helpful Points continued one leaf over.)
*
"T* HE older members of
the Medical Profession
Pluto Water
excellent for the counter-
action of those drugs
which suppress secretions
and in prescribing this
valuable water in small
doses the action is to flush
the intestinal canal and
stimulate the liver to re-
move from the ducts the
accumulated secretions.
Many practitioners direct
convalescent patients to
the spring for rest and
complete treatment.
French Lick Springs Hotel Co.
French Lick, lad.
You can buy with Confidence— See "Service Guarantee to Reader?' on page 240
TWiWric«piw«i»»j dn Honest Market Place 229
For Prostatic and
Gonadal Dysfunction
Proito-Orchoid Compound (Mlfata) contains prostate gland, orchic and lymph
glands, with nudein in suitable proportions. The synergistic relations of the prostate
and orchic glands are perhaps more pronounced than that of any other two glands in
the body. Physicians are obtaining the most gratifying results by the use of Prosto-
Orchoid Compound in Impotence, Sexual Neurasthenia, Prostatic Disorders, and Hyper-
trophy of the Prostate with Irritation of the Bladder.
Prosto-Orchoid Compound (Birtoo) is used with marked success in Senility, Chronic
Prostatitis, Prastatorrhea, and after Prostatectomy. It is a most valuable Cenito Urinary
Tonic.
Proato-Orchoid Compound (Ml two) has given remits of so brilliant a nature m Pre-
mature Senility and Impotence, particularly, that many physicians consider It as a specific
in these conditions.
Try it in your stubborn an—.
Package* of 100 ubtcti in sanitary glaii vials. 13.50
"'"■"" 'Bn"i"ZliJr%'L?£ The Mayson Laboratory
, etc., frtt. S 3. Waewk Avon* CHICAGO, ILLINOIS
ftclrd Piuriglandl
Creo-Tus&in in Whooping Cough
IF YOU ONLY KNEW the excellent results physicians are getting from
the use of Creo-Tussin in whooping cough you would not be without it for,
as one physician stated, "good results are evident the first night."
Physicians who are unfamiliar with Creo-Tussin are
requested to write us for sample and literature. Please
use attached coupon.
The Haltbie Chemical Company, Newark, New Jersey
-^ f—f , ._--- — -Cut Here and Mall Today_„___
\*TGOm M tiSStn J THE MALTBIE CHEMICAL CO.. Newark, N. J.
is a palatable solution of creosote, .
gelsemium, paasiflora, verba santa. Please mall sample Creo-TuMln to
menthol and aromatic*. Conveniently •
put up in 2 oz. bottles with blank la- ' K_ D_
bels for directions, each bottle in '
plain carton. ■
Mentioning The American Physician Insures Prompt, Careful Servic.
230
Helpful Points
[Philo., March, 1922
Specialties for
Tonsillitis
Benzomint
INTERNAL REMEDY
Compound of Sodium
Benzoate with Alka-
loids of Calisaya
A TIME-TESTED, highly
therapeutic formula which
has proved a veritable
wonder worker in many thou-
sands of cases of Tonsillitis.
Benzomint has pronounced anti-
septic and antipyretic properties.
It soothes instantly the intense
pain from swollen, inflamed
glands, and quickly counteracts
both local and systemic infection.
Glycodin
(GARGLE)
AN efficacious astringent
and antiseptic gargle of
great value in the treat-
ment of Tonsillitis.
Pint, $1.00; Five Pints, $430;
Gallon, $6.00. Either preparation.
Send for sample* and literature
THROAT SPECIALTIES
LABORATORIES
(MILBURN PHARMACAL CO., INC.)
BALDWIN, L. 1. NEW YORK
McKesson A Robbins
Wholesale Distributors
New York City
Invariably the Beat Method
Success in desperate cases — success in difficult
cases — makes a doctor's reputation.
If you have cases of spinal injury or spinal dis-
ease in your practice, and most physicians have, you
will find that the Philo Burt Method of Spinal Cor-
rection invariably accomplishes more and in a shorter
space of time than is possible with other methods.
The company is glad to receive the measurements
from any physician for any of his cases and co-
operate with him, and allow thirty days' trial with
money back if not satisfactory. They have done
this for over twenty years in more than 45,000 cases.
They will send their "Physicians' Portfolio," which
contains facsimile letters from reputable physicians
and surgeons throughout the United States. They
co-operate with the physician and guarantee perfect
fitting of the appliance. Write for interesting litera-
ture. Address: The Philo Burt Co., 115-15 Odd
Fellows' Temple, Jamestown, N. Y.
To Promote Health and Strength of Feet
Prevention of weak, tender feet is one of the notable
benefits that logically result from wearing O'Sullivan's
heels. It is a well-known fact that abnormal conditions
of the foot structures are often brought about by shoes
with hard, rigid heels, and lacking in flexibility. Free
movement of the muscles is prevented, muscular tone
is lost, and sagging of the arch naturally tends to follow.
Recommend O'Sullivan's heels and you will be doing
your patient a good turn.
Congestive Dysmenorrhea
Dr. F. H. Davenport, AB., M.D., Assistant in
Gynecology, Harvard Medical School, in his book on
"Disease of Women" and under the above caption
refers to the treatment of congestive dysmenorrhea
and the use of anodynes. He says, "It is by alt
means wisdom to avoid in these cases, if possible,
all the use of stronger sedatives and anodynes."
In referring to the use of medication in these cases*
Dr. Davenport, in this most excellent work on "Non-
Surgical Gynecology," says: "Hayden's Viburnum.
Compound has seemed to be the most effectual rem-
edy of this class, given in hourly teaspoonful doses
in hot water, for five or six times."
That Hayden's Viburnum Compound is of inesti-
mable value in the treatment of dysmenorrhea, is not
only indicated by its employment by gynecologists
of today, but in the past by no less an authority than
J. Marion Sims, who prescribed it and recommended
its employment.
Hayden's Viburnum Compound is not a narcotic
and contains no habit-forming drugs. It is a prod-
uct of known composition and as a uterine sedative
it holds first place in the opinion of many physi-
cians as not only a dependable therapeutic product,
but a remedy which is safe to administer to their
patients. Given in teaspoonful doses, administered*
in hot water, it will prove most effective.
{Helpful Points continued one leaf over)
MORPHINE
NEW HOME TREATMENT
For all Drag
ft!
yownK. No psio. vcijr Bltto dMconooct.
I lOt IboW Who <MM96. EttCMtC AftMD IOC M ■fc*
DR. QUAYLE'S SANITARIUM
MADISON, OHIO
BOX!
You can buy with Confidence — See "Service Guarantee to Readers'* on page 240
An Honest Market Place
Dilatation and spasticity
A prominent authority of international reputation who hat made a\
study of the therapeutic ralut of Liquid Petrolatum tayi that laxatives of all
sorts increase the spasticity of the intestine, whereas liquid petrolatum lubri-
cates and protects the sensitive surface of the spastic bowel, at the tame time
softening the intestinal contents so as to permit passage through the botoet with-
out mechanical i'r
makers of Nujol tried consistencies
ranging from a water-like fluid to
a jelly. The viscosity of Nujol was
fixed upon after exhaustive clinical
test and research and is in accord
with the highest medical opinion.
Sample and authoritative literature
dealing with the general and special
uses of Nujol will be sent gratis.
See coupon below.
NUJOL is especially suitable for
all forms of intestinal constipa-
tion. It is the . achievement of an
organization of fifty years' experience
in the making of similar products.
Nujol is scientifically adapted by both
viscosity and specific gravity to the
physiology of the human intestines.
In determining a viscosity best
adapted to general requirements, the
A Lubricant, not a Laxative
Mentioning The A:
Physician Insures Prompt, Careful Service
232
Helpful Points
[Phita., March, 1922
ma »-t r\ ¥ /"» i I V 17 "VH as"\ A D 1"\ sl"n Inflanunations Respond to Campho-Phcniqw
IflfjUi V^ALf KEiIDUAIxU Campho-i'hen.iiiie has decided germicidal properties
, and is also an antipruritic of more than usual power.
In chronic eczemas, attended by irritations, Campho-
Phenique applied several times daily will give gratifying
relief and help in restoring the skin to a normal state.
Interesting literature and samples will be sent to
American Physician readers, address: Campbo-
Pheniquc Company, St. Louis, Mo.
■ Support Adaptable to Any Case
' The Storm Binder is adaptable to any case where
an abdominal supporter is needed for man, woman
' or child. The Storm Binder is for general support
in visceroptosis, obesity, etc., for special support
in hernia, floating kidney, descent of stomach, etc.;
for post-operative support of incisions in upper, mid-
dle and lower abdomen, and for maternity cases,
__ relieving the nausea and discomforts of pregnancy.
_..„ . — -- - . c -,_, , Illustrated folder showing support for different
TYPEWRITER SENSATION uEfSvSS, conditions will be sent to American Physician read-
aiter trial sand iu only I6.M » month until the tow uut prio* of crs. Address: Katherine L, Storm, M.D., 1701
wrtil«£!u wwrTtaTon^w.CS'.nsn** WaS***! Diamond Street, Philadelphia.
mlnMm whan you oan pay fb.00 ■ month, and own one. Think of
it— Buying . iioo.M Machine for »».sa. Cub prf« fM.M, jnrt Has Marked Beneficial Action
. litu* mot. tku h^f It. original sri«. Hydroleine in bronchial and pulmonary affections has
L. C. SMITH NO. 5 MeS atm»AW *™ lound effective by many active clinicians. Hydro-
Perfect machines correspondence .He Keyboard of standard nm. leme ralses the P°wcr °' resistance and increases the
iera«l nrcingeme'ni, SB Keya, writing TO chancier*, with four nutrition and functional activity of body cells. It offers
medical characters and apecial paper holders for writing esrda and a permanent, pleasant and practical emulsion of Cod
S"« ■'haT'tha tabu"!™, the two color "ibbon* Wltb MtmoaS llver oil. a valuable energy producer, bloodmaker, tissue
reverse, the bach spacer, ball bearing type ban. ball bearing car- builder and nerve invigorator, and has marked bene-
riage action, ball bearing iblft action, In fact, every late itjl. ficia| acti(m „„ the respiratory tract
th*D«rewmp™te™ oSi" coSe™ 'opera ting book™anV°inatructlona^ Sample and literature will be sent to American
nothing eifrn to buy. Physician readers, address: Century National Chemi-
st". J£^ot..,!;^!?,r i,™ ^.'^"wl i,™ lS!i"S£!»J!3r!f?hSS «»1 Company, 86 Warren Street, New York.
typewriter until you haTa Been it. Wo have aold thousands of toes* ,¥, ,'\ t n , ', , , .
perfect lata stylo machine* at thli bargain price and every on* of (Helpful PotntS continued one leaf OVer.)
theae thouaanda of aatlallod customers had thla beautifnl, stiiotly —
up-to-date machine on fire deya' free trial before deciding to buy it, ... ,-
i?X5?JS£ C! « nVrSuaiff iSTi.°S W. Woodlaum
fjrr.?S',iS.™"Vr™T,T7.".V.T.",.7.t; X? Maternity Home
e.nnot equal tht. Rooderful value anj,.here. £ J/7 A Btrletl, private and elbieal Heme Retreat
SEND NO MONEY toy* Q C2 "™ W fe™»d^ttil™TbtS*SS3
P»,»Y.«rO,a.,NOW ^.Ot) TRIAL W g» |j~gg>-&g»g> „*^<~^
When the typewriter grrlvee deposit with the eipresa agent tt.SB I publicity avoided. Price* reasonable. For
and take the machine for live dan' trial. If you are convinced ,il_ particulars, pricei >lnd terms, address
that It la the heal typewriter you erer taw keep il end send u> ™-> rVOODLAWN. OWEGO, Tioga Co, N. Y.
16.00 a month until our bargain price of |U.B" la paid. If you . . - - , ,.
rf„"r,L'.:S,."V'4,,ri:r»vr,;,r,"^V.T..n~" DOCTOR: Write Us-
This marhlne I. guaranteed Jnal u If ye* pild 1100.00 for it. It ^^t^m^m^mmmmmtmm^m
ia atandard. Over balf a mill on people in and u-Jtheae type- f _| -J!T3«T| *1 ^S
writera and thlnli them Ibe beet crer manufactured. The supply at 13 ifilM ■ V I a V 40
this price ii limited, the price will probably be raised when neat l*YllssWsak-fllh-----W^l-4
advertlsemmt appe.ra. ao don't delay. Fill Is the coupon to-day— hiPi Thigh or Leg Set. BpUnti Raited Ready to Apply,
the typewriter will be ahlpped promptly, There 1> no red tape. Patienta pay (35 00 for 1 months or less. Your treatment
rim ™Piinde™too0d'''th0r,— "° ™"*'",™*— 1"> rl"'l'»1 mortgage. It It with the AMBULATORY PNEUMATIC SPLINT, in or out
I89.8S li paid. Ton cannot lose. Yon will perhapa never have health'in the tout pmalble time.' ToonleT. State n at
a erester typewriter opportunity. Do not Bend ua on* oent. Oat patient; fincture: nhich limb; length perineum
the oounee in the mallt to-day— aura. to heel; cireumfereuce of cheat; hlpa; and thigh
SMITH TYPEWRITER SALES CO. " perineum. Wire and mail ordere ezprwed
Dwpt. 180. 218 N. Well* St, Chicago 2" receipt, adjusted to Et with complete dirac-
__________ _'__■" _ _ _ _ Hon* for application. Specify our Splint and oni
Smith Typewriter Bales Co., TMpt IU, ais K Wells St Chicago AMnUMATIC WASHABL1! ABDOMINAL
If 1 ehooae m>t to keep it I will carefiilli renarlt it amT retnra Hsnda. Arma. Lega. Extension Shoes. Surg-icsl"
It to the express agent. It I. nnrtemtood that yon irlve the stand. Corsets. Crutches, Invslid Wlieel Chairs and
art guarantee. " 7™ ■"* "" ""'" Supplies. Write For Measurement Blanks and Illu.trsttd
_._. Cireolars. Superior Co-operative Service. Highest Quality
"■m* Prompt Delivery and Right prices, GUARANTEED.
«r**t Address AMBULATOKT PNEUMATIC SPLUfT MFG. CO.
City Stat* JO (C1 E. Haasol** St, CHICAGO.
You can buy with Confidence— See "Service Guarantee to Readers" on page 240
The American pbytieii
The American Physician
ORGANO THERAPEUTIC
SUGGESTIONS
creaaing the amount and
quality of toe milk, and
consequently, bettering
the nutrition of the in-
fant aa well at the invo-
lution of the uteiua,
PLACENTO-
MAMMARY CO.
(Harrowet) — List No. 3
— ia of decisive value.
Prescribe 2. q.i.d. with
food for 2 week>: then
I at meal..
"The Strangest Disease"
Spratling calls epilepsy "the strangest disease in
human history." The very name carries \yith it the
same heart-sickening fear that leprosy and tubercu-
losis do. Epilepsy is not only "the strangest disease,"
but it has been said that there is no older clinical
entity in the history of medicine.
But real idiopathic epilepsy is being cured by many physi-
cians— not with the bromides or other sedatives, which are
only makeshifts— but with ORGANOTHERAPY. Give
ANTERaPITUITARY CO.
(HARROWER)
a trial in several of your cases of epilepsy. You may get
the same gratifying results that other physicians are get-
ting. Further, such organotherapy also has decisive diag-
nostic value.
THE HARROWER LABORATORY
Heme Office: Be. U, Clenaele, Calif.
Portland, On., *07 Pit tack Block
>a. City, Ne. Til K. C Ufa Bide!
»1 Savin*-* Bank Bide.
Delia*, lMsy, Commerce St.
The Fat-Soluble Vitamin "A"
and Alkaloids
or active principles of Cod Liver Oil
are presented in a palatable form in
MORRHUOL and
MORRHUOL CREOSOTE
Prescribed for over thirty years
with gratifying results in the
so-called "deficiency diseases"
Recent studies on the Vitamin e have con-
firmed previous clinical evidence and have
definitely established the therapeutic value
of these Chapoteaut preparations in the
T. B„ Riclwte «od Bronchial
Catarrh
Prescribe in original vials
Literature and samples on request to
E. FOUGERA & CO., Inc.
90-82 Beahman Street Naw York
oil put
It £««
irtleed. ■
r bean ma
have be.
USOLINE an the fir.t ml
an the market la thii coun
Bever been extenelvely adv
•ncferaUd claim, have n*v>
■or It. therefore phyalejaai
■ taadily end lncrea.in«ly p
for internal um year by year
Wa aeain preaant to yon USOLINE a
u.hi,h Vrfined l0O% '"■Ported Ruaale
Miaaral Oil, with properly adju.tad erav
iijSjsssj, -raa s sss
opinion of eight lead-
S clinician. i favored Imported Ro.al.n
I0e> Journal. VoL 64. p.
'" -Il7 J?' '"'' * * "' *""* <f VSOUNB
roM
OIL PRODUCTS CO., Inc.
10 Union Square, New York, N. Y.
Mentioning The American Physician Insures Prompt, Careful Servic<
234
Helpful Points
[ Phil*.. March, 191
Inflammation of Respiratory Tract
of the respiratory tract and the beneficent results it
has yielded, is well known to the medical profession.
Calcreose, a loose chemical combination of approxi-
mately equal parts of creosote and lime, has creosote
action, but does not cause any untoward effect on the
ga st ro- intestinal tract.
Samples and literature will be sent free to American
Physician readers, address: The Maltbie Chemical
Company, Newark, N. J.
menopause and its phenomena, including hallucinations,
hot flushes, etc., nervous and menstrual derangements
and the troubles of adolescent girls.
Formula and sample will be sent to American Phy-
sician readers on request. Address: The Vibunw
Company, 116 Maiden Lane. New York.
In Uterine Troubles
Viburno is an anticongestive, with calmative and cor-
rective action on the bladder, and is employed with much
satisfaction in ovarian congestion and congestive dys-
menorrhea, weak pregnancy and deficient lactation,
Has Blood- Building and Restorative Power*
In post-febrile anemia and convalescence from acute
illness, where hematinic reconstructive treatment is in-
dicated, many physicians are finding Hemaboloids espe-
cially adapted. Try this in your next case and ante
improvement.
Samples and literature will be sent to American Phy-
sician readers on request, address : The Palisade Man-
ufacturing Company, Yonkers, N. Y.
(Helpful Points continued one leaf over)
Increase
Your
Income
Uiuurpautd In vntarapto.
tag kidney and poat-optnti
drtftiiiB on tba .nl.r plaxiu.
The Nnr
Abdominal-U
Supporter
(WuMIt)
UM up. WuhabU; nry
"NEVERSSLIP"
I Full supply for thirty cases at only a nickel each. Send us $1.50
llllllt and will ship at once prepaid.
HUSTON BROS. CO. Atlas American Bldg., Chicago
Recommend
Marvel Whirling Spray
MARVEL COMPANY
25 W. 4StJi Street New York
TALROCOL COMPOUND TABLETS
THE PAUL PLESSNER CO.
You can buy with Confidence — See "Service Guarantee to Readers" on page 240
The Ameriun physid.n] 7"fte American Physician
100% True Gadus Morrhuae
There are many grades but only one best
The therapeutic efficiency of cod-liver oil depends
largely upon its purity and palatability — its freedom
from admixture with inferior, carelessly made oils.
Cod-liver oil must be made right from the start
and kept right to assure maximum efficiency.
The "S. &B. PROCESS"
Clear Norwegian (Lofoten) Cod-liver Oil
is made right and stays right It is the culmination of
half a century of purpose to excel. It is guarai teed 100%
pure oil of true Lofoten Gada* Morrhuae
It is the efficient oil for the efficient physician.
SiochmJ by mo*t Liberal nunpfa will
B OraggUtM and by bm «n( to any
WhoUsaUrt gtntraKy physician* upon r*quc*t.
SCOTT & BOWNE, BLOOMFIELD, N. J.
Makers of Scott's Emulsion
Sli J
To ALLEVIATE PAIN, to PROMOTE DIURESIS
and to PROTECT the membrane of the urethra, especially
THE POSTERIOR PORTION— these are the important
objects of the treatment of acute cases of Gonorrhea.
The entire urinary tract should be influenced by means
of proper internal medication. Local injections alone will
not be sufficient.
This is the rationale of GONOSAN.
RIEDEL & CO., Inc.
104-114 South Fourth St. Brooklyn, N. Y.
LISTERS DIABETIC FLOUR
s
I
Strictly Starch-free. Produces Bread.
Muffins.Pastry that makes the
distressing features
I
TEs
Grow
Less and
Less ■
Litter, prepared casein Diabetic Flour — self rising. A month*, Mipply of 30 boxes $4.85
LISTER BROS. Inc., 40S Lexington Avenue, New York City
Mentioning The American Physician Inturei Prompt. Careful Service
Hdpful Points
Your Infant
Feeding Problems
Nestle's Milk Food offers the
practitioner a modified cow's
milk — in powdered form —
that is so simple and conveni-
ent in its preparation for use,
that all danger of error or
incidental contamination is re-
duced to a minimum. All that
it requires is the addition of
the requisite amount of water
to a given quantity of the Food,
and boiling for o
NESTLE'S
MILK
FOOD
A liberal supply of samples for professional
use and copies of "The Mother Book" for dis-
tribution to your patients sent on request.
Nestle's Food Company
Nwtlt Building 112M«k« Stent
Help on Constipation
Many physicians have found from experience thai
when you prescribe Liquid Albolene you get results.
Send for "Below the Equator," one of the most
helpful and instructive booklets ever written on the
treatment of constipation. It will be sent to Ambucas
Physician readers on request. Address: McKesson &
Robins, Inc., New York City.
In "Deficiency" Diseases
The fat-soluble vitamin "A" and alkaloids or active
principles of cod liver oil are presented in a palatable
form in Morrhuol and Morrhuol Creosote, prescribed
for over thirty years with gratifying results in the so-
called "deficiency diseases." Recent studies on vio-
mines have confirmed previous clinical evidence of the
therapeutic value of these Chapoteaut preparations in
the routine treatment of T. B., Rickets and Bronchial
Catarrh.
Samples and interesting literature will be sent to
American Physician readers on request, address:
E. Fougera & Co., Inc., 90-92 Beckman Street. New
York.
In Habitual Constipation
Active cathartics or purgatives that produce a water*
stool, do not give good results in habitual constipation.
The digestive secretions are carried off and a period of
constipation follows until the secretions again accnniu-
late and the natural process of digestion and assimila-
tion is resumed.
A mild tonic laxative, such as Cascara Comp. Tablets
(Killgore's) gives the best results. Liberal sample and
formula will be sent to American Physician readers.
Address: Charles Killgore. 82 Fulton Street. New York
(Advertising Standards one leaf over)
A Stand-By in
Uterine Troubles
VIBURNO
(BEACH)
The best evidence of this is the
repeat orders received from physi-
cians and druggists.
Nervine-Tonic and Anticongest-
ive, with calmative and corrective
action on the bladder. Employed
with much satisfaction in ovarian
congestion and congestive dysmenor-
rhea; weak pregnancy and deficient
lactation; menopause and its phe-
nomena, including hallucinations, hot
flushes, etc.; nervous and menstrual
derangements after "flu," and the
troubles of adolescent girls. Sterility
often responds after 2 or 3 bottles if
no lesion exists.
Unlike similar products, VIBURNO
i* palatable and pleasant to take.
Doae: 2 taup. (undiluted) LLd.
before meal*.
Put up in 11 ol bottle*
Sample and Formula an Requat
THE VIBURNO COMPANY
116 Maiden Lans, New York
You can buy with Confidence — See "Service Guarantee to Readers" on page 240
The American Physician)
An Honest Market Place
237
OUNCES OF PREVENTION
The best antiseptic for preserving the integrity of any mucous
membrane is its own normal secretion. The best corrective of mucous
membrane irritation, inflammation, congestion, hypersecretion or
atony is ALKALOL — "the something different that brings results."
Because ALKALOL is physiologically constituted not only to feed
exhausted or depleted cells with needed salts, but also to restore
circulatory and tissue tone, normalize secretory action, ALKALOL
is soothing and healing. As a nasal douche or spray, as a gargle
and mouth wash, ALKALOL is an efficient Prophylactic agent. In
the eye, ear, bladder, urethra, vagina, on the skin, or given internally
ALKALOL is prompt to bring about the success of Nature's efforts
to prevent or overcome disorder or disturbance.
Literature and sample to physicians on request
THE ALKALOL COMPANY
Taunton, Mass.
RHINOL
in All Affections of the Nose and Throat
The Rhinol Company, Inc.,
Dear Sirs:
Permit me to state that we have used Rhinol
at the Quality Hill Sanatorium with several of
our patients that were suffering from Hay fever.
The results were indeed good and pleasing.
Will be glad to have you publish this state-
ment for the benefit of the medical profession.
(Signed) J. S. MASSEY. M.D..
Physician and Surgeon.
Quality Hill Sanatorium,
Monroe, N. C.
July 8, 1921.
The Rhinol Company, Inc.,
Gentlemen:
1 want to inform you that during the last year
I have treated a large number of patients suffer-
ing from Coryza, Chronic Rhinitis, Pharyngitis,
Laryngitis and Hay fever with your Rhinol, and it
gives me great pleasure to state that the results
have been very satisfactory in each instance.
Rhinol is one of my standbys in my practice
and now that I have realized its great therapeu-
tic value in the treatment of the above named
conditions, 1 could not do without it. You may
make any use of this letter in any way you may
desire.
Sincerely yours,
(Signed) CHAS. B. GRAF, M.D.,
Physician and Surgeon.
230 E. 15th St., New York City.
The Rhinol Company, Inc.,
Gentlemen:
Enclosed please find check for three dollars for which send me one complete Rhinol outfit. Yon
have a vry superior preparation, and I was astounded at the quick results produced.
I am very much disappointed that you cannot or will not supply my druggist, Theo. Metcalf
Co., as I would like to prescribe your outfit for some of my patients. I cleared up my own acuta
frontal sinusitis in a few days, then gave it to a hayfever patient who has been more relieved than
by anything she has ever used. I dread being without the outfit for fear I may have another attack
or sinusitis. Hoping for an outfit by return mail, I am, gratefully yours,
(Signed) JACOB D. SNYDER, M.D.
542 Boy Is ton St., Boston, Mass.
Price Complete, $3.00 — Refilled Packages, $2.50
RHINOL COMPANY, Inc. 1416 Broadway, New York
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
[Phil*., Mircb. ]«2
THE STORM BINDER
AND ABDOMINAL SUPPORTER
_..rr needed lot
THE STORM BINDER IS FOR GENERAL
SUPPORT IN VUeMWtada. Obesity etc., etc.
THE STORM BINDER IS FOR SPECIAL
SUPPORT in hernia. Hotting kidney, descent of
""THE STORM HINDER IS FOR POST-
OPERATIVE SUPPORT of Inebrious in upper,
Middle and lower abdomen.
THE STORM BINDER IS FOR MATERNITY
CASES, relieving the nausea and discomfort! of
Aak for Illustrated folder.
Orders filled In Philadelphia only— in 24 boon
and tent by parcel post.
These Advertising Paget are am
Hohest Market -Puce
4 Cmmmimt FW. Wktrt Ym. C D«l Wat C— tdeaec a-aia-
faniocwr- naiaiercial. •riaditc, amnt-l&M I" at —J iJafe
We W,«. om ri|*( W « -«fi™l .maof aAeraw is Had
Our Advertising Standards
Advertisements must give honest service to our read-
ers and their patients — is the basic principle for these
standards and for the conduct of The A .ericax
Physician's advertising pages.
Our attitude in applying these standards is not one
of narrow technicality hut of practical service —
Advertisements must give honest service I* our read-
ers and their patients.
Advertisements of the following classes are not
acceptable for the pages- of The American Physician:
Fraudulent pharmaceuticals; those making dishonest
claims.
Pharmaceuticals charging excessive price; price not
warranted by content and by trade conditions.
Pharmaceuticals and other mixtures containing nar-
cotics or other habit- inducing drugs in quantities suffi-
cient to promote their repetition on prescription
(chloral -bearing proprietaries, etc.).
Potent pharmaceuticals which justly merit profes-
sional disapproval because of their lay advertising or
manifestly unethical exploitation.
Financial advertisements that claim returns not com-
patible with conservative investment Only conserva-
tive investments are advertised.
Further
Advertising copy is subject to revision by the
editorial staff, .
The American Physician agrees kcarUly with the
principles of the Council on Pharmacy and Chemistry
of the American Medical Association and we exclude
from our advertising pages such pharmaceutical prod-
ucts as they have definitely shown to be unworthy of
professional confidence and the manufacturers of which
have not removed the cause of objection; but we do
not accept such findings as are based on academic data
without due recognition of general clinical experience.
Concerning formulae, The American Physician is
urging pharmaceutical manufacturers to give full thera-
peutic data regarding formula;, stating quantitatively
active medicinal content, in order that physicians may
intelligently prescribe. We do not accept advertising
of secret pharmacueticals.
Bat We ao not Decline ---
Advertising of original drugs, compounds or prorations imi-
tated in current edition, of the (J. S. Pbarmaecpcda or National
Formulary (except habit-in ducinK preparations) ; new P™***
that leem to be honest and valuable, tut wh.eh h*« not been
reported upon by the Council on Pharmacy and Chemistry, «
similar products whose manufacturers have not yet submitted the
of dnigs in admi*
i buy with Confidences — See "Service Guarantee to Readers" on page 240
The American PhyiidmJ
An Honest Market Place
PYRAMIDON
After almoM thirty year* of *ervke rhi* drug (land* est pre-eminent u an
antipyretic, analgetic, anlineuralgic ud aedarive.
Pjrrunidon i> ■upplied in powder form in I o*., 'A lb. and 1 lb. carton* and
in tablet! of 5 grain) in aluminum tube* of 10, and in bottle* of 100 tabled.
Price* to phy*ician* we $1 20 per ounce, 40c per tube of 10 tablet), and
$3.00 per bottle of 100 tablet*.
ORTHOFORM
Utilizable a* a local *ne*thetic for the relief of pain front wound*, burn*,
k ^"V _ ulcer*, excoriation* and all expoted nerve -ending*. Orthoform a uaed a*
"f |us powder in iniufflatioo. at an emuliion, or in tablet form. It it given ii
•tt
:0;
nally for the relief of pain in gaatric ulcer and gaatralgia.
Orthoform i* diapenied in 1 oz. bottle* which id I to the phyncian at $4.50
and in 5 gram vial* at 90c per vial.
ORTHO TROCHES
Are employed for the alleviation of pain and the mollification of irritation
following all operative procedure* on the throat. They dhnolve tlowly,
liiui producing ■ prolonged antithetic effect. They are diapeued in botde*
of 100 tablet* of one-quarter grain each or of one grain each at $1.00 and
$1.75 per bottle, reapec lively.
Liltralurr can bt obtainid front
ftAMETZ lABOMTmiES^
OwTv)mty7v)o Hudstm Street, AU)>&A.
M rationing The American Physician Insures Prompt, Careful Service
240
Helpful Poinh
New Prices on
Merz Santal Comp.
Capsules
DISPENSING PHYSICIANS CAN BUY
OF US DIRECT
10 Minim Elastic Capsules, box of 100
Abo bom •( » ud bona of M
■ Mmim Pedes bottleof 30
1 « " bottle of 600
f « " bottle of 1000
Unsurpassed for happy effect in Urethritis,
Cystitis, Prostatic Troubles, difficult mic-
turition, etc.
PRICES AND SAMPLES UPON APPLICATION
THE MERZ CAPSULE CO.
DETROIT, MICH.
Our Advertising Standards
r fram friciima »•»*]
qualified phjaician who ii seeking ii
pharmacy in place of an eitempo
Product! composed of minor b
touR. provided tbtoe drag* have
hire and are well defined in male
the proprietary form elegant
■ prescription.
taaic remediej in adeoaat*
, real place in aSoatonl knaa-
o both physician
laymen without falie 01
led mineral wateri and
honestly advotujed
or fraudulent Mate-
Service Guarantee to Readers
MB-t-aata-auH wmmm^mae^^ sa K^B^aataaatati
IP YOU HAVE ANY UNSATISFACTORY
DEALING WITH AN ADVERTISER IN THE
AMERICAN PHYSICIAN, WRITE US THE
PARTICULARS AT ONCE.
WE WILL IMMEDIATELY TAKE THE MAT-
TER UP WITH THE ADVERTISER AND SEE
THAT THE ADVERTISER EITHER MAKES
GOOD, OR HIS ADVERTISEMENT IS ELIMI-
NATED FROM THE AMERICAN PHYSICIAN'S
PAGES.
Your Knowledge of
Anatomy
Cost you hun-
dreds of dollars
and months of
intensive study.
But much is for-
gotten after a
few years' prac-
tice.
Your knowl-
edge a little
stale? Regain
it quickly with a
Pilz Anatomical Manikin
l'nrudn *18.00
(including an obstetrical lupplement)
Mala SIS. 00 I Sexlsss S1S.M)
Dr. Minder's Manikin— 20 in. * * in.
Female $3-00 I Sexleaa S2JW
Sent on receipt of N. Y. ebock or C O. D.
Through all dealers.
Free booklet on requeat. Money-back gnar-
Yon can buy with Confidence— See "Service Guarantee to Readers," top of this page
An Honest Market Place
PNEUMO-PHTHYSWE
fa A*>j>a.
Pneumo-Phthysine
The best remedy (Pneumo-Phthysine)
misapplied, may defeat the combined
skill of all who have contributed to its
success. More especially in the treatment
of pneumonia, the un conquered foe of
medical science.
If PNEUMO-PHTHYSINE has failed
you, there is a reason.
How to Apply in PNEUMONIA
Apply ■ tbin layer, thickneaa of tilver doIUi
eheeaecloth, cut to cover front of cheat, incln
rnpra-elamcular apace and reachinR below to ant
eluding the true riba. Dn not beat olaater al
temperature of bodj'.
eilporation of Guaiac
'- Heat plaat--
•ppljinf to cheeaecla
radiator, lamp, etc.
of a,
e property of i
t hastens the
T'hoidinf Tt
Chicago, 111.
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
/Specially marked and a sub;cri,
tl it NOT inlrrdtd far ;
have Joit recently remitted and a bill i
incloaed hare, plena* Ignore it. With a aubecription llat a
lied. Urge ee our a it takea a few doya far a anbacrlprJon to pai
through, he Anally credited and the atancil transferred fro!
The Earth Has Gone Again Around the Sun
Since last we clipped an envelope here. But
we still have the same purpose — to give you the best,
the most valuable medical journal service for use in
your every-day practice it is possible to give.
And we still want that $3.00 for two years (or
$2.00 for one year, if you prefer) — that pays us for
that service and generally makes the wheels go 'round.
And we still want to thank you, most heartily,
Brother, for your usual prompt attention. Here's
the envelope— just slip $3.00 in it, check or bills (we
take ail risk) and send it along.
And here's the best of success to you in your good
C. C. Tayu*.
Sal Hepatica
THE
STANDARD SALINE
LAXATIVE
Brutol-Myen Co.
NEW YORK
GRIFFITH'S CBMPtHIND MIXTURE
of Guaiac, Stillingia, ate
A Powerful Alterative — Competed of Goalee,
<-.■„: — !. pHckly Aah, Turkey Corn, Colehicmn,
Olh ■ ■=3"- e-'f— '— - ■' -' "■■-
lies, Iodide o
b»^»ll°patienu~«ufferin( 17o
Preacrlb
To Physiciani only — we will upon request, aend ■
regular eight ounce bottle ($1.25 aue), for trial, ueea
receipt of 25 cent* for cxprcu charfea.
Griffith's Rheumatic Remedy Compuy
Ntrwburf b, N«w York
'Pond's
Extract
s object of maintaining
lickly ehown by removal
__, _ie reduction of awelling a
■ly reatoration of the injured muscle to
PONDS EXTRACT CO.. HjW York and London
Muscular/
Injuries
l buy with Confidence— See "Service Guarantee to Readers" on page 240
The American Phracun] Atl Hottest M OTI(Ct PlaCC
243
The Management of Infected Wounds
An open wound is always an unknown quantity — until it has healed
sufficiently to remove all danger of infection.
Every physician is familiar with the simple cut or laceration,
which, harmless at first, suddenly takes a "turn for the worse." Every-
thing will be going well at one dressing, and at the very next, a few
hours later, the wound may show a vastly changed appearance. The
margins will be red and angry, the tissues dark and congested, and the
whole wound bathed in an offensive yellowish-gray discharge. Pain and
soreness will be increased, and the patient soon give signs of systemic
absorption. Only the doctor knows the gravity of the situation and the
struggle before him.
Everything depends on the thoroughness and efficiency of the
treatment employed. General supportive measures are necessary, but
it is the local care and treatment that mainly determine the outcome.
Cleansing is all-important, but it is never wise to drench the tissues
by excessive washing or irrigation. To do so is to rob them of the
blood and lymph essential to normal defense and repair — to contribute
directly to the progress of the infectious process. Therefore, while it
is always desirable to clean the wound well, and remove all pus and
detritus, this should never be continued to the point of weakening or
injuring the tissues.
Th« Application off DIOXOGEN — A successful line of pro-
cedure is to wash out a wound with normal salt solution until all
discharge or loose fragments are removed. Then Dioxogen should
be injected into the wound, care being taken to reach every part.
The resulting effervescence means the liberation of pure, active
oxygen, not only the most potent of antiseptics and germicides, but
also the most powerful aid to normal tissue processes. After each
syringeful of Dioxogen the foamy mass should be washed away and
the injection of Dioxogen repeated until the effervescence in the
wound shows marked decrease. While it is usually desirable to
remove the frothy debris that may be left after the use of Dioxogen,
so free is this antiseptic from any toxic or irritating action, that
terminal irrigation after the last injection is seldom necessary.
Indeed, it is usually well not to irrigate the last thing, for any
Dioxogen left in the wound slowly gives off its oxygen, and thus acts
as a stimulant to normal cell functions.
The efficiency of the foregoing treatment is promptly shown by
the marked improvement in every respect — the infectious process is
checked, the discharge decreases, the inflammation subsides, the
tissues take on a clean, healthy appearance, and healing follows
naturally without interruption or delay.
The dependable action of Dioxogen in the treatment of infected
wounds — its control of germ activity and pronounced stimulation of
the normal processes of repair — with complete freedom from any toxic
or untoward effect, have made it the most widely used antiseptic today
in the treatment of infected wounds.
The Oakland Chemical Co.
59 Fourth Ave., New York
Mentioning The American Physician Insures Prompt, Careful Service
LIBERAL DOSAGE— MINIMUM EXPENS
' In iptdalLnng on Bartltiia Bulgirlcua Culture! the 7 c.c. doaea hmd proved off little benefit,
collaboration with eminent mertleal practitioner!, we Actlm on Ihii iclentlnc eonrlualon, we
haw arrlied at the ron»lctlon thit adequate douce worked oot the problem of LIBERAL. DOHA'
li one of the moet Important faciora In the effeotlve M1K1UUM EXPENSE. We hive alwaj-a mainli
application of the Baclllua Bulgarleui to therapeutic and atlll ■leadfaitly maintain, that It la onecle
twice dallr, fare aurprlilnglj rapid reaulca where In Individual, one-doa* bottle*.
THE BIG THREE
(ACTUAL SIZE)
"PINEAPPLE CULTURE. METCH-
• r-ludl rated. Price
"WHBT CULTURE, BACILLEH
BOLGAKICTJS, METCHNIKOIT."
Inaction and aM caeea where i " " ' "
— -■-. Juice medium It not dealred.
Seliiered to paUent'i id-
1, anywhere rut of Mlaala-
llnpl Riser. I2.2B.
All the above products can be obtained at the leading druggists or will be delivert
patients address without extra charge.
Literature and Sample* an Reqti**t
FRANCO-AMERICAN FERMENT COMPANY
225-7 SIXTH AVENUE, NEW YORK
The American Physician
Here's where genuine Atophan is
manufactured by a special process
completely precluding the possibility
of unpleasant empyreumatic admix-
tures
ur1n« L-sboratortoi
This means a still further im-
proved Atophan lor your cases
of Rheumatism, Gout, Neural-
gia, Neuritis, Sciatica, Lumbago
and "Retention" Headaches.
Ample trial quantity and literature
from
Schering & Glatz, Inc.
150-152 Maiden Line New York
AN IDEAL ARSENICAL
SODIUM DIARSENOL
SODIUM ARSPHENAMINE
Sodium Diarsenol marks a distinct advance in syphilology. It dissolves
very quickly in water, giving a solution ready for immediate injection. No
addition of sodium hydroxide is necessary. It has the therapeutic advantage
of arsphenamine with the solubility and convenience of neoarsphenamine,
and gives clinical results equal to or better than either of the two latter com-
pounds. Neutralization with alkali being obviated, there is no undue hand-
ling and consequent decomposition of the highly reactive solution.
SODIUM DIARSENOL has been accepted by the Council on Pharmacy and
Chemistry of the American Medical Association for inclusion in "New and Non-
official Remedies."
Mmoufactured bj Diirienol Laboratoric*
Smmpit* and Littrmtmrm
DIARSENOL COMPANY, Inc.
BUFFALO BOSTON ATLANTA
i buy with Confidence — See "Service Guarantee to Readers" on page 316
An Honest Market Place
]yj ORE people die from pneumonia than
any other disease.
Approximately 25 out of every 100 cases end
fatally. Dr. Gustav Goldman has demon-
strated that at least twenty of these twenty-
five deaths may be prevented by employing
Bacterial Vaccines.
Why delay and chance a fatal termination?
Dr. CiutW Col Jfiun'i article appeared in African Maircin*. March, 1921
B a e t »r lol o gi e* 1 UikiTttttNi »f
G. H. SHERMAN, M. D.
DETROIT. U. 8. A.
>W5*
Or TBI
HOS
d Tonic foi
No. 3. Pubiislttd monthly— Tha Ttytert; C. C. Taylor Publiihtr; Mti. J. J. Taylor, Ed. Mgr. Enlmd
--. Jau matttr Fib. It, ito6, at tkt foit afici at P hilod ilf Ma, Pa., nadir Act o; March 3, /I70. Tin Amiri,
rhttieiam. "Matt Width Circnlotid Uidical IfoniMj," ctmH*%.»a tht OMurtir it.tury of diitincliui arnica
COPYRIGHT IBM. by Tha fay-Ian, Publiihirt; *m W*!*.*. St.. Philodtlphio, V. S. A. ,
The American Physician
rPhrA.ApiB.lKl
Serobacterin
Immunity
Only One
"There la only one concern
thl* whole country which pi
oat a rabbet c*p on their a
"Tnln robber of the beet •
Ity le all that is needed U
(The MetUeo, War-
Is a development of the researches of
Besredka and Metchnikoff, in the Pasteur
Institute, Paris.
Serobacterins are suspension of killed bac-
teria, with their corresponding antibodies.
They produce both passive and active
immunity.
The PctMMive Immunity is conferred im-
mediately by the specific antibodies carried
by the serobacterin and promptly liberated
when injected into the body.
- The Active Immunity follows when tbe
body cells of the patient have responded
to the stimulation of the injected bacteria,
by producing additional antibodies which
replace the antibodies of the serobacterin
and remain for a considerable period.
The MulfOfd vl
St i.r e y loAbjio b a ,-rtm n
Staph VLO-ACNB SBKoii*crour
UN Stbhpto-Bhbobactbxih
rlRisiBx BbbobjICTBkin TypHo4BBOBkcTamin
PuBtrHO-SBHOBACTHfilN T YFB O^EBOB 1 CTEH! W MlUD
Ask for Mttfard Working B«Utin No. 18
H. K. HULFOBD COMPANY. Philadelphia, U. S. A.
You can buy with Confidence— See "Service Guarantee to Rtadtrt" on page 316
TW Aatricn Phrridu]
An Honest Market Place
LOESER'S INTRAVENOUS SOLUTIONS
EVERY
PHYSICIAN
SHOULD
READ
THE JOURNAL
OF
INTRAVENOUS THERAPY
A sixty-four page Journal, containing original articles,
reprints and attracts relative to Intravenous Medica-
tion from foreign and domestic medical journals.
The most comprehensive compilation on the subject,
including laboratory and clinical reports.
Copy mailed on request.
New York Intravenous Laboratory
100 WEST 21ST STREET
NEW YORK, N. Y.
ProJacmt E&ical /ntatOMB
Solution, for At Medial
Profusion Exdumal).
Mtmtiemmg Tk* Amurieam Pkyticia InmrtM Promt*, Cartful Strviet
The American Physician [pwu., April, 1922
You on boy with Confidence— See "Service Guarantee to Reader/' 00 page 316
The American Physician]
An Honest Market Place
251
/
STY PT YS AT E
THE REMEDY FOR HEMORRHAGES
Not Subject to Narcotic Law
The least disappointing remedy in uterine hemorrages. Very often acts
where Ergot and Hydrastis fail. Dose gtts.x-xv. Prescribed in 10 c.c. bottles.
Sold on prescription only.
A Few Short Clinical Report* Will Prove Interesting
W. H. Age 23. Menstruated regularly up to a year ago. Twice then every 10 days —
profuse hemorrhage. After Styptysate, duration and quantity of flow considerably lessened.
T. V. Age 25. Menses erery 3 weeks, very profuse during the last months — Styptysate
reduced the amount of flow to normal quantity.
L. A. Age 28. Menstruated regularly, duration 5 days. However, for the last several
months menses were irregular, and the flow, lasting 8 days, was very profuse. Styptysate
shortened the periods and reduced the flow.
E. T. Age 28. Menstruated first at the age of 14. Menses regularly up to about 10 weeks
ago, when they appeared every 2 week9 — accompanied by severe backache. After the use of
Styptysate the frequency of the periods was lengthened and the action of the drug regarding
the amount of the flow was surprisingly prompt.
A. Sch. Age 24. Menstruated formerly regularly; since 3 years very profuse flow lasting
3 days and appearing every 2 weeks. The hemostatic action of Styptysate manifested itself
after every administration in a surprisingly favorable manner.
A. W. Age 35. Menses appear regularly, but are of long duration, the last having per-
sisted for 3 weeks. Styptysate treatment for 3 days limited the flow to 4 days. Lasting result.
T. M. Age 49. Menses every 4 weeks, but very profuse flow of 8 days' duration. After
Styptysate medication a lasting limitation of the flow to from 3 to 4 days.
In all these cases, in spite of the difference in the ages of the patients, the dis-
turbance apparently was a functional one only, as the gynecological status was
normal, judged from the pathological point of view. However, the excellent results
obtained led Krummacher to employ Styptysate also in pathological conditions. In
particular does he mention a case of myoma, the size of a child's head, in a 43 year
old virgin. Frequent and very profuse hemorrhages — lasting 8 days or longer —
were not influenced by Hydrastis or various Ergot preparations, but were favorably
acted upon by Styptysate, so much so in fact, that the patient herself described the
action of the drug as unbelievable. In this case, Styptysate was given in doses of
gtts. XV t. i. d. and limited the hemorrhage, moderate in amount, to 3 days. It is
of importance to observe that Styptysate does not have any influence upon heart
action or respiration, although it has occasionally been given in massive doses (up
to gtts. XXXV single dose). The gynecologist as well as the obstetrician and
general practitioner will, therefore, find in Styptysate a safe, reliable and active
hemostatic.
Samples and literature on request
INTRODUCTORY OFFER
One-half Dozen Bottles of STYPTYSATE (or $2.50
(Regular Price $3.75)
Fill out, detach and mail the corner coupon with N. Y.
draft for $5.00, and we will send you one dozen bottles
of Styptysate.
Ernst
Co., Inc.
85 W. Broadway,
New York
ERNST BISCHOFF CO., Inc.
85 West Broadway
New York Address.
For $2.50 remittance en-
. closed send one-half dozen
.. bottles of Styptysate as per your
. Introductory Offer.
Name ,,
Mentioning The American Physician Insures Prompt, Careful Service
252
Contents
Copyright, i?**. by Th* Taylor*. AU rights restrvtd.
Editorials
Why Does Cancer Rage and tha People Imagine That
Vain Things Cure? 263
When Is Alcohol a Stimulant? 266
What Is the Matter With Endocrine Therapy? 266
Reviving Janet's Method In the Treatment of Gonor-
rhea 266
Original Articles
Prognosis and Choice of Operations In Cancer of the
Stomach.
By A. Wlese Hammer, M.D 267
Cancer of the stomach usually means death. A very
early operation — seldom possible because the condition
is usually discovered when it is well developed — offers
a dubious chance for a radical cure; but operation at
any time often prolongs life and mitigates suffering.
The various phases of the question involved, the medical
and surgical aspects of this all-vital problem, are deftly
and comprehensively discussed by Dr. Hammer in this
scientific but practical paper.
Is Cancer of Parasitic Origin?
By Albert Schneider, M.D., Ph.D 270
The etiology of cancer is still unsettled, its ravages are
still raging, while some minds still cling to the parasitic
theory of the origin of malignant growths. Just as
every man is entitled to his opinion, so is every physi-
cian entitled to the light shed by such opinion. The
paper of Dr. Schneider has aptly presented the pros and
cons on the subject under consideration. Read it and
draw your own conclusions.
Chronic Leg Ulcer — Determine Causative Factor Be-
fore Treatment.
By C. J. Broeman, M.D 272
The genesis of leg ulcers is as uncertain as repellmt,
and is indeed unyielding to corrective measures. Here
the best efforts of the best brains often fail Verily,
how are you going to treat the obstinate sore unless
you know that the causative factor is varicose veins,
tuberculosis, diabetes, phlebitis, trauma, or syphilis-
influenced additionally perhaps by elements such as age.
sex, occupation, constitutional or social environments?
This multi-phased subject is admirably discussed in
Dr. Broeman's paper.
The Acute Abdomen an Immediate Problem.
By Samuel Floersheim. M.D 275
An acute abdomen has sent many a patient to the grave.
An acute abdomen requires immediate attention. You
have no time to study an acute abdomen; you cannot
wait, you must act. To know what to expect, what to
anticipate, what to look for when called upon to treat
this condition, you will find Dr. Floersheim's paper,
which aptly reviews this vital subject, authoritative and
very helpful.
Habits Which Lead to Constipation.
By A. W. Herr, M.D 277
Ever since the human quadruped became a biped, con-
stipation became a product and a problem of civiliza-
tion. Whether this abnormality is due to the super-
imposition upon one another of the * body viscera*
"originally" intended to be hanging freely from the
posterior aspect of the body, as we believe, or is due to
the several factors enumerated in this splendid and
instructive paper, or both, is a question worthy of the
physician's consideration. At any rate. Dr. Herr pre-
sents a delightful paper which we are sure you will
enjoy.
(Content* continumd on pagm 254)
Chinosol
"A POWERFUL ANTISEPTIC. SOMEWHAT STRONGER IN
THIS RESPECT THAN MERCURIC CHLORIDE AND CONSID-
ERABLY STRONGER THAN PHENOL."
(COUNCIL ON PHARM. AND CHEM. A. M. A.>
AseptikonS0
producing complete
But
VAGINAL \
SUPPOSITORIES/
ANTISEPSIS
Non-poisonous, Non-irritating and No injury to membranes
Indicated in cervicitis, leucorrhea,
specific and non-specific vulvo-vaginitis, in all cases
where complete vaginal antisepsis is desired.
PARMELE PHARMACAL CO., 47-49 WEST STREET. NEW YORK.
You can buy with Confidence— See "Service Guarantee to Readers" on page 316
The American Physician]
An Honest Market Place
253
A new authoritative
book on yeast
Written by a physician for physicians, this
brochure discusses the manufacture, phys-
iology, chemistry and therapy of yeast.
Ihe growing interest in yeast
as a therapeutic agent has made
it essential that physicians
should have at their disposal
some book of reference which
will summarize in an authorita-
tive way the present known
facts about yeast.
This information, so neces-
sary for the busy practitioner,
has been ably brought together
in a book entitled "The food
value, therapeutic value, man-
ufacture, physiology and chem-
istry of yeast, also a symposium
on vitamins. "
The chapter headings speak for the variety to
be found in this treatise. These headings are:
What is yeast ?
The manufacture of yeast
Yeast Therapy
When and how to take yeast
Care and properties of a yeast cake
Boils, Furunculosis, Carbuncles, Acne
Constipation
General Debility
Arthritis and Rheumatoid Conditions
The vitamins
Yeast vitamin B
The vitamin C
The vitamin A
Fermentation and Enzymes
The value of yeast as food
J.HE FLEISCHMANN COMPANY
take great pleasure in announc-
ing the publication of this book.
They will be glad to send free of
charge a copy of this book to
any physiological chemist, hos-
pital or physician who will
write to The Fleischmann Com-
pany, Dept. S-4, 701 Wash-
ington St., New York, N. Y.
Mentioning The American Physician Insures Prompt, Careful Service
The American Physician
A campaign of education — No. 4
The Grinding
Surfaces
are more susceptible to
decay.
DURING the pe-
riod between
childhood and
adolescence the most
important part of the
teeth to be cleaned is
the grinding surface.
Because the corru-
gated nature of the
enamel is most suscep-
tible to decay. Clean-
liness of the grinding
surface is of the ut-
most importance.
ANTI-PYO
Dental Cream
contains vegetable soap
which forms a fine lather
and quickly mien all the
finest interstices, lti germ-
icidal propertiei are moat
. . effective in combating
typhoid bacteria which
cannot live in soap lather.
The Anlidolor
Mfg. Co.
32 Mala St.,
Sprtntville, N. Y.
MAIL THIS COUPON_TOpAY
ANT1DOLOR MFC. CO..
32 Main St, Springville. N. Y.
On receipt of voui professional card we will tend
you tpec-el tample tubes of Di- R. B. Waite'i
ANTI-PY-O Dental C.eam. including a full
siie lube lor youi personal use,
NAME . ...
ADDRESS
CITY.. -
C,Ont€TltS ™,//n,W/m™ pare 252
The Universally Abuser* Drug-
By A. D. Helnetuunn, M.D., Ph.D 279
Ami) salicylic ncid, aspirin, in the universally abused
drug. Of this the. layman Is woefully guilty, though
Ihe physician as well contributes his share to the pro-
miscuity with which this drug— eicel lent in Its place-
Is so carelessly employed. A drug of sucb eiteuslve
utilKatloo is certainly worth knowing, hence Dr. Helne-
mann's paper, we are confident, will be widely read. Do
not miss It.
Diet In Typhoid.
By T. 3. Stoctard. M.D 2*0
A Case of Injury at the Elbow Joint. Twenty-fifth
By A. MacKenzie Forbes. M.D 281
Footlights on the Feet or Puncta Dolorosa Perils.
By Charles Cross, M.D , 264
A helpful, graphic chart for anatomic review of the most
troublesome points of the feet.
Recovery from Tetanus (Report of a Case).
By John T. Moss, M.D 2tS
Acromegaly and Lymphatic leukemia — Review of Lit-
By Hymen I. Goldstein. M.D 2M
Efficient Future of Medical P. actice
Some Factors In Success That Are Often Forgotten. ..2*0
Principles of Medical Treatment 2M
Book Review
The Blood Supply to tha Heart In Ita Anatomical and
Clinical Aspect* SOS
Essentials of Laboratory Diagnosis 300
Autoerotlc Phenomena In Adolescence 300
Money Back Guarantee to Subscribers
really helpful in the problems of everyday pru
.u yamole and prated the apponunititi and interest* oi tat
.general practitioner in retry possible way; and, if IWj mark be
i mil done, to be financially serf -supporting and to earn a reason-:
I * It n completely fret from any outside influence, of either -*#-'
, connection or entanglement in flay way with either,
j If any subscriber, at any time, feels that Taa Aauicu
| running over") of such service, or is dissatisfied for any reus*.:
if he will write us we will cheerfnlly refnnd, without question,
the money he paid for the >nri subscription, even if he at
inly satisfied, interested
Sabmcription Continaanct
Prac
tally all of our subscribers, as a matter
of con
venienee,'
up fly
d-'n. %
advance, unless, of course, paid a
cad t
r longer
not the subscriber's desire, il is
carefully nalii.
'pnn'r
cceipt ol
free co
pirs oi
ak Physician does nn distribute s
any kind.
Sabicription Price
"'"
copies oi .
Fifty
$1.00
Domestic postage— U* 5™and po
Addr
ommunicariani and make ell fund
*"
Walnut Slrerl, Philadelphia, U. S
A.
You can buy with Confidences — See "Service Guarantee to Readers" on page 316
An Honest Market Place
Hay Fever Memoranda
Early Spring Type. Patients whose hay (ever develops in late March,
April, or beginning of May, should be tested with pollens of early flowering
trees, as: — Poplar, birch, maple, willow, walnut and oak, which pollinate
in the order named.
Late Spring Type. Patients whose hay fever develops in the latter part
of May, during June or early July, should be tested with the pollens of
sweet vernal grass, June grass, orchard grass, timothy and red top. The
one giving the major reaction should be selected for treatment to the
group. The unrelated rose pollinates simultaneously and is the primary
or secondary cause in an occasional case— hence, should be included in
tests, especially where direct exposure exists. The same is true of dandelion,
daisy and in some sections alfalfa.
ARLCO - POLLEN EXTRACTS
For Cutaneous Tests and Treatment cover early and late spring,
also summer and a
1 fill of pollew on request.
THE ARLINGTON CHEMICAL COMPANY
Yonkers, New York
BLAUDULES
Corresponding to Pills of Ferrous
Carbonate (Blaud'* Pill.) U.S.P.
— not a new iron compound
— just the old reliable mass of ferrous carbonate
— but always fresh and permanent
Each Blaudule represents 5 grains of fresh, active ferrous carbonate mass
made up with an oily excipient and enclosed in a soft gelatine capsule with
exclusion of air thus preventing oxidation and assuring for the patient a
full unco n laminated dose of
ferrous iron.
Prescribe Blaudules if you want
permanently fresh Ferrous Car-
bonate.
Your druggist has them
in stock.
m founded 1«1
ERRELLcohpant
•«■* Cisdi»u,u.S.A.
Uentiontng The American Physician Insures Prompt, Careful Service
The American Physician
[PhD»., April, 1921
e containing
... .~«o_ u.euuuu wmuiiiauuii, ajjiJiujuiniLci/ equal weights
of creosote and lime.
CALCREOSE differs from creosote in that it does not have
any untoward effect on the stomach; hence patients do not
object to its administration.
Price: — Powder, lb., $3.00. (Prepared by adding 1 lb. to 1 gallon of
water.) Tableti: 4 gr.. 1000. $3.00; 500, $1.60; 100, 40c.
Samplu (tableti) and literature free.
THE MALTBIE CHEMICAL CO. Newark, N.J.
Nervous Conditions
are invariably aggravated by the irritation that essentially
accrues from the repeated impacts of leather heeU on hard,
unyielding floors and surfaces. Happily it is easy to obvi-
ate this continual pounding, with its cumulative depressing
effects on the nervous system, by wearing
O'Sullivan's Heels
So pronounced are the resulting benefits, that the use of
O'Sullivan's Heels has become with many physicians a
fundamental detail in the care of the nervous patient The
relief of jarring not only adds much to the patient's com-
fort and well-being, but the marked relaxation of nerve-ten-
sion that follows often proves an important factor in assur-
ing a prompt and satisfactory recovery. O'Sullivan's Heels
are a boon to the neurasthenic patient.
O-SULLIVAN RUBBER CO., Inc., New Yoifc
■» ™*h rnnCilMW
vice. Guaranty
[The American Physician
An Honest Market Place
257
DIATUSSIN
One of die moat efficacious and best known remedies
FOR
ASTHMA, BRONCHITIS AND WHOOPING COUGH
For children or adults. Sold on prescription only
A FEW CASE REPORTS OF INTEREST
"Some time ago I received a sample bottle of Diatussin which you sent me at my request, for clinical
test. I at once put the Diatussin to work in my three cases of whooping cough, with immediate and
gratifying results. All three cases showed marked improvement from the very beginning of the treatment
with Diatussin, the paroxysms being diminished both in tensity and frequency. I shall be pleased to use
Diatussin in all cases of Pertussis in the future. You have my permission to use this letter in any
way you may see fit." — IV. C. Wohcrton, M.D., Linton, N. I).
"As to the value of Diatussin — you can quote me if you choose — it positively relieves and comes
as near a specific as I would wish in whooping cough"— Dr. $. Kahnt Detroit, Mich.
"I take pleasure in saying that while I have had the opportunity to test the drug in only two cases
of whooping cough, the results in both cases were so gratifying that 1 will undoubtedly prescribe the
drug in future cases. From the limited experience I have had with it, I regard it of extreme value in
allaying the cough and paroxysms of this stubborn disease." — Dr. B. R., Brooklyn, N. Y.
"I hereby report to you the following three cases of whooping cough and the successfulness of Diatussin:
"a. Child of I. C, 7 months old, 99 Bay 34th St., Brooklyn, % to 1 drop twice, daily and relieved
in a week and cured in about 4 weeks.
"b. Two children of Q. M.. 980 Prospect Ave., Bronx, 4 and 5 years of age. Paroxysms relieved
and recovering rapidly. (1 to 2 drops morning and evening)
"c Child of Dr. I. T., Dentist, 2 West 119th St., N. Y. C, 18 months of age, paroxysms relieved
and recovering rapidly. (One drop twice daily.) — L. C, M.D., N. Y. C.
"As I have been so well pleased with the results obtained from Diatussin in the case of a little girl,
will give you a brief history. F. H., female, 7 years, 3 weeks after developing whooping cough was
brought to me for treatment. At that time she was suffering from 20-30 paroxysms in 24 hours, vomiting
and loss of weight and sleep. I put the child on antipyrine and bromides, the paroxysms increased in
number and severity. The lungs on ausculation revealed rales over the upper portion. I placed the
patient upon one drop of the new remedy for whooping cough, 'Diatussin' night and morning and in three
days the paroxysms were reduced to 2-4 in 24 hours and less severe, vomiting decreased and the child
slept all night. The dose was then increased to 2 drops night and morning, then 3 drops with the result
that at the end of two weeks from the time the first dose of Diatussin was given, the mother stated that
the child had improved to the extent that she considered her cured. I wish to give Diatussin a thorough
trial and if it proves to be as serviceable in my future cases as the one mentioned above, I assure you
it will be a very valuable preparation to me." — Dr. E. H. C, Johnstown, Ohio.
Child D., 6 years, well developed boy, suffering from annoying cough, especially during the night.
General condition good, lungs normal, no whooping cough. After taking Diatussin 3 gtts. t.i.d. for 3 days,
cough disappeared completely.
Mrs. K., 38 years, always healthy up to some time ago, when she began to suffer from persistent
spasmodic coughs, which became particularly aggravated at night on retiring. Codein and Paracodein
gave only temporary relief. Examination of the lungs revealed no pathological lesion. Diatussin in doses
of gtts. V-VI in the evening eliminated the night attacks for a long time.
Mrs. H., 71 years, well preserved, healthy respiratory organs, suffered attack of influenza. No
pulmonary catarrhal symptoms, but severe attacks of spasmodic cough, day and night. Only temporary
relief obtained by Codein, etc. Diatussin gtts. IV t.i.d. eliminated the spasmodic character of the cough
during the day and permitted undisturbed rest during the night.
a-;<s"v
Samples and Literature On Request
ERNST BISCHOFF CO., INC.
85 WEST BROADWAY, NEW YORK
Mentioning The American Physician Insures Prompt, Careful Service
The American Physician
[Pliila., April, 1921
ENDOQUIN
END05AL
le&det.lal-cylJtU.Cck/lic'im
ENDO-SODIUM IODIDE
V&w^i. AC*
ENDOMETHYLENAMIN
Ibgrtms HaaiKtfy/eKnfnt
ENDOQLOBIN
(Chlorcii.Ptrnk.oujA^II.,*)
Hatcwg/etia
ENDOCAOPIN
toJthe
Intravenous
Method
Intravenous medication has
long since passed the experi-
mental stage. The favorable
attestations of thousands of
reliable physicians are unani-
mous in their endorsements of
this method of remedial treat-
At the hands of our chem-
ists, specialists in research, our
products are prepared with the
utmost care, skill and acumen.
Their purity challenges com-
parison.
Formulae of our specialties,
reprints of interesting articles
and price lists cheerfully fur-
nished to physicians on re-
quest.
. ENDOARSAN
, ENDOCR.EOD1N
T^ha felfowioi frramtiiB tee
I W h it ustd htrmrtmljf
GUIOLEUM
(fyr loco/ l£t On/y) .
GLYCO-ASEPTIC
Bfl-mx (fir *,lv*4 «*•*&)
You can buy with Confidence — See "Service Guarantee to Readers" on page 316
The American Physician]
An Honest Market Place
259
v»
Colds, Sore Throats, Coughs
and so-called "Flu " or "Grippe
»
Yield to These Remedies
Check the cold with
Calcidin, Abbott
Before it becomes pneumonia
Control the cough with
Anesthesin-Calcidin Troches
Affords immediate relief in irritated throat conditions
Relieve sore-throat with
Aromatic Chlorazene Powder
Makes the most effective antiseptic gargle
Aneskreme
The soothing, healing nasal
cream, gives instant relief.
Anespray
The analgesic oil-spray for
inflamed mucous surfaces.
PREVENT THE SPREAD OF INFECTION WITH
CHLORAZENE
The Dakin water-soluble antiseptic in handy tablet form
"Clean Out" With Abbott's Saline Laxative
These and other success-making remedies may be obtained through your druggist or
direct from the home office or branches of
THE ABBOTT LABORATORIES
3 IE. 17th St.
New York
DEPT. 49, 4739 RAVENSWOOD AVENUE, CHICAGO
227 Central Bid*. 559 Mission St. 634 I. W. HeHman Bid*.
Seattle San Francisco Los Angeles
Toronte, Canada Bombay, India
1
Mentioning The American Physician Insures Prompt, Careful Service
The American Physician
[PhUa., April, 1922
The Neutral SaluyKe
Esttr of Santalel
SANTYL
ntEAT
for the INTERNAL TREATMENT of
Odori— a. No Eructations
Frao front irritant i
Date: J eapaulea J or 4 tin
Litttnlmrt ami MMfJd
E. BILnUBER, be, 45 John St,
Digitan (Digipuratum)
Physiologically Standardized Digitamioids
This product, first introduced ■■ Digipuratum. is manufactured under license from the
Federal Trade Commimion and accurately standardized according to the original testa.
RAPID AND RELIABLE IN ACTION UNIFORM IN STRENGTH
Powder: In rial* of li oi- Information on request
orais0i«tio.i:*^.T.'o1Ji2 cc. MERCK & CO., New York
I(gcrUR)1
There h Mineral Oil —
And Then There Is Liquid Albolene
EVERY practitioner of medi
cine appreciates the superio
value of a mineral oil that can b
absolutely depended upon t
aughly remove adherent fecal mi
ter from me intestinal wells.
Such an oil can be relied up
implicitly for all medical uses, a
for a prcptialur in surgical opei
The Russian Mineral Oil has
powers of "mix. spread and pene-
tration", that are absolutely unique,
ll is incomparably the best of all
mineral oils for these purposes.
This explains the dc
results you may
Min.
.1 Oil.
the depend
onfidenlly ei
Liquid Albolene facilitates ex-
pulsion, overcoming auto-intoxica-
tion and the disturbed metabolism
Remember that Sir Arbumnol
Lane's experiments, which defi-
nitely establish the value of min-
eral oil as a laxative, were made
with Russian mineral oil.
Send for "Below the Equator",
one of the most helpful and in-
Brructive booklets ever written on
McKESSON & ROBBINS
91 Fulton Street
New York City
You can buy with Confidence — See "Service Guarantee to Readers" oa page 316
An Honest Market Place
INTRAVENOUS . Usu.1 do* 0.1 (run. runted every 2 or 3 dmy for 10 or II iota.
INTRAMUSCULAR i Uauil doHOJ»tnm.rcmtedemr4or5<liri forlOor lZdoui.
Count! of Mercuroral rnjccrkni ibould be iJleruttd irlih. ■npfaenuninc tKatmenu.
A Dependable Antiluetic
m
/HEN spirochetes become arsenic-fast— tolerant of arsenic so
that, temporarily at least, no further impression can be made
on them with Salvarsan or its derivatives— mercury becomes the
sheet-anchor of antisyphilitic treatment.
In the short time since our Chemical Research Department devel-
oped Mercurosal, trustworthy evidence has accumulated to justify
the conviction that this new synthetic compound is a dependable
antiluetic, well adapted for administration by the intravenous or by
the intramuscular route.
Clinical improvement following Mercurosal injections has been
observed to come rapidly. In many cases, too, the sudden dis-
appearance of a seemingly persistent V/assermann reaction has been
clearly attributable to the Mercurosal treatment.
Parke, Davis & Company
NEW LITERATURE
just off the press; gladly sent to physicians on request.
Mercurosal Reprints Glniid Therapy Booklet on Biological Products
Mentioning The American Physician Insures Prompt, Careful Service
52 The American Physician ma*. April, i«a
THE CRITICAL AGE
The menopause is not due simply to insufficiency of the genital
glands, but is the expression of an "endocrine crisis" complex,
varying in different persons, of which the said insufficiency of the
genital glands is the central factor, but, with it, other glandular
disturbances play an essential part. — Maranon.
The menopause, therefore,
is a functional plurigland-
ular derangement and is
best treated by plurigland-
ular therapy.
In hypotensive cases use
Hormotone
and in high blood pressure
cases
Hormotone Without
Post-Pituitary
Dose: — One or two tab-
lets three times daily be-
fore meals.
G. W. CARNRICK CO.
419 Canal Street New York, U. S. A.
You can buy with Confidence— Sec "Service Guarantee to Readers" on page 316
The A
mencan
VmL 27
April, 1922
N*. 4
Why Does Cancer Rage
And the People Imagine That Vain Things Cure?
PLAIN TALK is needed in the cancer menace,
for the fact that it has become a menace to pub-
lic health may not be gainsaid, despite the work of
commissions, research foundations and special soci-
eties. We say plain talk is needed in the cancer
menace, even though the sentence is a bit awkward,
because this article is addressed to physicians who
are actually in the cancer fight. We approach the
cancer problem too often by indirection, viewing it
sociologically, anthropologically and every other way,
talking at the subject, or about it, devising cam-
paigns and calling congresses, whereas it is a fight,
a scavenger job, and a human clean-up work that
demands rolled-up sleeves on the part of actual
workers, not talk by theorists.
We do not know the cause or causes of the more
serious types of neoplasms; and we knew little
about the causes of malaria until after physicians
went to the swamps and investigated malaria right
among the malarious. We never learned how yellow
fever was distributed until after a few heroic physi-
cians lost their lives in the midst of epidemics. A
fireman does not investigate the cause of a fire until
after he quenches it, when it is small, if possible ; then
he makes his investigation. Cancer is becoming a
conflagration, with the evidence of original causes
burned up. Our job is to attack instantly every lit-
tle cancer fire, and then investigate.
The writer has been in this fight, and he wishes to
record some actual experiences and express his views,
even at the risk of offending some of his colleagues.
This is no time to be touchy.
Years ago the writer made sections for the micro-
scope of practically every known form of neoplasm
affecting human beings, and he became somewhat
skilled in the laboratory diagnosis thereof and was
called upon to examine many specimens. Surpris-
ingly few of them were characteristically malignant
in appearance, hence were not treated surgically, as
they ought to have been, for many — very many —
became malignant and the patients ultimately died.
Physiologic activity (Da Costa) favors development
of sarcoma and benign tumors; physiologic decline
favors cancer. We wish to add to this postulate
that physiologic decline develops cancer from appar-
ently benign tumors, in a surprisingly large num-
ber of cases, and the only safe rule is to remove
benign tumors, if at all possible, before physiologic
decline shows itself. The outstanding cause of ma-
lignancy, we venture to assume, is physiologic de-
cline, either from ill health, poor nutrition, bad en-
vironment, defective personal or public hygiene,
defective inheritance, debilitating habits or occupa-
tions and advancing years. This physiologic decline
may induce arteriosclerosis, tuberculosis, cancer, and
what not. At all events, we may, very logically, as-
sume that physiologic decline is the danger line and
may well be the factor in cancer that demands our
attention, whatever we may ultimately determine as
the more immediate cause of malignancy.
Run the whole neoplastic gamut — fibroma, lipoma,
chondroma, osteoma, leiomyoma, keloid, neuroma,
glioma, angioma, lymphangioma, sarcoma, endothe-
lioma, papilloma, adenoma, epithelioma, cysts, car-
cinoma and even dermatologic and syphilitic growths
— and they are all dangerous neighbors to adjacent
tissues. Any day they may "start something," the
end of which no man can foretell, and "the day"
is apt to be that one wherein physiologic decline
commences. Don't wait for that day; get busy
now!
Physicians should scent cancer afar, watching every
sort of neoplasm that does not promptly yield to
non-surgical treatment. Don't let the patient decide;
decide for him. Don't fool with chronic dermatologio
or superficial lesions; get busy on the case. Make
your patients submit to adequate examinations. Let
them know you are guardians of their health and
insist on their coming to see you at the first inci-
dence of any "swelling" or abnormal appearance.
Doctor, you will reduce the mortality from cancer
264
Why Does Cancer Rage?
[The American Physician
if you look on it as you do the fire menace and
respond at the first alarm. Laboratory findings are
all right in their way, but you do not wait for the
laboratory report before administering diphtheria
antitoxin. The laboratory may tell you much as
regards neoplasms — usually too late. That was the
experience of the writer, and it was his further ex-
perience that a negative report on malignancy
lulled many a patient and his physician to sleep.
That is a sad mistake in practice.
JVra-MrftcoI Tremtrntemt
When the X-ray was first added to our armamen-
tarium, the writer was placed in charge of what
was then an up-to-date laboratory, and one of his
duties, day after day, was the irradiation of can-
cers and alleged cancers — many hundreds of them.
Pardon a non-flattering statement, but we were
amazed at the lack of diagnostic acumen on the
part of the great majority of physicians who sent
in these cases; that is, as regards the diagnosis of
neoplasms and dermatologic lesions. Perhaps con-
ditions have bettered somewhat since, but they are
far from what they ought to be. The proportion
of neglected cases was startling, and we hear similar
reports from X-ray operators of today, who talk
freely to an editor, but who fear that they will
anger the profession if they write as they talk in
private. Gentlemen, this should not be — this lack
of familiarity with the appearance and clinical sig-
nificance of neoplasms on the part of so many prac-
titioners. Herein is one cause why cancer is on the
increase, and it is also the fundamental reason why
so many neoplasms gone beyond the stage of suc-
cessful surgical removal fall into the hands of the
man who is doing his level best with the X-ray,
radium and other electrical and physical measures
to do what he should rarely be called upon to do,
viz. j treat with these measures cancers that should
have gone to the surgeons long before.
Two other factors must be mentioned here: First,
the fact that, in the overplus of specialists we
have a smaller proportion of the profession who
regularly see neoplasms and learn how to diagnose
these cases by experience; second, too many X-ray
operators, etc., have scant knowledge of pathology
and diagnosis. Many a country doctor would recog-
nize with a glance and his trained sense of smell a
case that gets by the narrowly trained specialist.
Non-surgical treatment has its place, and that
place should be determined by the surgeon who exam-
ines the neoplasm, not by the patient or by the
specialist in physical "modalities," as they are rather
fantastically called.
Statistics amd What Pouts for Them
Mortality statistics on cancer are fairly accurate,
for the terminal state of cancer is so plainly labeled
that few mistakes are excusable or even exist, and
these cancer statistics are very, very bad — are get*
ting more alarming year by year.
Record of cancer incidence (morbidity statistics)
is marked by its absence. The writer has seen what
passes for statistics of cancer morbidity, but has
little confidence in most of these data. It falls to
his lot, however, to record "incurable disease" cases,
a large proportion of them being reported as can-
cer. A few deductions from these reports may be
illuminating. Cases are reported as cancer — many
of them — that investigation shows not to be cancer,
nor even neoplasms of any type. Some are enlarged
spleen, a few prove to be cirrhosis of the liver, still
more are abscesses. Ignorant physicians make some
of these erroneous reports, but diagnosis of internal
cancer is often difficult and capable men may be
misled. It seems hardly believable, but it is a fact
that many reports of cancer are made on the basis
of the patient's own statement. Some persons be-
lieve they have cancer because some quack told them
so, or they have internal disease and cancer "runs
in the family," and a few drug addicts will tell an
honest physician that they have cancer and will cite
alleged hospital examinations, etc, thus deceiving the
physician. Erroneous reports are also often due to
hasty examinations and snap-shot diagnoses.
The really serious matter is this: These incurable
cases of cancer are, to a large extent, neglected cases,
the neglect usually being chargeable to the patient
himself, but too often to his physician. Not one-
third of them were ever examined by a surgeon, this
being often due to residence in remote communities,
far from hospitals or specialists in surgery. Many
of these incurable cases should have been taken
early in hand, but were not. It seems a pity that
all cases of cancer, or suspected cancer, are not re-
portable by law. Few physicians have many such
cases and it would be little additional burden to
report them to departments of health.
Wherein the
U of Fault
We have been gently scolding the medical profes-
sion, but the people at large need a regular tirade
on this subject, for there is where the principal
fault lies. Most physicians are capable, even though
sometimes neglectful, especially of cases they know
they cannot cure. Their early cases of cancer they
take promptly in hand, usually referring them to a
surgeon, but the advanced cases of cancer, no longer
operable, they are inclined to let drift. The result
is that the incurable cases of cancer usually appear
on the reports as under the care of physicians of
less capability, some of them quacks.
In practically every community of size, one or
more men secure reputations as cancer doctors, and
the incurable cases the capable physicians let slide
drift into the hands of these men. Not only that,
Phila., April, 1922]
Why Does Caacer Rage?
265
bat every early and curable ease they can scare into
avoiding the knife go to these men, who use can-
cer pastes and every vain thing exploited by quacks
and semi-quacks as "good for cancer." No won-
der the deaths from cancer are on the increase.
Cmeer m « FMk H**h Cmcm
The propaganda in tuberculosis control had an
immense influence in teaching the people how to
prevent and avoid tuberculosis and how to take care
of themselves if they contract the disease. Not only
that, but the same work went a long way in awaken-
ing physicians to an appreciation of the tuberculo-
sis menace and how to prevent and control the dis-
ease in their own practices and communities. Per-
haps a cancer propaganda would be just as useful.
People need to be taught that, despite the fact
that we do not know the immediate cause of cancer,
we do know sufficient to guide us in preventive
measures. Also we definitely know the urgent need
for immediate treatment of all neoplasms. We know
definitely that certain long-exploited treatments for
cancer are ineffective and that the important thing
is to realize that keeping the body up to par, remov-
ing all sources of local irritation, avoiding excesses,
etc., will prevent the development of many cases;
and that, after a neoplasm develops, it should be
given immediate attention, operative if indicated.
We should help in freeing the minds of the people
from the fear of the knife in skilled hands, and we
should warn against the vain things that not only fail
to cure cases, but may make curable ones incurable.
We need to know the facts as regards the inci-
dence of cancer; the disease should be reportable, and
then the health authorities would be in position to
study cases and arrange for the care of those n)t
in professional hands. In many instances physicians
would welcome aid in the diagnosis of obscure cases,
and this aid could be arranged for by co-operation
between health authorities and hospitals. Many use-
ful people in the initial stages of cancer, or develop-
ing neoplasms that may become malignant, might be
saved to many years of usefulness by such co-
operation. As it is, many of them are poor and their
cases are neglected. Who knows but that they may
leave an impress upon coming generations.
Be all of these things as they may, we need to
take a part in the cancer fight; get out as cancer
scavengers on a clean-up, rolling up our sleeves and
putting our hearts into the work.-
When Is Alcohol a Stimulant?
SURELY from the therapeutic point of view, and
having no bearing on the problem of national
prohibition, the recent vote taken by the American
Medical Association reveals the fact that there are
many competent physicians who believe that alco-
hol, at least under certain circumstances, is a stimu-
lant in therapeutic doses.
Campbell, of London, for several years president
of the British Society for the Study of Inebriety,
does not agree with the dictum that "alcohol is always
a narcotic and not a stimulant." That alcohol may
act as a narcotic he considers as proved, and he
agrees with Wilks that in health it is commonly a
sedative. He has no great faith in alcohol as a
therapeutic agent and believes great harm comes
from its use as a beverage and often as a medicine,
but in states of exhaustion he contends, alcohol in
proper dosage has a temporary reviving effect,
especially in a person advanced in years who is
slowly recovering from a severe case of influenza.
Probably the fair statement to make is this: In
states of health, alcohol, while temporarily stimulat-
ing in the same way as ether is, has as its main
effect narcosis or sedation, according to the dose;
but, as regards certain conditions of disease, animal
experimentation which shows alcohol to be a narcotic
in the healthy subject does not negative clinical ex-
perience to the effect that in exhausting disease it
may possess properties of value.
Practically considered, competent physicians are
little inclined to administer alcohol except to pa-
tients so ill that they are, or ought to be, confined
to bed.— T. S. B.
The scratch of a lion's claw is almost as deadly
as his bite, for he never cleans his nails, and he
always carries under them rotting meat that is rank
with deadly germs. Flies and water bugs do the
same thing on a smaller scale; and, "Don't forget,"
says the U. S. Public Health Service, "that they never
wipe their feet."
What Is the Matter With Endocrine
Therapy ?
CUSHING AND OTflERS have been indulging in
some probably needed destructive criticism as re-
gards therapeutic claims made for the endocrines, but
this should not blind us to the fact that in the endo-
crines we have a most promising line of rational
medication, which has been grasped by Weil, in his
recent textbook, better than by our popular American
writers on the subject.
After various experiences with endocrine products
in actual practice, with some successes and more fail-
ures, we are impressed with the need, not only for a
better scientific basis for prescribing them, but for
more standardization of the preparations on the mar-
ket. It is inevitable that poor products are common
until after exact methods for their standardization are
perfected, and this through no fault of the commer-
cial interests placing these preparations before the
profession. A beginning has been made in this direc-
tion, but we incline to the view that various glandular
products are brought into reproach from the fact that,
266
Announcements
[The American Pfcysidtn
as commonly secured, they are not of established
potency and are not physiologically standardized,
either qualitatively or quantitatively, the result being
that practitioners unwittingly use inert material all
too frequently.
It has been proved, so we are told by the English,
that thyroids of animals raised near to the sea con-
tain more iodine than do the glands of those raised
in the interior ; and if this is true of the thyroid, some
parallel factor may inhere in the case of every other
endocrine organ, and that the method of selection
of material is as important in endocrinology as in the
selection of plants used medicinally.
Coming In Next issue
Reviving Janet's Method in the Treatment of Gonorrhea
REPEATED hot injections of the urethra, advo-
cated by Janet, dropped out of sight because of the
time consumed, copious injections of various heated
solutions being made at frequent intervals, but since
genito-urinary work seems to be drifting more and
more to hospitals and dispensaries, the method is
being revived.
There is, now, more or less modification of Janet's
method, but friends of the procedure assert that
temperature is of prime importance, the chemical
composition of the solution used being a matter of
secondary importance. The temperature should not
be less than 102 F., and it may be run up to 108 F.,
as the urethra is fairly tolerant to heat carefully
applied. A weak permanganate solution is commonly
employed, and some use the Valentine irrigator in
making the injections. The method is said to be
free from any untoward results and is reported as
giving excellent results.
For many years we have encountered foreigners,
who under our care always heated the injections pre-
scribed and who consistently objected to strong and
astringent injections, and their cases turned out
well. These Hungarians, Slavs, Greeks and others,
explained that they were accustomed to warmed injec-
tions in their own countries. Some of these men go
to bed for a week or ten days, when they have an
attack of gonorrhea, treat themselves, as indicated,
and we understand they secure good results. *
Perhaps we have been neglecting a good thing, and
we are not so doubtful of the genito-urinary sense of
some of these foreigners as to call in question the
validity of their reasoning. Perhaps they are right.
The perambulating dental clinics of the U. S.
Public Health Service have proved that poor health
makes poor chewing, and that poor chewing makes
under-nourishment and poor health. Particularly
it urges that the "six-year" molars" of children should
be watched. These are not the last of the first
teeth, but the first of the last, and once gone, they
can never be replaced.
Diagnosis of Blood Diseases by the General Practi-
tioner. First seen by the General Practitioner;
on His Diagnostic Ability Depends the Remaining
Few Years of the Patient's Life.
By D. A. Smith, M.D.
Undoubtedly correct in stating that "the general
practitioner does not diagnose the blood diseases as
often as he should/' it was the author's happy
thought to write this timely and well-planned paper
on all important blood dyscrasias and allied disorders,
covering them admirably and leaving out, at the same
time, burdensome details and dry technicalities, and
presenting the subject in an interesting and readable
form.
Medical Diathermy.
By Elnora Cuddeback Folkmar, M.D.
Medical diathermy is not a panacea for all diseases.
Yet its indications are many; and it is a most excel-
lent adjuvant to many other therapeutic measures.
In many cases it is the indicated therapeutic agent
par excellence. For diathermy is heat, and heat is
necessary to life, to health, to function, to repair
in injury, and to the restorative processes when dis-
ease is present. And diathermy furnishes the needed
heat where it is wanted and when it is wanted, with-
out taxing the heat-regulating forces.
This first installment goes thoroughly into definition,
essential equipment, fundamental principles, technic
and therapeutic indications. We hope you will get as
much of a stimulus as we did from reading Dr.
Folkmar's excellent paper.
Therapeutic Value of Ice Bag In Acute Inflammatory
Conditions. Brings Out New Points and Widens
Field of Use of This Old Stand-by.
By A. J. Colton, M.D.
The use of cold in attempted reduction of elevated
temperature is as old as man. The feverish animal
instinctively plunges into cold water to obtain relief
just as the feverish human applies the wet handker-
chief to relieve headache. Still Dr. Colton brings out
new and interesting points on the utility of this
excellent remedy. You wIH agree with us that It U
a paper worth while reading — and you will be sur-
prised at the extent of the use to which you can put
this good, old-fashioned ice bag.
Footlights on the Feet. No. Two Anatomy.
By Charles Cross, M.D.
Dr. Cross says the most needed service on feet in the
doctor's office to-day is a knowledge of prophylaxis— the
prevention of foot ailments. This particularly appli***
to prevention in children. A service which can he ren-
dered in the office and with home treatment and periodic
observations. The practitioner qualified and equipped to
render this service is assured much practice now nejf
lected.
By Charles Cross, M.D..
Report of a Case of Toxic Encephalitis.
By C. T. Knuckey, M.D., and Lanning E. Likes.
M.D.
An interesting case with histr:*> and symptomatology,
and some unusual features.
The Qreedy Colon and Auto- Intoxication Case Report.
By Norrls W. Gillette, M.D.
If your patient were constipated would you excise
his colon? There are good surgeons, with good
reasons, that do. Read Dr. Gillette's paper and see
whether you would do it or not.
Dibromln, An Ideal Moist Dressing.
By David Tandell Roberts, M.D., F.A.C.S..
The author has used dibromln in more than eighty
cases of surgical Infection in the past year, with uni-
formly good results. It is an active germicide, at least
equal to chlorine compounds, and has met all the
requirements of a surgical bactericide because of Its
ease of preparation, its efficacy, and the absence of
irritation, odor and color. Particularly has It proved
ideal in those cases requiring irrigation and where a
continuous moist dressing was desired.
The following papers
org contributed exclu-
sively to this journal.
Republication is per-
mitted if credited as
follows: AMERICAN
PHYSICIAN, Phila-
delphia.
Original Articles
ItitntiL tti sttfeMM, tan dinnt ibn ust cninni
We are not respon-
sible for the views ex-
pressed by contribu-
tors; but every efort
is made to eliminate
errors by careful edit-
ing, thus helping the
reader.
Prognosis and Choice of
Operations in Cancer of the Stomach
Danger of Unthinking Routine Treatment of Dyspepsias
PRACTICAL SURVEY FOR THE GENERAL PRACTITIONER OF AN IMPORTANT SUBJECT
By A. Wiese Hammer, M.D., F.A.C.S.,
218 South 15th Street, Philadelphia.
Importance of Early DimgmoaU
Cancer of the stomach usually means death.
A very early operation — seldom possible be-
cause the condition is usually discovered when
it is well developed — offers a dubious chance
for a radical cure; but operation at any time
often prolongs life and mitigates suffering.
The various phases of the question involved,
the medical and surgical aspects of this
all-vital problem are deftly and comprehen-
sively discussed by Dr. Hammer in this scien-
tific but practical paper. — Editors.
THE PROGNOSIS in cases of cancer of the
stomach is a matter of much varying opinion.
The choice of operation allows of wide interpretation,
because this preference depends so largely upon the
location, the extent and the duration of the growth
among other debatable factors. So that a considera-
tion of the subject from these viewpoints would
appear a desiratum in surveying the contradictory
opinions that almost daily burden the medical press.
For obvious reasons, therefore, the subject matter
of this contribution records the views and details the
experiences not so much of the general surgeon or of
the occasional operator in this important field — rather
the text bears the imprint of authority because the
data that it offers is the review of the practical knowl-
edge gained through the observations of the best
abdominal surgeons in this country and abroad.
The Medical ami the Smrgicai Problem
As there is no medical treatment of canter, surgery
offers the onlv chance of relief and the onlv chance
of cure. The physician can only be of service when
the case is too far advanced for interference on the
part of the surgeon, or where operation is declined.
And yet, in the face of hopeless obstacles, the late
James Tyson and also William Osier proved that much
could be done to mitigate the suffering that the dread
malady had inflicted upon its victim. The late Abra-
ham Jacobi obtained almost unbelievable results from
his own method of administering methylene blue and,
more recently, L. Duncan Bulkley, member of the
American Assoc iation for Cancer Research, has caused
almost endless controversy in claiming that cancer is
the result of "constitutional factors," and can be in-
fluenced favorably by diet. Although an authority
upon the subject, his recent work has brought out
much debate because his teachings, it is asserted, are
against the early and radical surgical treatment of
cancer.*
Cameer Primarily m Local Conditio*.
There is much evidence to prove conclusively that
cancers that are exposed to view, such as cancer of
the penis, tongue and breast, are first purely local and
when they are energetically and early attacked by the
surgeon, allow the patients to live happy and com-
fortable lives after the removal of the offending neo-
plasm.
What is true of these cancers is equally true of
cancer of the stomach, only that in the latter the diag-
nosis is, as a rule, not made sufficiently early to allow
of the same thorough and complete ablation of the
malignant neoplasm. If so-called "dyspepsias" were
not allowed to persist so long, and if consultation
between physician and surgeon were more common, an
exploratory incision would not infrequently divulge
a beginning gastric carcinoma and under proper sur-
gical care and treatment would eventuate in complete
and lasting recovery.
The Pro* ami Com of Smrgicai Treatment
Admitting that the nature of the affection is diag-
nosed at an early stage, what is the surgeon's duty
under these circumstances? That will depend upon
♦Cancer and Its Non-Surgical Treatment, by L. Duncan Bulk-
ley. William Wood & Co.. New York, 1921.
268 Prognosis and Choice of Operation in Cancer of the Stomach — Hammer TThe American Physician
the position and extent of the growth, the presence of
adhesions and the amount of glandular involvement.
It is not so many years ago that many excellent
surgeons maintained that in gastric surgery, palpa-
tion of a tumor through the abdominal wall, at the
position of the pylorus, was the signal for little hope
and often for little interference.
Admitting that an early diagnosis offers the very
best prognosis in cancer of the stomach, the ultimate
result of operation is judged at least three years after
the operation has been performed. When no opera-
tion is performed, what is the duration of life under
medical treatment alone f
From the elaborate statistics gathered by Robson
and Moynihan from the Kronlein and Mikuwicz clinics
and Kausch's examinations of the results of non-sur-
gical interference at the Czerny and Kocher clinics,
patients with gastric carcinoma have one year to live
under purely medical treatment. According to most
authorities, a year is much longer than the average
that such a patient can survive.
Per contra, Moynihan observed at these clinics that
the average duration of life after operation, in no
specially selected class of cases, was often two years
of comparative comfort to the patient, as against a
year or less of suffering in patients treated by purely
medical means.
Kausch reported an average duration of life of 18.3
months after operation, in patients operated upon at
the Mikulwicz clinic; of 18.7 months in Kochcr's pa-
tients and of 18 months in Kronlein's patients.
Though the chances of permanent cure are slight,
nevertheless cases are recorded from the clinics of
eminent surgeons who assert that some of their carci-
nomatous patients got well and stayed well. This
leads to the important thought — is it not possible that
the pathologist as well as the surgeon was in error,
and that these were other than cases of cancer of the
stomach 1
And yet so brilliant a surgeon as Charles H. Mayo
asserted in 1919 that 37 per cent, of such cases oper-
ated upon for cancer, are alive three years after the
operation of partial gastrectomy, and of 234 patients
traced for more than five years after operation, 25
per cent, were alive and well after this long interval.
Deaver believes that "we may expect 10 or 15 per
cent, of patients treated by gastrectomy to be per-
manently cured without the liability of recurrence."
It is never to be forgotten that all palpable tumors
in the region of the pylorus are not by any means
always carcinomatous. It is just in such conditions
that an exploratory laparotomy finds its greatest use-
fulness. According to Lebert, carcinoma is found in
54 per cent, of cases at the pylorus, in 16 per cent,
on the lesser curvature, 9 per cent, at the cardiac end,
3 per cent, on the anterior wall, 4 per cent, on the
posterior wall, 4 per cent, on both walls (in the same
case), 4 per cent, on the greater curvature and in 6
per cent, it is diffuse.
Many surgeons, among them Deaver and Moynihan
and the late J. B. Murphy, consider a study of statis-
tics for benign diseases of the stomach in the light of
preventive operations for cancer. Thus, in 1920,
Moynihan reported 835 operations, with 12 deaths
or a mortality of 1.4 per cent. Deaver reported in
582 operations between the years 1908 and 1920 in-
clusive, 28 deaths, a mortality of 4.8 per cent The
Mayo Clinic, 1915 to 1919 inclusive, 3480 cases, 53
deaths, a mortality of 1.5 per cent. For as Kocher
so aptly remarks : "The majority of practitioners do
not sufficiently realize what brilliant results are to
be obtained by operative means in chronic affections
of the stomach commonly known as gastric catarrh.
Not only can the numerous dangers of ulcerating
affections of the stomach such as hemorrhage, perfora-
tion, and transition into cancer be prevented but the
disease and its results may be so rapidly and cer-
tainly cured that the medical treatment of obstinate
cases must be put in the background. The patient
does not require to pay any further attention to the
nature of his food. The pain in the stomach has dis-
appeared, likewise the vomiting. The bowels have
become regular. Repeated investigations of the gas-
tric contents show progressive improvement in the
processes of digestion, hyperacidity diminishes; if too
little acid is present it becomes increased, a statement
which is in accord with Steudel, Carl and Fantlno,
Kausch, Hartman, Soupault, and Mintz.
When a Raited Opermtim U C—trmmdicmttd
When a radical operation is contraindicated, what
course shall the surgeon pursue? The most rational
operation is gastrojejunostomy. The mortality rate
is always high, but this is not surprising when the
fact is considered that in this class of patients the
vitality is at ebb-tide and the disease has already
made its inroads both locally and throughout the entire
system.
In variance with this generally accepted dictum, are
the observations of Moynihan and Robson :
"There can be no doubt that in such cases gastro-
enterostomy is productive of the most remarkable
benefit to the health and well-being of the patient.
The weight increases, the appetite and the power of
gratifying it return, and vomiting, often the most
distressing and unceasing symptom, stops at once.
But there can be no doubt that in some instances
when the growth does not actually obstruct by its bulk
the onward passage of food, a decided benefit results
from operation."
A little later they thus modify this statement:
"The question may arise as to whether gastrectomy
should not be performed deliberately as a palliative
operation in cases where an early secondary deposit
can be seen in the liver, or inaccessible or irremovable
glands to be found in the pancreas or along the aorta
PhiU., April, 1922] Prognosis and Choice of Operation in Cancer of the Stomach— Hammer
269
or vena cava. If we take into account the following
advantages of gastrectomy as compared with gastro-
enterostomy; that in the most competent hands its
mortality is not greater but is even less than the
mortality of gastroenterostomy, that a period of life
ten months longer than by gastroenterostomy is the
rule, that the comfort, general health, appetite and
well-being of the patient are all emphatically better;
and, finally, that the patient has always a chance, even
though it is of the slenderest, of a complete recovery
from the disease — if we take all these into considera-
tion, there can be no doubt that the operation of
choice will always be gastrectomy."
Ten or twelve years ago, Robson did not expound
this theory; he at that time believed that, "Because
of extensive adhesions, secondary growths or involve-
ments of glands, it is unwise to attempt pylorectomy
or partial gastrectomy, though there is sufficient free
stomach wall left to enable a gastroenterostomy to be
performed. In such cases a gastroenterostomy, if
performed with proper expedition and adequate pre-
cautions, affords the greatest relief to the sufferer,
who not only loses the distress due to painful peris-
talsis and to the irritation of the retained secretions,
but also becomes freed from toxemia due to absorption
of the poisonous, fermenting stomach contents."
FrndtM m the Choice •/ Opermtitm
With a consideration of the prognosis we pass to
a brief review of the choice of operation in cancer
of the stomach, mentioning the type of operation best
suited in certain locations and under certain condi-
tions and circumstances, as well as the contraindica-
tions to certain operations.
When the disease is found too extensive for opera-
tion, it is desirable that the remaining weeks of the
patient's life should be spent in bed. In the early
stages of the disease, an exploratory incision for diag-
nostic purposes in efficient hands, is practically nil.
In 1905 the Brothers Mayo, at the St. Mary's Hos-
pital, Rochester, Minn., reported 25 exploratory in-
cisions for cancer, without a death.
The operation of total gastrectomy is always a
formidable one and should only be attempted by an
adept in the field. The operation, at best, should very
rarely be ever attempted. The operation must be done
early in the disease. Unless the whole offending mass
can be removed, no good purpose will be served by
its performance. It is contraindicated late in the
disease, or when extensive adhesions have formed or
where the lymphatics have been invaded or secondary
growths have developed.
Partial gastrectomy is a far safer operation and, as
indicated by its name, aims at the removal of certain
definite portions of the diseased organ including the
pylorus and neighboring parts of the stomach, includ-
ing, if needs be, the whole of the lesser curvature.0
If the gastric area removed extends still further along
the greater curvature toward the fundus, we speak of
the operation as a subtotal gastrectomy. Partial gas-
trectomy is the operation of choice for the radical cure
of gastric carcinoma. The mortality according to
different observers varies between 10 and 14 per cent.
After the operation of partial gastrectomy, the first
method of Billroth for the purpose of restoring the
continuity of the gastrointestinal tract is emphasized
so as to unreservedly condemn it. The simple suture
so often allowed of a leakage, that the operation was
always associated in surgical minds with ''the fatal
angle of Billroth."
When the cardiac pouch is small, the second method
of Billroth (anterior gastrojejunostomy) is well
adapted to cases of subtotal gastrectomy.
What is sometimes termed the method of trarn*-
me so colic gastrojejunostomy is also indicated in sub-
total gastrectomy. The operation originated with
Poyla, and he described it as "an anastomosis between
the jejunum and the open stump of the stomach."
Kocher closes the cut-end of the stomach bv means
of a continuous catgut marginal suture taking up the
whole thickness of the cut surfaces including the
mucous membrane, after which the united edges are
invaginated and closed with sutures. The open end
of the duodenum is then applied to the new opening
made in the posterior surface of the stomach, to which
it is united.
The subject of gastroenterostomy has been suffi-
ciently dwelt upon in this paper.
When the carcinomatous mass is found in the
esophagus or at the cardiac end of the stomach, resort
is often made to gastrostomy. But, as a rule, the
operation is delayed so long and the patient by this
time is so exhausted that the operation offers a dis-
couraging mortality. In some cases of dysphagia,
when done early, this operation is said to have accom-
plished most excellent results.
When the median portion of the stomach only is
the seat of malignancy, resort may be made to cylin-
drical gastrectomy. But the operation is contraindi-
cated if the glands in the gastrohepatio omentum be
involved, as such a contingency will demand removal
of the entire lesser curvature.
Gastric resection is adapted for the following can-
cerous conditions in the stomach : When the neoplasm
affects the anterior or posterior wall (involving neither
curvature) ; or when the growth is confined to the
greater curvature alone and near the fundus Such
growths are extremely rare in these locations, and
the consensus of opinion is that the operation of
partial or subtotal gastrectomy offers a better prog-
nosis as to ultimate cure.
•The expressions, Mayos's line, Mikulwicz's line, and Hart-
man's line have been purposely omitted from the text. These
are imaginary, arbitrary lines extending from the lesser to the
greater curvature. They map off certain areas, and are of little
practical worth, as they cannot limit the extent of the cancerous
invasion. Robson says they have no use in gastric surgery.
270
Is Cancer of Parasitic Origin? — Schneider
[The American Physician
Jejunostomy and duodenostomy may rarely be per-
formed, and are courts of last resort when nothing
else can be done. When a case of carcinoma of the
stomach is far advanced and extensive, where no
healthy spot of sufficient size on the stomach wall can
be found for the purpose of gastroenterostomy or
other procedure, these operations offer themselves to
the consideration of the surgeon. Naturally, these
patients are desperately ill and the operation must
be done by one expert in the field and be accomplished
with the greatest dispatch.
Is Cancer of Parasitic Origin?
Until the Cause of Cancer is Discovered We Work in the Dark
By Albert Schneider, M.D., Ph.D.,
University of Nebraska, Lincoln.
The etiology of cancer is still unsettled, its
ravages are still raging, while some minds
still cling to the parasitic theory of the origin
of malignant growths. Just as every man is
entitled to his opinion so is every physician
entitled to the light shed by such opinion.
The paper of Dr. Schneider has aptly pre-
sented the pros and cons on the subject under
consideration. Read it and draw your own
conclusions. — Editors.
ON THE QUESTION of the origin of cancer,
scientists are divided into two camps. In the
one camp are those who argue that cancer is of
parasitic origin, and in the other camp those who
declare most emphatically against the parasite theory.
For a time the proponents of the parasite theory
were dominant, but even from the first there were
those who vehemently denied and opposed the con-
cept; and, at the present time, the opponents of the
parasite theory are in full cry. It was this wholly
useless and aimless controversy which caused the
breaking up of the International Association for
Cancer Research fostered by Czerny and by the Ger-
man Committee for Cancer Research as early as 1900.
The German Cancer Research Committee was un-
fortunate in formulating its activities on the assump-
tion that this disease was of parasitic origin, an
opinion for a time upheld by many, if not most, of
the American investigators, but generally opposed by
English and French investigators. More recently
American investigators have drawn away from the
supporters of the parasite theory, and the defenders
of the parasite theory are usually met with ridicule.
The following is believed to be an impartial and
unbiased presentation of the arguments for and ,
against the idea of the parasitic origin of cancer,
without making any reference to recent discoveries
touching on the subject. After considerable reading
we have decided to submit the statements of Dr.
Charles Powell White (The Pathology of Growth.
Tumors. London, 1913) as the basis for the argu-
ments, quoting from his work and wherever, indicated
introducing the counter argument. It may be ex-
plained that Dr. White is himself an opponent of
the parasite theory, whereas the writer is a supporter
of the theory. To quote from Dr. White's work :
Improkmb&ty oflmtra- or Extra-Farmtitic Origm of Camcer
"If the continued cell proliferation in tumors be
the result of direct stimulation by an extrinsic irri-
tant, such irritant must of necessity be a living organ-
ism, since the proliferation, being continuous and pro-
gressive, demands a continually increasing irritant.
This applies equally to the histomata and cytomata,
and since, as we have seen, there is no sharp boundary
between the two classes of tumors, we must infer that
the essential causal factor is of the same nature in
both cases. The supposed parasite must be either
intra- or extra-cellular. If it is extra-cellular it is
impossible to explain the absence of infection of the
surrounding tissue; for, as we have seen, the growth
of a tumor is the result of the proliferation of its
own cells, and the surrounding tissue takes no part
in it, except in certain cases in connection with the
area of origin. If, on the other hand, the parasite
is supposed to be intra-cellular it would seem neces-
sary to suppose that the division of the cell and of
the parasite was so timed as to be simultaneous, each
daughter cell receiving a daughter parasite. In all
cases in which parasites are found within cells the
effect is the destruction either of the parasite or of
the cell."
Reply. — The last statement is not in harmony with
fact. Biology records innumerable instances of
Phila., April. 1922]
Is Cancer of Parasitic Origin?— Schneider
271
growths in which the intra-eeUular parasite does not
kill the cell in which it lives and it (the parasite) in
turn is not killed. We need onlv recall the root nodules
of leguminous plants. The parenchyma cells of the
interior of the root nodule are packed with bacteria
(Rhizobium leguminosarum) which, instead of hinder-
ing cell division, actually stimulate such activities re-
sulting in tubercle formation. Furthermore, the tu-
bercle consists of two distinct portions, the area
containing the bacteria, and the non-infected area,
both portions being neo-formations, the result of the
infection. The fact that in the case of the leguminous
root nodules we have a case of mutualistic symbiosis,
whereas in cancer the symbiosis, if such exists, is
clearly antagonistic, does not in the least negative the
comparison. Biology also records innumerable in-
stances where extra-cellular parasites, by their mere
presence, induce extensive cell proliferation, as in
gall formations. It has even been suggested that
many so-called normal growths, as tubers, fleshy roots
and possibly fruits, are the result of initial bacterial
or microbial stimulation. Infections of all kinds
induce abnormal cell proliferation, and with the dis-
appearance of the infection the abnormal cell prolifera-
tion also ceases and the tissue soon returns to normal.
In those instances in which the intra-cellular parasite
acts as the stimulus to mitosis, as in the root nodules
of the bean family, the abnormal mitosis is dependent
upon the invading organism. If the parasitic stimu-
lation becomes excessive, death of some of the cells
results, the tubercle breaks down, and the parasites
are set free. Cancer behaves as though it were under
the influence of some intra-cellular parasite, which
sooner or later results in excessive cell proliferation
with death and disintegration of some of the infected
cells. Dr. White continues:
Nimal mmi Ahmrmd Ccfl PrMtrmiitm
"Since cell proliferation in tumors is similar to
cell proliferation under normal conditions, the assump-
tion of a parasite to explain it is quite unnecessary,
and makes an explanation of tumor growth more
•difficult."
Reply. — The above statement is so unworthy of a
scientist as scarely to merit a reply. Cell prolifera-
tion in cancer is far from normal. It is no more
normal than any other pathological cell proliferations.
If cancer is of parasitic origin we wish to know it,
no matter how difficult it may make the explanation
of tumor growth.
Sywtk'msu mmi CeB Crmwtk
"Direct stimulation of cell growth by a parasite
is an unknown occurrence in biology and is opposed
to the facts of parasitism, and the difficulty is not
avoided by applying, as some do, the term symbiosis
as explaining the association between the supposed
cancer parasite and the organism. In symbiosis the
partners receive mutual benefit from the association,
but symbiosis does not lead to proliferation."
Reply. — These statements are contrary to the proven
facts in biology and cytology. All parasitic infec-
tions cause more or less stimulation of cell growth,
as is generally known. The statement that symbiosis
(mutualistic symbiosis is here meant) does not lead
to (cell) proliferation is not so, as is clearly shown
in the case of the root nodules of the bean family.
Furthermore, many inflammatory processes and granu-
lation tissue formations are induced by parasites of
various kinds. Whatever cancer mav be, it certainlv
does not present any of the characteristics of a mu-
tualistic symbiosis between the cells of the host organ
ism and the cancer parasite. The writer has else
where designated the relationship that exists between
cancer and the normal cells of the organism as "para-
cytosis," as contrasted with the condition which, for
example, we find in phagocytosis ("patrocytosis").
However, these terms (namely, paracytosis and patro-
cytosis) do not explain anything. Nor do we find
any great satisfaction in the statement that cancer
is due to certain cells having "gone wild" or having
"gone on a rampage" or that they are "dormant,
embryonic cells which have been stimulated to ac-
tivity." What we wish to find is the cause which
made the cells wild or which made them go on a
rampage, or which made them proliferate as do
embryonic cells. We have not yet proven that the
cause is not a parasite and there are no sound
reasons which would preclude absolutely a parasite
of some kind as such a cause.
Cmmeer Orgummt — Ntn-lflmkU
"Numerous micro-organisms have been described
by different observers as occurring in cancers, and
for many years there has been a great controversy
between those who uphold and those who deny that
cancer owes its origin to one or more specific para-
sites. Investigation has been carried out both by
histological and by cultural methods and, at differ-
ent times, bacilli, cocci, torula?, protozoa, myxomy-
cetes, spirochaetes, nematodes, and ascari, have been
suspected as specific organisms for cancer, but no
organism yet described has stood the test of criti-
cism. No one has vet isolated from cancer anv
organism which will give rise to cancer when inocu-
lated into other animals, except the cancer cell itself,
which, as we have seen, will, under suitable condi-
tions, continue to live and produce cancer when
grafted into an animal of the same species as that
from which the cancer was derived."
Reply. — The above is only too true. Leaving out
some very recent observation, we will admit that
thus far no organism has been isolated in pure cul-
ture to which may be ascribed the cause of cancer.
Even if this were absolutely true, such evidence
would not disprove the parasitic origin of cancer.
The Plasmodium of malaria has not yet been cul-
272
Syphilitic Leg Ulcer — Broeman
[The American Physician
tared artificially, and yet all must admit that ma-
laria is of parasitic origin. Other diseases, due to
two host parasites, might be named. May not cancer
be due to such a parasite? The writer believes this
to be the cose, as is explained elsewhere.* Dr. White
concludes as follows:
of Cancer CeU Itself
<rWe thus see that the assumption of a specific
parasitic origin for cancer leads to insuperable diffi-
culties in explaining the observed phenomena. The
difficulties entirely disappear if we consider the can-
cer cell itself as a parasite and cancer as a process
of infection by cancer cells."
Reply. — We believe we have shown that Dr. White's
arguments do not prove that cancer is of non-para-
sitic origin. To say that the cancer cell is the para-
site is on a par with the statement that cancer is
epithelial or embryonic cells gone wild or gone on
a rampage. It does not mean anything and is wholly
unsatisfactory to the scientific mind. Cancer does
present many characteristics which point to a para-
sitic origin. Only on the assumption of a parasitic
cause can we explain the sudden and rapid prolifera-
tions and metastases into practically all parts of
the body. Just because we have not yet found the
cause of cancer is no reason why we should give up
the hope of finding it. What is more, not until we
have found the cause of cancer will we be able to
control this malady. Until then we will continue
to work in the dark.
Chronic Leg Ulcer
Determine Causative Factor Before Treatment
DIFFERENTIAL DIAGNOSIS WITH REPORT OF A SYPHILITIC CASE
By C. J. Broeman, M.D.,
4 West Seventh Street, Cincinnati, Ohio
Assistant Director, Department of Dermatology and
Syphilis, Cincinnati General Hospital, Medical
Department, University of Cincinnati. Derma-
tologist to other Cincinnati Hospitals, and Radi-
ologist to Seton Hospital.
A Mmlti-pkmted Smbject Mmit dear
The genesis of leg ulcers is as uncertain
as repellant, and is indeed unyielding to
corrective measures. Here the best efforts
of the best brains often fail. Verily, how
are you going to treat the obstinate sore
unless you know that the causative factor
is varicose veins, tuberculosis, diabetes,
phlebitis, trauma or syphilis — influenced ad-
ditionally perhaps by elements such as age,
sex, occupation, constitutional or social en-
vironmentst This multi-phased subject is
admirably discussed in Dr. Broeman's
paper.— Editors.
ALTHOUGH much has been written about the
various kinds of crural ulcers, the treatment
has been so diverse and the results so uncertain that
practitioners have grown indifferent to this repel-
•Albert Schneider, Preliminary Report on the Probable Cause
of Cancer «nd of other Tumor Formations; The Medical Woman's
Journal XXVIII (No. 12), 289-298, Dec, 1921.
lant and loathsome disease. When the frequence of
its occurrence is considered we are amazed at the
scatter-brained methods which are resorted to. Many
physicians seem to work on the principle that no
remedy will do any harm and consequently they run
through their stock of ointments and pomades, trust-
ing to fate that one will prove effective.
Is it therefore any wonder that the term chronic
is so usually applied to the condition of leg
ulcer f Surely, not all the measures tried, whether
founded on theory or guesswork, have yielded only
negative results. Instead of taking for granted the
economic burden to the community and the indi-
vidual, when years of pain and distress are spent
beating a path to the clinic, we should arouse our-
selves to a concerted effort to make chronic leg ulcer
obsolete.
£faofogtc Factors
No attempt at treatment is justifiable until the
causative factor has been determined. Predisposing
causes are varicose veins, tuberculosis, diabetes, lep-
rosy, phlebitis, trauma and syphilis. Of these, vari-
cose veins are the most frequent. Trauma may de-
velop into an ulcer itself, or, more often, may be the
inciting agent superimposed upon other pre-existing
disease. Age, sex, occupation, social and constitu-
tional conditions are also influencing factors.
Leg ulcer, as a complication of tuberculosis, dim-
betes or leprosy, is too rare to require discussion
here. Other evidence of these diseases would furn-
ish the clue to diagnosis in such circumstances.
Syphilitic Leg Ulcer- -Brocmau
273
The point of special difficulty seems to be the
differentiation between ulcers of varicose and those
of syphilitic origin. The characteristic peculiarities
should be carefully noted and looked for in each
ease as it presents itself.
The ease history is of paramount importance. The
essentials of history taking and their incalculable
assistance to accurate diagnosis have recently been
discussed by me* and I refer the reader to a careful
consideration of the points discussed therein. Some
other evidence of specific infection is usually avail-
able as the ulcers manifest themselves most fre-
quently late in the progress of the acquired form
of the disease. Occasionally they appear soon after
the primary lesion or in young persons who have
congenital syphilis. As is characteristic of all luetic
ukers, they seem to have a predilection for joints
and the most frequent site is the knee. However, a
sufficient number appear in the neighborhood of the
ankle, as in the case cited in this, article, to be con-
fused with varicose ulcer if one were to depend upon
location alone for a diagnosis, the latter being more
likely to appear near the ankle.
The syphilitic ulcer follows upon the breaking
down of poorly nourished subcutaneous gummata.
Contributing complications are the atheroma and
obliterative endarteritis characteristic of the specific
infection. As a rule the patients have acquired the
most pernicious life habits and many signs of low-
ered vitality, filth and even drunkenness complete
the picture. For these reasons, we commonly find
the condition among the poor, in males (on an aver-
age of three to one), and habitual drunkards.
Evidences of syphilis in other parts of the body
help to corroborate the diagnosis, but no reliance can
be placed upon failure to find such evidences or to
elicit a positive history. Objective symptoms are
the most reliable guide. The presence of consider-
able induration laterally and at the base is charac-
teristic, as is also the tendency of the ulcers to
arrange themselves in circles or semi-circles and
coalesce. A typical syphilitic leg ulcer, as just de-
scribed, must be differentiated from (1) simple ab-
scess, (2) erythema nodosum, (3) varicose ulcer, and
(4) epithelioma.
Thickly studded patches of ulcers occur as the
gummata break through the soft parts of the leg.
Very occasionally the ulcer is solitary. The multiple
form, as shown in the illustration, is more typical,
the ulcers varying from the size of a pea to that
of a hen's egg or larger. They usually oecur be-
tween the third and sixth year of the disease, but
may begin at any time after the second year. The
gamma first appears as a deep-seated nodule or lo-
calized perivascular granuloma set in the subcu-
taneous tissue. The center, however, soon breaks
down into a gelatinous, gummy mass. Held together
by a network of connective tissue, the necrotic masses
enlarge and burst through the skin. A yellow sero-
sanguinous fluid exudes which has an almost un-
bearable odor. The outline of the sore is rounded
with intact edge, giving a punched-out appearance.
A thick, firm, pinkish gray granulation may eover
the base ; it may be replaced . by a tough grayish
1. Simple abscess develops rapidly as compared
vith the number of weeks or months required for
274
Syphilitic Leg Ulcer — Broeman
[The American Physician
a syphilitic gumma to become an abscess. More-
over, in the former there is no history of trauma or
infection. An incision into an abscess releases only
a few drops of bloody or purulent serum, in contrast
to the gushing of pus which comes from a gumma.
Before the gumma reaches the stage where it re-
sembles an abscess it gradually becomes red and
tense and then, softening, becomes purple, boggy and
tender to pressure. A simple abscess has no such
incubation period. A positive Wassermann or his-
tory of lues is conclusive.
2. Erythema nodosum appears suddenly as a
bright red, rosy nodule, the color changing to a dark
reddish hue. The process is very acute, running an
extremely painful course through seven to ten days.
There is usually more than one lesion, and fre-
quently both legs are involved. The temporary char-
acter of the lesion serves to distinguish it from the
specific ulcer.
Voricwc Veims
3. Varicose veins as a rule, are overstressed as
a forerunner of ulcer, to the exclusion of syphilis.
That is, if a varicosity is present, the general prac-
titioner is likely to conclude forthwith that no fur-
ther search need be made for a cause. As a matter
of fact, varicose veins may be and frequently are
present when the ulcer is syphilitic. Because of the
frequent confusion of the two forms, the points
of differential significance have been tabulated to
facilitate distinction.
Syphilitic Ulcere
Any part of leg but in
the region of the knee
is most characteristic.
Calf of leg usually in-
volved.
Most often multiple.
Round.
Edges sharp; ulcer deep,
indurated with formed
crater.
Very little redness.
Ulcen
(1) Confined to lower
third of leg, usually
on internal surface.
(2) Usually single; very
rarely multiple.
(3) Irregular shape.
(4) Edges round, shal-
low and never
undermined.
(5) Surrounding skin
reddened, thickened,
pigmented and often
itchy.
(6) Base appears as
large island of hy-
pertrophied granu-
lation.
(7) No other evidence
of syphilis, negative
history and blood
tests.
(8) Varicose veins al-
ways present.
(9) Antisyphilitic treat-
ment ineffective.
Sloughing or considerable
induration at the base
as well as lateral 1 v.
Evidence of syphilitic in-
fection ; specific his-
tory; positive Wasser-
mann.
Varicose veins may be
absent.
Antisyphilitic treatment
cures.
CmfmimtUi
4. An epithelioma may occasionally present con-
siderable resemblance to a broken down gumma. Its
occurrence is very rare, comparatively speaking.
It usually involves adjacent lymph nodes causing an
enlargement, while a gumma is self-contained and
sluggish in growth. An epithelioma bleeds more
easily, is more shallow and has an infiltrated border.
A gumma forms for itself a deeper, cone-shaped
excavation and exudes some of its sloughing eon-
tents. Microscopic examination of a small excised
portion of the growth may be of assistance bnt it
is quite difficult at times to state with certainty
whether the pathological entity is an epithelioma or
a gumma.
The results of anti-syphilitic treatment are most
enlightening in all doubtful lesions.
A CmeRtpmL
The following case report is particularly interesting
because of the extent of ulceration and the fact that,
in this age of enlightenment, the man had never been
treated for syphilis, thus allowing the condition to
progress to the extent of involving the lower two-
thirds of both legs.
Mr. D. B., age sixty-five, admitted to the hospital
for ulceration of both legs. There was no history
of trauma or infection. Patient stated that about
ten years ago, a small sore developed on one leg.
Soon afterward another sore began on the other leg.
The original ulcers spread gradually, becoming quite
extensive until at present they nearly encircle both
legs in the region of the ankle and lower calf. The
hypertrophied edges and surrounding tissues of a
c&uliflower-like growth constitute almost two-thirds
of the growth.
The patient's Wassermann blood test was strongly
positive.
Treatment was mildly anti-syphilitic, consisting of
one injection of arsphenamine every three weeks,
deep intramuscular injection of mercury and twenty
drops of potassium iodide internally four times a day
after eating. The iodide dosage was increased two
drops per day, until he was taking 60 drops three
times a day. He was also given weekly, a deep intra-
muscular injection of three minims of grey oil. Lo-
cally, wet aluminum acetate dressings were alternated
with a 1 : 10,000 bichloride of mercury dressing. When
the ulcer began to granulate, a soothing ointment
was applied. This ointment contains zinc oxide and
calomine each one dram, carbolic acid five drops and
vaseline one ounce. The patient, while confined to
bed for a period of one month, was kept with the
limbs continually elevated. This is an important
point in the treatment of all forms of leg ulcers,
especially in elderly persons. While in the hospital,
the patient improved considerably. Since his dis-
charge he has been lost sight of and we fear that the
con^Hion has become stationary again.
Phila.. April, 1922]
The Acute Abdomen — Floersheim
275
The Acute Abdomen an Immediate Problem
You Must Knorv What to Expect, Anticipate, Look For
By Samuel Floersheim, M.D.,
1015 Story Building, Los Angeles, Calif.
Aptiy Renem* this Vital SmkJ€ct
An acute abdomen has sent many a patient
to the grave. An acute abdomen requires
immediate attention. You have no time to
study an acute abdomen, you cannot wait, you
must act. To know what to expect, what
to anticipate, what to look for when called
upon to treat this condition, you will find Dr.
Floersheim's paper, which aptly reviews this
vital subject, authoritative and very helpful.
— Editors.
GENERALLY SPEAKING, the acute abdomen
is a problem for the surgeon. To delve deeply
into all phases of the issue would take too much space.
It is therefore evident that much good and instructive
material will necessarily be omitted. That which in-
terests the medical man particularly is the diagnosis,
upon which will depend whether the treatment will be
medical or surgical.
PatMaftcal Cmuidtrcfom
There are a number of pathological entities of acute
abdomen in which the physician is deeply interested.
They are:
All forms of acute appendicitis (catarrhal, hemo-
rrhagic, infected, gangrenous, perforated or ruptured),
acute gastric ulcer, perforated gastric ulcer, duodenal
ulcer, acute gall-bladder — with or without stones, acute
septic cholecystitis or empyema. These are the more
frequent types of acute abdomen, but I wish to deviate
therefrom and give you a short dissertation upon the
more infrequent issues which have crept into my path
in the years of practice of my specialty.
Checking up the list, I find it to include, in addition,
the following interesting entities :
Diaphragmatic hernia, ruptured psoas abscess into
the peritoneal cavity, ruptured kidney either from
external or internal violence, from pus collections or
ruptured cysts, impacted ureteral calculi, superim-
posed hydrostasis or pus collection, enteroliths, rup-
tured extopic gestation, ruptured pus tube and ovarian
cyst, peritonitis from a perforated uterus, acute intus-
susception, acute volvulus, hemorrhagic pancreatitis,
perforation of the small intestine with abscess forma-
tion, hemorrhagic spleen, infarct of the omentum,
torsian of a long pedicled tumor, rupture of the
abdominal aorta.
The liver, in my experience, has been extremely
reserved in the causation of an acute abdomen. An
•Read before the Harbor Branch of the Lot Angeles County
Medical Society, at Ha stated meeting, November. 1920.
abscess of the liver is usuallv of a chronic varietv.
I recall, however, that many years ago in consultation
I diagnosed a case as one of probable septic embolism,
as there was a history of a recent recto-perineal opera-
tion. This was definitely established at autopsy.
te
A few of the more interesting points in the symp-
tomatology of this condition will be well illustrated by
the following cases:
An acute abdomen, with the usual symptoms of
pain, chills, fever, pulse rate and shock, was seen by
me after three or four days' illness. The diagnoses
previously made were malaria, gastric fever, gall-
stones, acute appendicitis and hysteria. Upon recto-
vagi no- abdominal examination, a diagnosis of acute
cystitis, with the presence of a hard mass, probably
a stone, was advanced. At operation, a sty letted
catheter, coiled up in the bladder with a stone as large
as a walnut upon the fenestrated end, was found in
addition to the cystitis. Later, confronting the pa-
tient with the evidence, she admitted that a hard
catheter was passed into her uterus and was never
recovered. At the time of introduction of the catheter
into the uterus, she experienced no extraordinary de-
gree of pain. The catheter had perforated the uterus
and bladder with apparently little immediate un-
toward effects. Before the operation no history of
catheter introduction was given or suspected.
In another case, the family physician diagnosed
the attack as one of abdominal rheumatism. Careful
study of the history, a careful and delicate examina-
tion of the exquisitely tender abdomen, and an ex-
tremely ill patient, gave me the impression that we
were dealing with a ruptured right ectopic gestation.
It should be mentioned here that the pathognomonic
symptom which was present in this case — air-hunger,
the patient crying for air — usually means internal
hemorrhage. The surgeon called in to operate dis-
counted the diagnosis and thought he was dealing with
a ruptured ovarian cyst. Operation proved it to be
a left ruptured ectopic pregnancy, with the peritoneal
cavitv filled with clotted blood.
The lives of four women were saved bv insistence
upon immediate operation for acute volvulus. The
diagnosis advanced by the family physicians in three
of these cases was acute indigestion and in the fourth
case overstrain of the abdomen from heavy lifting.
Numbers of other cases, many of which we agreed
upon as to the preoperative diagnosis, include a
hemorrhagic pancreatitis, perforation of the pancreas,
in which operation demonstrated a ruptured cyst,
infarct of the kidney, fulminating gastritis, infarct
of the omentum and torsion of a long pediculated
tumor. A diagnosis of ruptured appendicitis was
276
The Acute Abdomen — Floersheim
iThe American Physician
concurred in by me and, upon opening the abdomen,
it was found that we had a markedly prolapsed stom-
ach with a perforated gastric ulcer. Here we had a
patient who never gave any history of gastric dis-
turbance, yet had much stomach pathology.
In one instance, a diagnosis of septic peritonitis
was made, which proved at operation to be one of an
acute miliary tubercular peritonitis. In another case
a diagnosis of acute septic peritonitis was made and
established at operation, yet the etiology was never
clearly established. It was believed to be of hemato-
genous origin, but at the time of operation and later
at autopsy the small intestines could not be definitely
ruled out.
The following is an interesting case :
The patient was a prominent surgical specialist in
whom a diagnosis of acute appendicitis was made and
concurred in by more than fifteen consultants. An
eminent surgeon and particular friend of the patient
operated upon him and, to the amazement of all, the
appendix was not to be located and the absence of the
cecum was noted. After more than an hour and a
half of diligent search, a rudimentary cecum and as-
cending colon, with an acutely inflamed append ir.,
were found tucked up high in the abdomen and at-
tached to the under-surface of the liver and behind-
the gall-bladder. After considerable difficulty, the
appendix was removed and an apparently uneventful
and rapid convalescence ensued for ten days, when
suddenly an acute paralytic ileus carried the. patient
off in twenty hours. The cause of the ileus could not
be ascertained, even after a most careful autopsy. No
infection whatever could be demonstrated.
In another case a diagnosis of a rather rapid tumor
growth of the small intestines was made and, owing to
its rapidity of development, an abscess was also sus-
pected. At operation the surgeon stated that we were
dealing with a tubercular condition of the intestines.
He showed us miliary areas all over the meso-intes-
tines, extending far more than two feet each side of
the mass. Another prominent surgeon present so id
he was certain we were dealing with a cancerous con-
dition, as he saw many such cases. A pathologist
present just then was handed the resected specimen
with a portion of the gut attached to it. He stated
offhand that he believed it to be an intestinal abscess
not often encountered, and due to a punctured wound
of the wall of one of the coils of small intestines.
On close examination, he proved himself correct.
A severe attack of gastric pain, with vomiting of
blood, was diagnosed as an acute gastric ulcer with
impending perforation. Upon the operating table the
surgeon found a spastic stomach, with a large movable
mass within. On opening the stomach, a hair ball
was removed. Otherwise, the stomach was found to be
normal.
A stomach may be so prolapsed that in an acute
attack it may simulate either acute appendicitis, ure-
teral stones, urinary bladder or tubo-ovarian disease.
An appendix may be so misplaced as to give most
all signs and symptoms of gall-bladder, kidney, utero-
ovarian, stomach, and even left-sided inflammatory
conditions. Left-sided appendicitis has been recorded
Four to six years ago prominent Philadelphia and
New York surgeons were active and enthusiastic in
presenting cases of acute abdomens, due to acute
hemorrhagic and perforated pancreatitis. Within the
past three years duodenal ulceration and perforation
have come into the limelight.
In acute abdomen, it is quite important to make as
near a correct diagnosis as is possible, and at the
same time not to increase the hazards of our patient
by delays of operation when necessary.
Tentative diagnosis may be made in the absence of
definite diagnosis, in order that the surgeon may be
directed to the apparent offending organ or area, and
at operation, if feasible, the exact pathology should
be ascertained.
Usually appendicitis and gall-bladder diseases are
easy of diagnosis, yet many mistakes are made and
will be made. The two may co-exist and complicate
matters, and each or both may at times simulate dis-
ease of the many other organs in their vicinity.
The treatment depends on the lesion present. Our
diagnosis should, therefore, be as nearly correct as
possible. Treatment is either medical or surgical.
The medical men must admit that from 60 per cent
to 75 per cent., at least, of acute abdomens require
surgery for their relief. One could argue rightly that
all cases require surgical treatment, yet in the light of
our inability to make 100 per cent, correct diagnosis
and the apparent cures at times under medical treat-
ment, arguments for the medical side appear to have
a standing. Some of the apparent acute surgical
abdomens have turned out to be acute functional con-
ditions which did not require operative interference,
and among which can be cited acute gastritis, cardio-
spasm, gastrospasm, pyloro-spasni, entero-spasm, and
colono-spasm or spastic colitis. Other definite entities,
such as gall-stone colic, acute catarrhal gall-bladder,
and acute catarrhal appendicitis, are oft times cured
medically, at least in their initial stages, though you
may take the opposite position and say it is not good,
rational, modern treatment. From 30 per cent, to 100
per cent, of acute catarrhal appendicitis recover from
their attacks without operation. Cases of acute gas-
tritis and gastroduodenitis may simulate closely acute
gall-bladders, gastric ulcers and acute appendicitis
and under medical treatment, cures of the simulated
disease may seem to be accomplished. This, of course,
is erroneous, but the trouble lies not in our treatment,
but in our wrong diagnosis.
We must keep in mind the fact that gastric crises
of tabes may occur even though the patients truth-
fully deny acquired infection. Operations upon these
patients will not bring relief.
Phila., April, 1 922 j
Habits Which Lead to Constipation— Herr
277
Habits Which Lead to Constipation
Civilization Is the Primal Cause of Constipation
By A. W. Herb, M.D.,
381 Arcade, Cleveland, Ohio.
Ever since the human quadruped became
a biped, constipation became a product and
a problem of civilization. Whether this ab-
normality is due to the superimposition upon
one another of the body viscera, "originally"
intended to be hanging freely from the pos-
terior aspect of the body, as we believe, or
is due to the several factors enumerated in
this splendid and instructive paper, or both,
is a question worthy of the physician's con-
sideration. At any rate, Dr. Herr presents a
delightful paper which we are sure you wiU
enjoy. — Editors.
CHRONIC CONSTIPATION is a disease of
civilization. Wild animals and domesticated
animals living under natural conditions, or men liv-
ing a normal life, do not suffer from this malady.
Something is evidently wrong with the civilization.
Were we to return to the pastoral life of our fore-
fathers, eat as they ate, dress as they dressed, and
exercise our muscular powers as they, in felling the
virgin forests and battling with wild nature's forces,
we doubtless would hear little of this disorder of
alimentation, a disorder which, aside from the dis-
comforts it causes, is responsible for a host of other
ailments and bodily distempers.
It is a responsible factor in many backaches. It
may have a relationship to diabetes and tuberculosis,
as these diseases are invariably preceded by chronic
constipation for a prolonged period. It is a cause
of congestion of the abdominal organs, which con-
gestion results in cold hands and feet and numb-
ness of the limbs.
To dispose of the absorbed poisons of constipa-
tion all the glands of the body are overworked ; liver
and spleen may become enlarged; the thyroid gland
may become affected, resulting possibly in goitre in
its various forms. Colitis is induced; diseases of the
kidney, liver and gall-bladder may ensue. The adren-
alins may be overworked, resulting perhaps in Addi-
son's disease Eczema and other skin affections,
rheumatism, gout and high blood pressure can some-
times be traced to constipation.
Temporary Jtdatf md Chrmit AfUr-*i*<t
Countless potions prepared with pharmaceutical
nicety, prescribed and taken to flush this tubal canal,
generally afford temporary relief at the expense
of future chronicity. The daily flushing of the
canal by means of mineral and saline irritants is
usually at an immense cost healthwise to the pa-
tient, for by washing away the normal protective
agencies of the bowel it leaves a congested mucous
and submucous tract more open to germ invasion
and local infection.
Besides this, habitual flushing of the lower ali-
mentary canal causes an uneconomical waste of di-
gested and undigested food material, particles of
which have not been afforded sufficient time to be
absorbed by the lacteals, and papillae of the intestinal
wall are washed away, as high as 50 per cent, of the
food ingested again appearing in the stool.
To handle a case of constipation intelligently, the
physician needs to become conversant with habits
which lead to and the several causes producing con-
stipation, and then he will be able to ascertain
which one or more of these causes are operative
in any one case. This simplifies the management,
which calls for a removal of the responsible condi-
tions present in each case.
As stated, the primal cause of constipation is
civilization. Primitive men rarely ever suffered from
this disorder. Country people suffer less than city
dwellers. The modern toilet seat is a factor; the
normal position is a squatting one during evacuation.
" Tis worth much to be well born." Granted then,
that at birth we have a normal infant, let us ask,
is it possible to so train this child that it will grow
to manhood with normal alvine discharges, free from
this malady; or, if a female, must she grow up
"a constipated thing with a pain in her back?"
Let us emphasize the following fact : had man from
earliest childhood days been educated to make use
of his masticatory powers, as had the wild man
of the forest and the lower animals, in the chew-
ing of cane, roots and nuts, thus bringing into
exercise the jaws in the effort to extract their sac-
charines, constipation would be an unknown quan-
tity among us, whereas it is the rule; it is rare that
we find a man, and a woman never, who is not or
has not been constipated at some time in his or her
life.
Amtimmc md PkjtmUgic Ciniiitnimu
Man is endowed with powerful masticatory mus-
cles and three sets of salivary glands, indicating
that they were placed there for a daily, definite
use. Scientific cooking has so thoroughly denatured
food that the average human seems not to be con-
scious of the presence of these muscles and glands,
278
Habits Which Lead to Constipation — Herr
[The American Physician
and knows less of their purpose. The ordinary man
as we find him in primitive or savage life makes
proper use of these functions. Our teeth are not
those of a turkey, merely a gizzard in our stomach,
but are placed at the entrance of the tubal canal
with the idea of properly dissolving the food and
insalivating the same before deglutition takes place.
We have no teeth in our stomach, therefore insuffi-
cient mastication means insufficient salivation, which
thus induces constipation. The stomach has no ac-
tion upon starch. The place of dissolution of the
starch granules is the mouth and not the stomach.
The gastric juice acts only upon proteins of the
food and not at all upon the carbohydrates. Con-
sequently, if the saliva is not commingled with the
starch and acted upon by the ptyalin ferment there
is no starch digestion, at least not until the stomach,
after hours of worry, has emptied itself and the food
has entered the intestine, where an extra burden is
imposed upon the pancreatic digestion in dissolv-
ing the starch, where work is carried on slowly and
imperfectly, resulting in fermentation, followed by
constipation and auto-intoxication. One should not
live upon slops and mushes and over-cooked foods
if he does not wish to become constipated. A solid
or semi-solid diet in the form of baked cereals and
vegetables, raw fruits and green salads furnish just
the necessary exercise for the masticatory muscles
and salivary glands. Further, the mastication of
sueh food stimulates reflexlv the remainder of the
digestive glands along the alimentary canal, so that
at the entrance of the food into the stomach there
is present sufficient amount of gastric juice to dis-
infect this food and to dissolve the proteins present,
which then readily pass into the grasping and hun-
gry intestinal chamber for quick dissolution and
ready absorption.
Nmwud mmi Ftmity Digestion
Undigested starch is not a laxative and conse-
quently has a tendency to be held back a longer
period than usual at the ileocecal valve, and this
long delay results in fermentation and marked dis-
tention of the colon. Normally food does not re-
main in the body a longer period than twenty-four
hours, but under conditions just described may re-
main for a period two or three times as long, which
often results in an infection of the mucous mem-
brane. This may later develop into chronic colitis
or appendicitis.
In a thorough disintegration of the carbohydrate
cells by the action of mastication lies the possibil-
ity of conversion, by amylaceous ferments, of these
Btarchy molecules, into laxative sugars. Starchy
food particles, therefore, should be subjected to
prolonged contact with ptylaine ferment of the sa-
liva, and later to the pancreatic ferment Thus by
a series of oxidations and hydrations from starch
and cane sugar we will have produced dextrose and
levulose which are freely hygroscopic and therefore
food laxatives.
The Diet mmi Coatti pddmm
One other lesson may be learned by a study of
the habits of lower animals, our friends beneath us,
is that they subsist upon but one or two articles
at a time rather than the conglomeration that oft
finds its way upon our tables and into our stomachs.
Foods will agree with each other better in the stom-
ach if but a few articles of diet are partaken of at
each meal, as the stomach is supposed to secrete a
different quality of gastric juice for each article,
and confusion is liable to result if these articles
be too numerous at each meal. Besides, living upon
but one or more articles of diet at a time will not
lead to surfeiting, which of itself is a marked cause
of constipation.
A flesh diet usually constipates because it lacks
in bulk and because of the tendency under bacterial
action to putrefy and produce highly toxic sub-
stances which narcotize the nerve endings in the
bowel and retard peristaltic action.
A lack of fat in the dietary is a frequent factor
in constipation, as the bowel needs lubrication. Fat
in an emulsified form is the best, as in this form
fat does' not interfere with stomachic digestion, as
does free fat. Ripe olives contain 60 per cent, of
olive oil in an emulsified state and these we have
found to be excellent in overcoming intestinal stag-
nation, and in many cases it is all that is needed
to regulate the bowels.
Bile being the natural laxative of the bowel, if
the liver becomes torpid or diseased in any way, and
there is a lessened secretion of this product, the
bowel suffers from a lack of bile stimuli. Measures
to overcome torpidity of this organ must be insti-
tuted.
Stiertmry Life mmi AmtiperUtMs
Again, the female tendency to sedentary life and
a failure to answer "nature's calls" are factors not
to be overlooked. Action is equal to reaction; anti-
peristalsis is equal to peristalsis, and, according to
experiments of Dr. Cotton, of Boston, made by
means of the X-ray, after giving bismuth pellets
with food, when the call of nature is not attended
to, anti-peristaltic action carries the stool back up
into the bowel again. The rectum is an irritative
receptacle and must be emptied. When relief to a
loaded rectum is not afforded at the propei time
and manner, then it must be unloaded the only re-
maining way, and that is back into the bowel again,
where absorption of moisture from fecal matter
and the consequent shock to the nerve endings re-
sults in eventual blunting of their sensibilities by
these retained poisons. This leaves a hard and
oft impacted mass that must eventnally be un-
loaded with more or less effort and discomfort. Or-
ganic changes in the bowel walls take place because
Phila., April, 1922]
The Universally Abused Drag — Aepirin^-Heinemann
279
of this irritating mass and chronicity results.
Bmlky F~d*
Lack of sufficient bulk in the food, as the use of
fine bolted flour bread, is a common cause of con-
stipation. In a three years' practice in the South I
observed that in many families where corn bread and
Johnny cake were staple breadstuffs, constipation
was rare.
Cellulose as found in most vegetables, such as
squash, beets, beet greens, celery, lettuce, asparagus,
potatoes, parsnips, carrots, spinach, brussel sprouts
and cabbage, afford bulk and may well enter into
the dietary with advantage. These bulky foods act
because of the presence of indigestible residue in
the form of cellulose. Cabbage contains 9 grains
of cellulose to the ounce; parsnips. 8.6; brussel
sprouts, 8; kohl-rapi, 7.8; celery, 7; turnips, 6.6;
asparagus, 5; carrots, 5; beets, 5; spinach, 4.6;
cauliflower, 4.6; lettuce, 3.6; onions, 3.6. About 300
grains per day is needful. Remember that meat
contains no cellulose; that sterilized bran contains
200 grains to the ounce, while agar-agar or colaz is
composed entirely of cellulose. The German and
Russian peasant keeps his bowels regulated by the
use of sauer-kraut because of its content of in-
digestible residue in the form of cellulose.
A flesh diet with the use of white flour bread
contains but very little residue and is therefore
constipating. Foods in the form of combination
salads, tender, green corn, lettuce and celery afford
more bulk and roughage when served raw than when
cooked.
Tern, Cmttt mmi Fried F—d*
Tea and coffee are constipating because of their
caffein and tannin content. A cup of strong cof-
fee contains 4 grains of the former and 2 grains of
the latter. The tannin acts as an astringent and
therefore would be of use in the treatment of diar-
rhea. It is by means of tannin that we tan leather.
Evidently not just the thing to put in the stomach.
Fried foods (and how can we escape themf)
need an indictment. Grease coats the particles of
food, so that neither starch nor albumin can be
reached by their appropriate digestive fluids, conse-
quently the bulk of digestion falls upon the in-
testines; these, being overworked, perform their
work imperfectly and throw a mass of fermenting
and undigested starchy and other food material upon
the lower bowel. This proves to be another strong
constipating factor hard to overcome except by edu-
cation of our cooks.
The Universally Abused Drug
Acid am Acetyl Salicylicum — Acetyl Salicylic Acid, Trade-Mark Name — Aspirin
By A. D. Heinemann, M.D., M.Ph.,
640 Adams Street, Memphis, Tenn.
Acetyl salicylic acid, aspirin, is the uni-
versally abused drug. Of this the layman is
woefully guilty, though the physician as well
contributes his share to the promiscuity ivith
which this drug — excellent in its place — is
so carelessly employed. A drug of such ex-
tensive utilization is certainly worth knowing,
hence Dr. Heinemann's paper, we are confi-
dent, wiU be widely read. Do not miss it.
— Editors.
ACETYL SALICYLIC ACID is obtained by heat-
ing salicylic acid with acetic acid (acetic anhy-
drid). It is also made by the action of chloric acid
on salicyclic acid, this in turn being made by the
action of hydrochloric acid on acetic acid (acetyl
chloride). Acetyl salicyclic acid occurs in colorless
and odorless needle-shaped crystals with a slight
acid taste. It is soluble in 300 parts of water, 3 parts
of cold alcohol and 20 parts of ether, and readily
soluble in chloroform. To show the presence of
salicylic acid, add 0.1 gramme of acetyl salicylic
acid in 5 c.c. of alcohol, diluted with 20 c.c. of water,
and add 1 drop of a diluted solution of ferric chlor-
ide; if acid is present, it shows a violet color.
Action and uses of aspirin are same as salicylic
acid and the salicyclates in rheumatism, neuralgia,
gout, influenza and neuritis; also used as a sedative
in manv diseases. It does not dissolve in the stom-
ach and is, therefore, not prone to irritate this
viscus as do the other salicylates. Dose is 5 to 20
grains in capsules, tablets or powders, or in some
pleasantly flavored vehicle.
Dmmger Marks mmi Tremhmemt
In my experience, this drug is a heart depressant;
whvf Because it is a derivative of coal tar; be-
cause we no longer get a natural supply of salicylic
acid, there being not enough true oil to supply the
demand (gaultheria or wintergreen). It should
not, therefore, be used in depressant diseases, espe-
cially where the heart muscles are involved, whether
it be from the "flu," arterio-sclerosis, faulty degen-
eration, mitral insufficiency, or fevers which affect
280
. Diet in Typhoid — Stockard
[The American Physician
action of the heart or its surroundings. If used
at all, it should be in co-ordination with heart stimu-
lants, although, as stated, I do not favor its use at
all in any depressant condition. The action of the
salicylates (aspirin included) depends on the accumu-
lation of the drug in the system; therefore, to get
results, large doses — or small doses repeated often —
must be given. Now this accumulation, whether it
be in the tissues or the circulation, is subject to
certain chemical changes in our bodies, and in my
opinion, untoward manifestation is the result.
The original salicylates, or taken as aspirin, under-
go changes when taken internally (due to the action
of the secretions on excess of the drug) and form
salol and phenol. Now, brother practitioners, how
many of you have been called to see a patient who
was cyanosed and down and out physically? To find
the cause, one should question the patient and it will
usually develop that he or she is an aspirin eater —
aspirin, the stick candy drug of the public; the
cyanosis has probably developed from the changes of
the drug and caused "phenol poisoning."
Now this is the appearance and history of an
aspirin poisoning case. Two (5) grain aspirin tab-
lets (or more) are taken one hour apart. Partial
collapse, cyanosis, oedema of the eyelids and dry
fauces, with or without temperature, pink lips, heavy
breathing, fast pulse are present from four to six
hours later; in fact, the patient is down and out.
This is the picture of two cases I had, and there
have been several more reported since in medical
books and journals, so, brother confrere, watch this
drug; it is dangerous. Treatment consists of hypo-
morphia, % grain; atropine snip., 1/50 grain; rest
in bed, elimination, stimulation and restricted diet.
The condition usually passes off in two days. So
patients with heart symptoms should be watched and
should not take this drug ad Ubitum, which is so
extensively done now, as trouble may arise.
Never prescribe aspirin in an aqueous menstrum,
for it forms acetic acid and, with alkalies, gives off
CO»; you thus defeat your own purpose, the final
result being salicylate of soda and acetate of soda.
This is a common prescription going the rounds:
Alkali and acid ; sometimes the fluid extract of cas-
cara sagrada, aromatic, is added.
1J Acetyl salicylic acid, 1 drachm; sodii bicarbon-
atis, 2 drachms; elixir lactopeptone q. s. ad. oz. ii.
M. et sig. dr. i. q. three or four hours.
Acids and alkalies ought never be prescribed to-
gether, and last, but not least, one ought to beware
of this one — the most dangerous of all the very
toxic— quinine and aspirin, which forms quinotoxin, a
very toxic and poisonous substance. No deaths have
been reported as yet, but some day we may learn
of some fatal results.
Diet in Typhoid
Editor The American Physician :
I notice in your November, 1921, issue quite a
good many remarks by our colleagues on typhoid
feeding. Especially do they condemn "milk feed-
ing, and encourage feeding a liberal diet," one even
"feeding more than he ate."
1 am aware of the practice in recent years of
feeding a liberal diet, and of which 1 have nothing
to say, but when one condemns the feeding of milk
in typhoid, he is just talking, and he would never
convince me that milk is injurious, or that it is
not beneficial as an easily assimilable diet. Milk is
a natural food, as we know, and has all the ele-
ments of nourishment and nutrition up to a certain
age, and especially is it intended by nature for the
weak, feeble digestive powers of infants. And in
a real typhoid infection, is it not true the digestive
powers are weakened by a reduction in the secre-
tion of the gastric glands f Then why not return
to the most easily assimilable and digestible food
we can obtain? Have our colleagues improved on
nature t
When I read such remarks as written by Drs.
Walker, McNeal and Boyd, I wonder did the above-
named gentlemen have a Widal on all those cases
that, upon a very liberal diet, 100 per cent, recov-
ered and 50 per cent, upon milk diet died? Dr.
Walker says a typhoid temperature of 105° will drop
to 102° on good, wholesome food. I would go
further and say it would probably and very likely,
too, go below normal — following hemorrhage or
perforation.
I have seen a typhoid patient, who had a positive
Widal, run temperature three to four weeks with
hemorrhages, and finally improve, temperature at
normal for four days, patient sitting propped up,
and upon eating steak died in twenty hours. An-
other ran about the same course, and after eating
freely of biscuits when left alone, went the same
route, both from perforation. I feed somewhat more
liberal diet than formerly; in addition to milk. But
don't tell me that a real typhoid case can eat the
same diet and same quantity as a well adult. I
notice also that one of the gentlemen named above
condemns Brand's treatment. That's enough; I cer-
tainly do not intend to discard hydrotherapy in
typhoid, and I am sorry to know there is anyone
practicing from an allopathic school who would do so.
I think this, next to feeding, is the most beneficial.
Very little drugs are necessary, except to meet com-
plications.
T. J. Stockard, MD.
Lawrenceburg, Tenn.
Doctor MackeKK Forbes9 Pott-Cradiate Diagnostic Oaks
A 5<mt of Thirty Clone* Emphmzm? Diafmons uW ShomU U Uo$t Htlpfwl to ti* Ccnerml Pradili
By A. Mackantto ForbM, MJ>^ 615 Uahrmfttjr $U Moatml.
Twenty-Ma Clinic
A Case of Injury at the Elbow Joint
THIS BOY, A. W., number 31/20, Children's
Memorial Hospital, age seven years, fell down a
few steps yesterday morning and, in breaking his
fall with his left hand, caused some injury to his
left elbow joint.
Injuries to the elbow, as you will all realize, are
very important and serious, especially in children. I
remember when I was a student we used to be
told that the results following treatment of injuries
about the elbow joint were so unsatisfactory that
many practitioners, in at least one of our provinces,
would not undertake the care of such injuries with-
out getting guarantees that no legal action should
be taken against them if the results should prove
to be unsatisfactory to the parents.
With the discovery of X-rays we hoped that our
ability to diagnose and treat these conditions would
be made easier, but, unfortunately, because of the
many ossifie centres about the elbow joint and the
late ossification and union of the various epiphyses,
one is apt to be confused in endeavoring to read
an X-ray of a child's elbow.
In studying the anatomy and physiology of the
elbow joint we find that normally there is no lateral
movement. Only flexion and extension are pos-
sible. Both of these movements are limited by the
tension of the soft structures and normally by con-
tact with bone. The bony structures check forced
motion. A point of practical importance is that if
the arm be extended, a line drawn from one condyle
to the other passes over the tip of the olecranon.
This is said to be as useful a line as that of Nelaton
in the hip. If the elbow be flexed to a right angle,
the olecranon lies a little more than one inch below
and not quite half-way between the two condyles.
It is a little nearer to the internal condyle. The
humero-ulnar joint slopes obliquely downwards. This
makes the axis of the extended forearm diverge out-
wards and gives rise to the so-called carrying angle.
Amongst the common injuries of the elbow joint
(1) Dislocation of the forearm backwards.
(2) Dislocation of the head of the radius forward.
(3) Fracture of the external condyle.
(4) Supracondylar and condylar fractures.
(5) Fractures of the internal condyle.
(6) Fracture of the head of the radius.
I do not believe that fracture of the olecranon
process is common in children.
I should like to discuss with you the characteris-
tics of each of the injuries named and after hav-
ing discussed each individual injury I will be very
glad to discuss the treatment with you because, as
I have said, the treatment of fractures about the
elbow in the past has often been followed by evil
results; thus if it is possible for me to draw your
attention to more modern methods than those some-
times used I feel that you will be forearmed and
thus able to save many children from deformities
and loss of function which, in the past, have some-
times followed the most common schemes of treat-
ment.
(I) IKabcKiM W tfc Fttmrm BmekmmriM
In the backward displacement of both bones there
is a fulness behind, just below the bend of the elbow.
The joint is usually flexed at an angle of about
140°. The head of the radius is very superficial. It
lies to the outer side of the olecranon and behind
the external condyle. The forearm is shortened an-
teriorly and broadened. In its upper part there is a
deviation or the axis of the arm, limited flexion and
extension and a varying amount of lateral move-
ment. This dislocation is due to a fall on the hand,
and the elbow is thereby hyper-extended and usually
abducted. Occasionally it is coincident with a Coles'
fracture or an atypical fracture about the lower end
of one or both bones. Fractures of the olecranon,
coronoid and tip of the internal condyle or head
of the radius may complicate this dislocation.
(2) DUUc*mm W At Hemd W At Rmdimt Ftmmri
This used to be called subluxation of the radius.
It is usually seen in small children. The child may
be brought with a painful elbow held in a position
of partial extension and semi-pronation. The arm
can be freely flexed, but there is some limit in supi-
nation. The injury is almost always inflicted by a
pull upon the arm, accompanied by abduction or
adduction, as is seen in a sudden tug to lift a child
out of danger. In this case the head escapes more
or less completely from the orbicular ligament. In
later life this injury is most often due to a blow
from behind while the arm is pronated, to a severe
twist or to a fall on a pronated forearm. The head
can easily be felt lying both forward and inward
282
A Case of Injury at the Elbow Joint — Forbes
[The American Physician
from its normal position. The three bony points
maintain their relationship. There is limited supi-
nation. The head of the radius, of course, moves
with the shaft and flexion is naturally checked at
the elbow.
(3) Fracture* of the External Condyle
Fractures of the external condyle are fairly com-
mon. Sir Robert Jones found twenty-one instances
in a series of one hundred and twenty-one. The
line of the fracture follows the epiphyseal line fairly
closely. It runs up from the condyle into the joint
in the vicinity of the trochlear groove and it car-
ries with it a small portion of the diaphysis. The
condyle is displaced upwards, not usually far, be-
cause it is held by its ligamentous attachments. One
often notes both rotation and flexion of the frag-
ment. There is a swelling, more especially on the
outer side of the elbow, crepitus, mobility and im-
pairment of flexion.
The relationship of the three points of bone pra
altered, the transverse diameter on the injured side
being increased. This injury is due generally to a
fall on the flexed elbow.
(4) Supracondylar Fracture*
In the majority of supra-condylar fractures the
break occurs above the epiphyseal line. The diagno-
sis of supracondyloid fracture is often confounded
with backward displacement of the elbow. In both
cases there is a prominence at the bend of the elbow ;
a prominence of the olecranon posteriorly and lateral
mobility at the elbow. In the fracture, however,
the three bony points maintain their relationship
and crepitus can be elicited on reduction. Displace-
ment is, however, apt to occur unless the arm be
immobolized.
(5) Fractmres of the Internal Condyle
Sir Robert Jones draws attention to the fact that
the line of fracture in this often begins above the
epitrochlear and runs to the centre of the elbow
joint.
The ulna is attached to the fragment and both the
condyle and ulna held in fair position by the radius.
The change in the relative position of the three
great bony points is, therefore, not great. The
olecranon maintains its relationship to the internal
condvle.
(6) Fracture of the Head of the Rodin*
This fracture is common and any displacement is
usually outwards and forwards. It is liable to be
mistaken for a fracture of the external condyle.
As we have now discussed the common injuries
to the elbow, we are in a position to continue the
study of the history of the patient I have brought
before you.
Let me repeat, on January 21, 1920, while the
boy was playing on the back steps of his home he
fell five steps, breaking his fall with his left hand.
A doctor was called who said that the boy had a
fracture of the left elbow and for this he was sent
to the Children's Hospital.
Careful examination was made of the elbow and
it was found that the left arm was held in a posi-
tion approximating full extension. There was swell-
ing and ecchymosis about the elbow joint.
The finger carried up the posterior surface of the
olecranon demonstrated that this lay in a position
much posterior to the humerus; indeed, the finger
seemed to sink into a mass of soft tissues, thus
demonstrating a dislocation backwards of the fore-
arm from the humerus. An X-ray confirmed this
diagnosis.
As I have stated in my opening remarks, injuries
about the elbow joint, during my studentship ami
in the early days of my career as a practitioner,
were considered to be commonly followed with bad
results, even indeed wtih disastrous results. For
many years there was a tendency to fix injured
elbows in angular splints closely applied and firmly
bandaged, but, as Sir Robert Jones has stated, little
attention was paid to forestalling by flexion the limi-
tation of movement which the exudation of callus
entails.
I think it was in 1892 that Sir Robert Jones
first drew the attention of the medical world to the
position of acute flexion as a safe routine in the
treatment of grave elbow lesions. This position
seems to be a rational one, because by flexion one
can get relaxation of all the muscles on the an-
terior surface of the elbow, and in fractures in this
region as well as in all fractures the consideration
of muscular attachments and muscular function are
of greatest importance. Again, it is possible to
maintain reposition of the fractured portions of a
bone by flexion and in this position the best pos-
sible circulation will be assured as well as the abil-
ity to observe the part injured.
A Student. — You have said that it is possible to
maintain the reposition of the fractured ends. But
how are we to reduce the deformity t
The Clinician. — The method used by Robert Jones
is to supinate, to extend and to flex the forearm.
A Student. — One can easily see the advantages of
treatment by flexion to forestall that callus founda-
tion which will so interfere with movement that the
important functions of the joint are limited, but
flexion can hardly be depended upon to relieve that
lateral deformity which is so common where there is
a supracondylar fracture or, again, to prevent inter-
ference with extension which is not so very un-
common.
The Clinician. — Your point is well taken, but the
position of flexion assures the best function in the
greatest number of cases for whom non-operative
treatment is chosen, as the most suitable method.
Phila., April, 1922]
A Case of Injury at the Elbow Joint — Forbes
283
Certain deformities, as suggested, are not relieved
by manual reposition and flexion. Let us take, for
instance, what is known as "gun-stock deformity."
This is a deformity which reminds one of a knock-
knee. It is very apt to follow a fracture of the
internal condyle or transverse fractures through or
above the condvle. But we must remember that Sir
Robert Jones has impressed us with the fact that
some of the ugliest elbows present the best function,
while others whose appearance cannot be criticized
lack function.
I have been interested in the work reported by
A. R. Shands, of Washington. Beginning in 1896
he operated on all cases in which the X-ray showed
that the fragments were not properly reduced by
manipulation. He says that the broken ends can be
readily put in the best possible position through a
small incision and held there until union is firm.
After this the arm should be placed in a plaster
of Paris splint with the forearm in ACUTE
FLEXION.
Supracondylar fractures where the line of frac-
ture is oblique will present some difficulty in keeping
the fragments in position. Shands says: "In this
class of cases it has been my custom to insert a
drill at a right angle to the line of .fracture through
the broken fragments and to leave it for about
two weeks." . . . . "I remove the plaster of Paris
at the end of three weeks, when passive motion and
massage are begun."
"I do not intend to say that it is necessary to
adopt the operative method in every case of fracture
about the elbow, for there are cases where the dis-
placement is so slight that it will not interfere with
obtaining a perfect result . . but where the
fractures are oblique or transverse with much dis-
placement, the patient is not given the best chance
of a perfect recovery unless such procedure is insti-
tuted/
A student: Will you give us some rules to govern
dur procedures t When are we to treat recent in-
juries about the elbow and how are we to treat
themf
The clinician: The deformities must be corrected
without delay. All injuries about the elbow, except-
ing fracture of the olecranon should be fixed at an
acute angle. First supinate them, extend them by
traction and acutelv flex the elbow. I remember Sir
Robert Jones used to employ the following scheme
for cases when an anaesthetic was not required.
The f otic* Sit* %m a Ckmr
The operator stands before the patient with a foot
on the rung of the chair on which he is seated and
with his leg placed between the patient's knees.
The operator places his right thumb over the an-
terior surface of the head of the radius. With the
left hand he pulls firmly on the wrist. Thus traction
*N. T. Med. JLP Dee. 22, 1920.
is made in a line with the arm.
The operator now presses the head of the radius
with his right thumb, and at the same time flexes
and supinates the forearm with his left hand. These
three movements are synchronous.
Gentlemen, in closing this clinic let me impress
upon you the fact that until acute flexion became
the routine treatment in these cases, calamitous re-
sults were common.
Broadly speaking, we have discussed two methods
of treatment.
Undoubtedly, non-operative treatment by flexion
should be that of our choice in the great majority
of cases, but there are a limited number of cases in
which judgment will dictate that operation should
be decided on in the interest of our patient.
To return to the historv of our little patient,
A. W.
#The patient was anaesthetized and the disloca-
tion was easily reduced by the practical application
of the principles laid down by Sir Robert Jones,
which we have just discussed. The arm was then
fixed in a position of extreme flexion by the use
of a leather collar and cuff.
On October 19th, 1920, just nine months after his
injury, the patient reported at the Children's Me-
morial Hospital. Examination demonstrated per-
fect movement at the elbow.
Us* •fthmg* im NemnUgy tmi Ptydmmtry
Of the various symptoms which demand attention
from the neurologist and the psychiatrist, C. MacFie
Campbell, Boston (Jour. A. M. A., October 15, 1921),
says the most common are pain and distress, sleepless-
ness, agitation and excitement. These are the symptoms
for which the physician has recourse to drugs, while
the complex, underlying disorders are recognized to be
beyond the reach of such simple methods of treatment.
As for the treatment of pain and distress and sleepless-
ness, the danger of a purely symptomatic treatment is
well known. They are merely indicators of the under-
lying disturbance, and it is the business of the physician
not to confine himself to the warning sign, but to pene-
trate to the underlying disorder. Merely to remove the
disconcerting symptoms involves the double danger of
neglecting the fundamental trouble, and of developing
an ignoble dependence on the drug. But symptoms de-
serve some attention on their own account, and pain is
the one which is the most insistent. For conditions of
mental distress with agitation, barbital in comparatively
small doses is a very useful drug. Paraldehyde is the
drug which gives the nearest approach to a normal
sleep, but owing to its disagreeable odor the coal-tar
derivatives have been much preferred, and of the series
barbital is the most uniformly satisfactory. If in
psychiatry the use of drugs is somewhat limited, it is
largely because in these complex disorders the chief
weight in the treatment must be laid on the personal
relationship between physician and patient, on the
organization of the nursing personnel, and on the
atmosphere of the hospital with its occupational and
recreational elements. It is in virtue of the presence
of these factors that treatment in hospitals is, as a rule,
to be recommended in preference to treatment of the
patient at home.
284
Painful Points of the Feet — Cross
[The American Physician
Footlights on the Feet
or
Puncta Dolorosa Pedis
By Charles Cross, M.D.,
California St. and Fifth Ave., San Francisco
A helpful graphic chart for anatomic
review of the most troublesome points of the
feet. — Editors.
In submitting this chart and this short paper for
publication, I wish to bring before my colleagues a
simple method for rapidly recalling the usual loca-
tion of painful points of the feet.
In an examination service of many years, this
chart has been very useful to me. At a glance it can
be referred to to refresh the memory and recall the
importance of pain as a symptom in any location of
the foot. My repository of recollection of anatomical
knowledge seems .to have the habit of requiring more
PUNCTA
DOLOROSA
PEDIS
(Painful Point 8
of the Feet)
DORSAL <
review, to keep me on speaking terms with the sub-
ject, than any other of the medical studies. Dr.
Holmes is credited with saying that anatomy was a
subject to learn seven times, and that it would be
forgotten as often. In my case, it seems that the
number should be multiplied by ten or more, to keep
it with me. Therefore, charts are my helpful aids, and
this one is especially useful.
Ammtomy— Broke* Arch*
In studying anatomy of the legs and feet, reading
and re-reading chapters on the bones, ligaments, mus-
cles, tendons, blood supply and enervation and os-
seous development and re-reading it all over several
times, something new will be found at almost every
reading, and Gray's is the anatomy I recommend. A
very good plan is to cheek off the special points dis-
Anterior Metatarsal Arch (A M A )
Posterior Tarsal Arch (P 0 S T A)
Astragalus
Cuboid.
Scaphoid.
Toe Nails.
Great Toe.
Ingrowing.
Focal Infection.
Pathological.
PLANTAR
LATERAL 1
Anterior Metatarsal Arch (A M A)
Posterior Tarsal Arch (P 0 S T A )
Os Calcis Inner Tubercle.
Os Calcis Outer Tubercle.
Calcaneo-Scaphoid Ligament.
'Internal Longitudinal Arch (I L A).
External Longitudinal Arch (E L A).
Tuberosity of Fifth Metatarsal.
Bunion Joint Internal.
Bunion Joint External.
Malleoli.
Great Toe.
J Internal.
\ External.
PhiU., April, 1922]
Recovery From Tetanus — Moss
285
covered in each reading. It will demonstrate that
much is gained by each review. The anatomy of the
ligaments is a very important study.
To prevent broken arches and flat feet, and to re-
build broken arches, it is quite necessary to be
familiar with the ligamentous arrangements before it
is safe to attempt the technique of bloodless surgery,
to break up adhesions, and adhesions must be broken
up before it is possible to rebuild broken arches.
From an observation of many years it has occurred
to me that my colleagues have not paid to the feet
quite the attention they deserve. This chart and
paper are published with the hope that they will aid
colleagues in an interesting and entertaining review
of a very important part of the body.
Recovery From Tetanus
REPORT OF A CASE
By John T. Moss, M.D.,
Memphis, Tennessee.
Tetanus is always a desperate condition.
Dr. Moss has been fortunate in effecting the
cure of his patient — which goes to show that
it is always worth trying. — Thb Editors.
J. W., Jr., boy, age 12, July 1, while playing in
the street, stuck splinter in base of left middle toe.
This the mother thought she had removed. Wound
continued, to discharge though.
July 11 patient complained of soreness and stiff-
ness in jaw and neck and sore throat, which was
thought to be tonsillitis. This continued to grow
worse. The next morning, while playing with other
children, he was offered a piece of banana, but was
not able to open his mouth, at the same time the
other children noticed slight convulsions and told him
to go home. His condition continued to grow worse,
jaws were set and spasms became hard and often.
He had an extremely bad night.
I saw the patient on the morning of the 13th, about
9.30 A. M., and found him with facial muscles and
jaws set, muscular rigidity throughout body, and on
very slight disturbance he would go into clonic con-
vulsions, raising himself on his heels and head.
Abdomen was as stiff as a board, arms were not
affected as much as the rest of the body, but stiffened
when moved, unless he moved very gently. Tempera-
ture was 102 F., pulse 96, res. 28 and very- shallow.
He would strangle when an effort was made to swal-
low, but with care could be made to swallow very
slowly, and only a sip at a time, without exciting
spasm. Patient appeared to be in desperate condi-
tion.
Wound was opened, cleansed, and gauze drain pui
in, dressings were kept wet with Dakins sol. This
was continued throughout the course of the disease.
Twenty thousand units of antitoxin were given, ten
thousand units under skin and ten thousand intra-
venously, at ouee. No medicines were given except a
large dose of castor oil, which was repeated whenever
the bowel failed to act. Room was kept dark and
quiet.
July 14, patient slightly improved. Twenty thou-
sand units more of antitoxin were given intra-
venously, one quart of 10% glucose sol. given per
rectal drip.
July 15, patient improved. Twenty thousand units
antitoxin administered intravenously, one pint of glu-
cose repeated also.
July 16, patient improved. Twenty thousand units
antitoxin intravenously given again. Five grain
doses of chloral ordered when convulsions were severe.
July 17, patient further improved. Twenty grain
doses of bromide of potash ordered along with the
chloral. Only two to three doses were given a day
and these only at night, as it was then we had the
most trouble. Muscular rigidity continued right
along, but the convulsions were less severe and not
so frequent. Temperature and pulse improved.
Convulsions had stopped by the 25th and on the
date of dismissal (29th) the muscular rigidity was
about 60% improved, mouth could be opened about
halfway. Throughout the course of the disease appe-
tite remained good and patient was fed freely on- milk
and egg albumen. He complained very little of pain
at all times. Pulse and temperature were both ele-
vated while taking antitoxin.
July 22, a small splinter about one quarter of an
inch long was removed from the wound, or rather
did the splinter remove itself.
August 13, patient came to my office to see me. At
this time he looked well but said there was still
some stiffness over the body, and I could see that he
could not control the facial muscles as well as he
normally should. He had no pain at this time.
I consider recovery principally due to sufficient
antitoxin, aided also by castor oil and nourishment
which is preferable to filling the patient with medi-
cine, upsetting his stomach and thus hindering his
recovery instead of helping it.
286
Acromegaly and Lymphatic Leukemia — Goldstein
[The American Physician
Acromegaly and Lymphatic Leukemia
REVIEW OF LITERATURE
By Hyman I. Goldstein, M.D.,
1425 Broadway, Camden, N. J.
Walton's case of acromegaly was a man 44 years
of age. His feet measured 12% inches in length.
The measurement of the hand from the carpal border
of the palm to the tip of the middle finger is 8>4
inches, the width is 4l/2 inches. The cranial circum-
ference is 26 inches, and the chest circumference is
46 inches.
His patient complained of muscular pains and
weakness, vague sensations of numbness and prick-
ling without real inability to feel objects, pains in
various parts of the body, and paresthesiae.
Walton divides the symptoms into (1) those of
disordered metabolism, excessive growth of osseous
and connective tissue structures; (2) symptoms of
pressure, such as cranial nerve paralysis, pyramidal
tract paralysis, and diabetes mellitus, optic nerve
atrophy from pressure of the nerve against the
orbital plate, and preceding the atrophy, various
disturbances of the visual field resulting from pres-
sure upon the optic commissure, either anteriorly
or posteriorly, the most common finding being a
loss of vision for objects on the temporal side of
the field. Hemianoposia appears less frequently, and
is due to pressure on the optic tract behind the
chiasm; (3) general symptoms — headache, somno-
lence, lack of mental vigor, resulting from pressure
and from disorder of the pituitary secretion. Pares-
thesiae and pain seemed to be due to irritation and
pressure caused by increase of connective tissue
about the nerve fibres.
Acromegaly is a steadily increasing disorder of
nutrition, due to primary pituitary disease and*ex-
cess of its glandular secretion. In Walton s case
there were no double vision, impairment of eyesight,
disorders of olfactory sense, or other cranial nerve-
function, no headache, vomiting, somnolence, or
loss of memory, no spastic gait, no local paralysis,
and disturbance of reflexes. There was good vision,
the fundus as in my case was normal, and the visual
field was complete.
If hyperphasia affects the pituitary gland in in-
fancy, gigantism results, the long bones growing
rapidly longer till a height of 7 or IVi feet is reached.
It is only when the glandular portion of the hypo-
physis is diseased that acromegalic symptoms ap-
pear. Although acromegalics are usually large and
appear strong, they are generally weak, tire easily,
and have no "pep."
Cuy Hinsdale's prize essay on "Acromegaly," of
87 pages, including a complete bibliography of 7l/2
pages, appeared in "Medicine" (Detroit) in 1898. It
is a most thorough and complete review of the
subject.
M. Pierre Marie (1886), about thirty-five years ago,
first described this condition, and reported cases of
acromegaly as well as cases (1890) of hypertrophic
pulmonary arthropathy.
Cases have been reported of acromegaly with
Grave's disease, with myxedema, with mental disease,
with diabetes mellitus, diabetes insipidus osteitis de-
formans, gigantism, elephantiasis, chronic rheumatism.
Berkleys (1891) case occurred in a negro. G.
Ranzier (Rev. de Med. ii, 1891, p. 56) discusses the
diagnosis of acromegaly and pulmonary osteo-
arthropathy. In Medicine (Detroit), 1898, pages
823 to 830, will be found a complete list of refer-
ences to the literature on acromegaly to that year.
M. Sternberg classifies acromegaly into three types:
(1) A benign form. Duration about 50 years,
changes slight.
(2) Usual chronic form. Duration, 8 to 30 years.
(3) Acute malignant form. Duration, 3 to 4 years.
In this type the pituitary is sarcomatous.
Dalton's (1897) patient was a man aged 23 years,
who died of diabetic coma in King's College Hos-
pital. The symptoms of diabetes had only been
observed during the last two months. The liver
weighed 96 ounces and look quite normal. The
thymus was very large, and consisted of two sym-
metrical lobes, each five inches long, the pituitary
body distended the sella turcica, and projected well
above it. The lymphatic glands by the pharynx,
in the posterior mediastinum, and in the mesentery,
were large, soft, and pale, but in other parts of the
body (axilla, groin, etc.) they were not enlarged.
The suprarenals were normal. The thyroid was
moderately large and quite firm. Dalton remarks
the enlargement of the pituitary body appears to
be essential to acromegaly, and the thymus and
thyroid appear to be constantly enlarged in this
disease. He concludes by saying that in his case
there were enlarged organs — pancreas, liver, and
thyroid, with glycosuria and myxedema.
Dallenmaync's (1895) case was similar to Dal-
ton's in that there was acromegaly with diabetes
and enlargement of all the viscera, the liver weigh-
ing 200 ounces and the pancreas 7 ounces. (Arch,
de Med. Experiment, et d'Anat Pathol., Paris, vii,
589, 1895.)
Mitchell and LeCounU in the New York Medical
Journal (1899, LXIX, April 15, April 22, and 29),
give a necropsy report of a case of acromegaly and
a critical review of the recorded pathological anat-
omy in the literature. The liver and spleen are
enlarged in a large number of cases of acromegaly
that came to autopsy. The thyroid gland was
found enlarged in half of the cases that were ex-
amined at necropsy. The enlargement of the pit-
uitary body has been due to adenoma, sarcoma, or
other neoplastic growths in the great majority of
cases examined. In thirty necropsies the kidneys
were found enlarged twenty-one times.
Bourneville and Bricon, Dolega, Niepec (five
cases)," and Osier have reported cases of cretinism
in which either absence or atrophy of the thyroid
gland was accompanied by enlargement of the hypo-
physis. Boyce and Beadles, in a case of myxedema
with atrophied thyroid, found a compensatory en-
largement of the hypophysis and in a case of sporadic
cretinism with entire absence of the thyroid, the
hypophysis was also enlarged. LeCount states that
acromegaly does not depend upon a hyperplasia of
the epithelial elements of the anterior lobe, for
numerous cases are on record in which no symp-
toms of acromegaly were evident, and yet similar
changes in the hypophysis to those seen in acro-
megalic cases were found present.
Mussalango (1892), Tamburni (1894), Benda
Phila., April, 1922]
Acromegaly and Lymphatic Leukemia — Goldstein
287
(1901), Modena (1903), and Fischer (1910), consider
acromegaly the result of an hyperplasia or adenoma-
tous condition of the anterior lobe of the hypo-
physis. Some believe the enlargement of the
hypophysis to be only one feature of polyglandular
syndrome, and that it is the result, rather than the
cause, of acromegaly. However, while some dis-
turbance undoubtedly underlies the gradual hyper-
trophy of the anterior lobe in acromegaly, clinical
and anatomical evidence support the fact that bone
changes follow instead of precede the hypophyseal
hyperplasia.
Caselli and Cashing, working on dogs (with feed-
ing and injection experiments), and Aldrich and
Miller, working on white rats, were not able to
produce "acromegaly or gigantism" — no overgrowth
in puppies, or acral changes in old dogs were pro-
duced. As a matter of fact, these feeding and in-
jection experiments not only do not increase the
stature of animals, but retard their growth and
stunt them. Parisot in his experiments found no
noticeable changes with repeated injections of an-
terior lobe extracts into adult dogs, nor in puppies
injected with small doses. With large injections in
young animals, diminution in weight resulted. On
the other hand, hyposecretion of the anterior lobe
of the hypophysis is accompanied by bone changes
exactly opposite to those of hypersecretion.
NeaTs (1898) case of acromegaly occurred in a
woman, aged 41 years. Total duration of disease,
18 to 19 years. The thyroid gland was enlarged,
weighing 6^2 ounces. The thymus gland was not
seen. The spleen was greatly enlarged, and weighed
18 ounces. No actual enlargement of the bones
of the hands or the feet was present. The pituitary
tumor showed a remarkably uniform structure of
polyhedral cells, somewhat large in size, and with-
out visible intervening substance. In general char-
acters, the cells resemble those of the anterior lobe
of the pituitary body. The changes are classed
by Shattock as under the head of hypertrophy, be-
cause the enlarged body everywhere is encapsuled,
and the surrounding bone is uninvolved. The pit-
uitary gland was remarkably enlarged and measures
2l/2 inches in the vertical direction.
Morris (N. Y. Path Soc'ty Proc. 1907, vii, 19)
reported a case of acromegaly in a German, a driver,
aged 33 years. He was admitted to Bellevue Hos-
pital in December, 1902, and died four years later
(Jan., 1907). He was in Dr. Frank W. Jackson's
service. Duration of illness was four and a half years.
He complained of persistent frontal headache and
attacks of vertigo. Gradually increasing loss of
vision, ending in double optic nerve atrophy and
complete blindness. Recurrent epileptiform attacks
occurred. Glycosuria for 22 months. Splanch-
nomegalia was not present. Thymus was persist-
ent; weight 70 grams. The tongue was very large
and broad. Maximum breadth was 7 cm. and measur-
ing 11 cm. from apex of tongue to apex of circumval-
late papillae. Lingual tonsils were large. Thyroid
gland was symmetrical and normal in size and ap-
pearance. The only lymphatic hyperplasia that was
noted was found in the larynx and pharynx, the
splenic follicles of the spleen not being hyperplastic.
A tumor 5x4.5x3 cm. was found on the inferior
surface of the right frontal lobe, and was connected
by a broad pedicle to the pituitary gland proper,
which was enlarged, the spheroidal pituitary mass
being 30 mm. in diameter. The pituitary tumor, in
its growth, has enlarged the sella turcica, and
pushed aside the spheroidal cells and the clinoid
processes. Spleen weighed 510 grams, being almost
double in weight. The capsule was wrinkled. Pan-
creas was large and weighed 170 grams, being 1/6
above normal in relation to body weight (90.9 kils.
in wt., length of body 5 feet 8J4 inches).
The tumor showed many spheroidal or oval, cells,
grouped in irregularly shaped lobules or alveoli by
delicate capillary walls, apparently composed only
of endothelial lining. The tumor is extremely cel-
lular and very vascular.
Tamburini (1897) reported upon thirty cases with
autopsies. He found that all had tumors of the pit-
uitary— either a simple hypertrophy of the gland, or
a total involvement in an adenoma, in which were
preserved the principal elements of the gland. Tam-
burini (Archiv. de Neurologie, 1897, Tome V, p.
621), found the pituitary gland was never atrophied
in acromegaly, and that acromegalic symptoms were
absent in cases of pituitary tumors where the gland
was diseased and atrophied, and where its function
has been lost. He therefore concluded that hyper-
secretion was the etiological factor of acromegaly.
Brooks (1898) in his excellent paper, also supports
this view.
Sternberg, in his study of 210 cases, found six
acute cases, in all of which there was a true sarcoma
of the hypophysis. Brooks believes these sarco-
matous cases were incorrectly diagnosed, and that
they were probably all of them adenoma or hyper-
plasia.
According to Sternberg, 20% of the acromegalics
are over 177 cm. in height, that is 5*1 1", and 40%
of all giants are acromegalics. Giantism and
acromegaly are therefore frequently associated.
Percy Furnivall (1898) reports on a case of
acromegaly in a man aged 58 years, a commission-
aire. The man was admitted to the St. Bar-
tholomew's Hospital complaining of weakness,
nervousness, and enlargement of the feet, hands,
and lower jaw. He suffered from numbness, weak-
ness, and trembling of his hands. Circumference of
the head at the level of the external occipital tuber-
osity, and the superciliary ridges, was 23$i inches.
Round the front of the lower jaw, from angle to
angle, is 9J^ inches. The liver, spleen, and pan-
crease were natural. The thyroid was slightly en-
larged. No trace of the thymus gland was seen.
Lungs showed well-marked emphysema. The pituitary
tumor consists of an enlarged anterior lobe, the seat
of an adenomatous tumors or a simple hypertrophy,
affecting the central zone of the anterior lobe, which
had degenerated and become cystic in its central
part. While M. Sternberg, in his monograph on
"Acromegaly" (1897), collected 47 cases with
post-mortem reports, Furnivall was able to collect
7 more cases, making a total of 49. He includes in
his review an analysis of these 49 cases, in all of
which the hypophysis was found to be affected.
Gumma of the pituitary has been reported by
Weigert (1875), Barbacci (1891), Beadles (1897).
Hunter (1898), and some others. No acromegalic
symptoms were mentioned in any of these cases.
The four cases mentioned occurred in women, aged
64, 41, 41, and 47 years, respectively.
Hunters case (1898) of acromegaly occurred in a
driver, aged 52 years. He complained of shortness
of breath and sweating. Body was 5'9", spleen
weighed 6 ounces, natural. There was no enlarge-
ment of sella-turcica, and the pituitary appeared
normal in size. On section it appeared extremely
288
Acromegaly and Lymphatic Leukemia — Goldstein
[The American Physician
vascular, the glandular substance increased but
normal. Thyroid gland was enlarged, weighing \l/i
ounces, firm, red hypertrophied. The changes found
were principally those of hypertrophy of the pit-
uitary and thyroid, kidneys, bones of head, hands
and feet, thigh and legs, and hypertrophy of the
skin of the hands.
Rollestons (1898) case was a woman aged 35
years. Her headache, which was extremely severe,
was relieved by a combination of pituitary and
thyroid extracts. She had several epileptiform fits
for several months before her death. There was a
soft, creamy tumor of the pituitary body. The
sella-turcica was very deeply excavated and as large
as a walnut, the posterior clinoid processes were
markedly displaced backwards, as the result of
pressure exerted by the growth. The brain weighed
49 ounces. The thymus gland was persistent though
not hypertrophied. The thyroid was normal in size.
The liver was enlarged, weighing 76 ounces. Spleen,
8 ounces in weight, was normal. Microscopically,
the pituitary growth was a medium-sized round-celled
sarcoma. The brain and petrous bone had been in-
vaded by the sarcomatous neoplasm. The disease
had lasted three years. The epileptiform fits and
intense headache were due to the cerebral involve-
ment. Osborne's and Williamson's cases were also
sarcomata of the pituitary. In Woolcombe's (1894)
case of psammoma of the pituitary body, no symp-
toms of acromegaly occurred. In Osborne's case
splanchnomegaly was well marked. The heart
weighed 41 ounces. Liver weighed 7 pounds, 2
ounces. Spleen, 36 ounces. Thyroid weighed 101
grams. There was also an accessory thyroid in the
thorax, weighing 36.5 grams. The man was 47 years
old; duration of disease, 24 years. The sarco-
matous growth in this case was probably implanted
on an old-standing and previously existing cystic con-
dition of the pituitary body.
Pierre Marie found glycosuria present in one-half
the cases. Hinsdale found it in 14 out of 130, while
Von Hansemann found it in but 12 of the 97 cases
he collected. In one of Strumpell's (1888) cases it
would appear and disapper at intervals.
According to Sajous' views, a nervous center exists
in the hypophysis, and the several ductless glands are
connected by a nervous pathway. Diabetes of hypo-
physeal origin is the result of an irritation, a disturb-
ance produced in this nervous centre, in the same way
that the nerve-path in its bulbar course is influenced
by puncture of the fourth ventricle. Loeb believes it
to be due to pressure exerted on the structures at the
base of the brain, and of course cerebral tumors, de-
veloping from or in the neighborhood of the hypo-
physis, are the most likely to cause glycosuria. He
believes a centre regulating the mechanism of sugar
exists in this region.
Konigshoffcr, Oppenheim, Rath, and Weil have re-
ported polydipsia with polyuria without glycosuria.*
Atrophy of the genital organs may occur. In many
instances, even though there may be an enlargement
of the genital organs, there is usually a diminution of
desire and potency which may progress to complete
loss of the sexual function. In my case there was
total loss of function for several years, with a return
of the sexual desire and function during the past two
years.
Pechkranz and Babinski were among the first to
report changes in the genitals. Roubinowitch re-
ported a case studied by Marie, who developed acro-
megaly after childbirth and showed progressive atro-
phy of the organs of generation. Launois and Ces-
bron conclude that sexual atrophy can form part of
the hypophseal syndrome, but that it is not invariably
a consequence of tumors of the hypophysis.
Bartels and GOtzl and Erdheim reported cases
with a lowering of the internal temperature. (91 2/5 3
F. to 96 4/5° F.) In myxedema, too, we may often
get low temperature readings.
In his original description, P. Marie clearly sepa-
rated the two dystrophies — acromegaly and gigan-
tism. However, this view has been disputed by nu-
merous investigators. In 1889, Virchow stated that
acromegaly was a secondary condition of degenera-
tion succeeding upon the excessive growth.
Frilsch and Klebs, Langer, Taruffi, Tamburini,
Cunningham and others, in examining the skeletons
cf giants, found the characteristic deformities of
Marie's disease, and Massalongo concludes that
acromegaly was nothing but a delayed abnormal form
of gigantism.
/. F inlay Alexander discusses fully the subject of
hypertrophic pulmonary osteo-arthropathy in his
thesis in St. Bartholomew's Hospital Reports (1906,
XLII, pp. 41-78), and reports five cases of this con-
dition that he has seen, with a review of 103 cases
on record. As to the differential diagnosis he states
that hypertrophic pulmonary octeo-arthropathy does
not occur without clubbing of the fingers, but club-
bing is not hypertrophic pulmonary osteo-arthro-
pathy, and no case ought to be considered genuine
unless, in addition to the clubbing, there are bone
changes. These latter can easily be proved by ski-
agraphy, which ought always to be employed.
Acromegaly has on occasion masqueraded as hy-
pertrophic pulmonary osteo-arthropathy; but the
changes of the extremities in the former disease are
hypertrophic, with maintenance of the normal pro-
portions, whereas in the latter there is marked de-
formity. With acromegaly are associated changes
;n the facial bones and cartilages of the ears, nose,
and eyelids, as well as nervous symptoms.
Other symmetrical conditions which may be mis-
taken for hypertrophic pulmonary osteo-arthropathy
aic rare, for a simultaneous affection of bones and
joints is most uncommon apart from hypertrophic
pulmonary osteo-arthropathy. In secondary syphilis,
for instance, there may be symmetrical synovitis in
certain joints, generally the knees, and in congenital
syphilis symmetrical hypertrophy of the tibiae, with
anterior curvature about their centre. These two
conditions are not found together, and either, occur-
ring separately, ought to be readily recognized.
Osteo-arthritis is distinguished by the creaking of
the joints and the definite osteophytic lesions.
Though in patients suffering from syringomyelia
there may be symmetrically swollen joints, with en-
largement of the bones in the neighborhood This
condition is not lasting, but gives way to atrophic
changes which disorganize the joints; moreover, the
changes of syringomyelia are generally asymmet-
rical, while dissociated anaesthesia?, muscular atro-
phies, vasomotor and paralytic symptoms serve to
mark the disease.
Alexander's conclusions are:
1. The condition known as hypertrophic pulmonary
osteo-arthropathy consists essentially in a deposit of
new bone on the shafts of longbones.
2. A constantly associated but not peculiar phe-
nomenon is clubbing of the fingers and toes.
3. The disease is mostly found as an accompani-
ment of lesions which result in copious and chronic
(Continued on Page 292)
Efficient Organization of Medical Practice
THE GENERAL PRACTITIONER IS THE FUNDAMENTAL FACTOR IN EFFICIENT MEDICAL SERVICE
While surgery, the specialties, hospitals, people ere to be served, the primary im- ordinate* in constructive co-operation unth
institutional medicine, public health work, portance of the function of the General the essential service of the Family Physician,
industrial medicine, etc., have their definite Practitioner must be recognised. Other dwi> This is an integral purpose of The American
functions, if the best health interests of the sions of medical service must be Properly co~ Physician.
Some Factors in Success That Are Often Forgotten
IV s Easy to Be an Individualist, But It Takes Many Good Qualities to Be a
Personality
INDIVIDUALITY and personality are often mis-
taken for each other. The dictionary definition
of individuality is, "separate or distinct existence;
oneness." Anv fool can be an individualist, but it
takes many good qualities to be a personality. Per-
sonality is variously defined. Robertson said: "Per-
sonality is made up of three attributes — conscious-
ness, character, will."
Nearly every quack prides himself on his indi-
viduality; he believes in self-determination. Take
most any cultist, say, Mary Baker Eddy, who in-
vented Christian Science; Still, who inaugurated
Osteopathy; or Palmer, who started Chiropractic,
and they were all individualists. There is no limit to
individualistic interpretations except the number of
the people in the world. The individualist who is fan-
tastic enough in his theories to attain to publicity can
always get a certain following. The patent medicine
business is an illustration of this fact, and, as well,
of the further fact that advertising pays in dollars
and cents. It takes advertising, whether free or paid
for, to put across the individualistic propaganda; but
the poor or unworkable propaganda ultimately fails
out despite advertising, while the good one that is
practical and workable, always helped by advertising,
remains as an asset for years and years. Good propa-
ganda, or good business, while it may have a certain
individuality, must have personality.
The physician may "sell" his individualistic theory
or method for a while; but the doctor, while often
called an individualist, is so merely in a social sense
unless he is also a narrow bigotist or egotist. The
average physician, in his beliefs and methods, is very
far from being an individualist, for medicine as we
have it today is an accretion which took centuries to
elaborate. In this it differs radically from any cult
or pathy.
The SmccoMahl Doctor u m Fersomeiky
One is often amused in reading attacks made against
*80-called authorities." That sort of thing is just as
futile as unwarranted war against majorities, for no
man becomes an "authority" unless he is so recognized
by a respectable majority of persons interested in
the subject he has studied, investigated and written
about.
Yet a physician never becomes an "authority"
simply by believing what his predecessory colleagues
taught; he must develop and add to their teachings,
from a firm foundation building a new structure. It
may be that the foundation proves defective for the
more modern super-structure, and if so it must be
strengthened, not torn out and discarded. "Author-
ity" must be constructive of facts and theories in
harmony with the truths painfully worked out by
preceding generations. An entirely new proposition
may be advanced by a scientific man, but he proposes
it simply as a theory, the truth or falsity thereof to
be determined. Relativity, for instance, is a new
proposition, but it is based on mathematics, astronomy
and physics. For this reason discreet men are willing
to entertain it as a fit subject for study, whereas,
if it denounced mathematics, astronomy and physics
the scientific reader would read no farther than the
preface to Einstein's book. Then why should phy-
sicians feel called upon to give any credit whatever
to a new theory that denounces chemistry, physiology,
biology, and bacteriology?
The doctor of real personality, of consciousness,
character and will, always respects "authority," both
past and present ; he works from premises of respect-
ability and soundness. He is not servile to authority,
for he knows that errors have always existed along
the whole pathway of knowledge and that he is apt
to make mistakes himself.
The "Doc" ami the Doctor
You know the difference between these two men,
and that no real authoritv is ever called "Doc" bv anv
courteous person and, in fact, by very few discour-
teous ones. And how much does "Doc" leave behind
him when he dies, either in prestige or property t
Rarely very much.
290
Some Factors in Success — Often Forgotten
[Phila,, April, 1922
It is the easiest thing in the world to talk through
one's hat, as the saying is, to denounce a thing one
does not understand. Once in a while one encounters
a physician of this caliber, who is carping and criti-
cal of medical and scientific advances he has been too
lazy to study. How far does he get with the public t
Ask his wife, who has trouble to get market money
from him and who leads a discouraged existence. It
is "Doc" who is responsible for the low estimate often
placed on the medical profession. He is the chap who
takes up every hare-brained easy way of practice that
verges on quackery, who writes prescriptions for mere
patent medicines, and he does it because he. does not
know therapeutics. He is the chap who denounces
hospitals, the medical societies, the health authorities
and the competent physicians in his own community.
The harm he is doing, in these days of cults and un-
rest, is infinite. He has no personality worth while,
is a rampant individualist, is utterly incompetent as
a physician, a failure from the financial standpoint,
and he is a menace to public health. The only differ-
ence between him and the out-and-out quack is that
the latter has more brains and enterprise than he has
and usually knows more about modern medicine.
It is time we realize that the medical profession is
on trial. Medicine itself is no t on trial, for the gen-
eral public knows its great achievements and honors it,
even though people may experiment with the cults
more or less. But the profession in the aggregate is
on trial, for the public estimates the profession on
the basis of its personnel actually in practice. We
know very well there are many men in practice who
are utterly unfit ; then why do not the medical societies
do something about it f
Coming Down to Brat* Ticks
The present writer, who has the hard and thankless
job of being a state official in addition to his practice,
has two lists on his desk as he writes this. One list is
very lengthy, and in it are the names and records of
physicians whose record of violation of law is taken
from the court archives, or they are proved or admitted
drug addicts or inebriates, or they are abortionists
or guilty of other malpractice. One by one evidence
is proved up and these men are given hearings and
their licenses to practice medicine suspended or re-
voked. It is a tremendous task to get witnesses to
testify against any of these men, that is, medical wit-
nesses. There yet remain on this docket a long list of
men in practice who are menaces to their communi-
ties; and just as soon as charges are brought against
them delegations of reputable physicians come down
to the Capital with protests which, boiled down, say :
"Let the poor devil alone. Why he is a graduated
M.D., and the profession can't afford to raise a stink
over him." Nevertheless, the public health comes first,
and the only concession this official makes is to give
these men sixty days to reform, and, if they are hope-
less, to make their hearings and the action taken as
private as may be.
The other list is the one submitted by the federal
government of physicians whose purchases of narcotic
drugs are enormous — from 130 ounces a year down.
The only comment necessary is this: all of the hos-
pitals of Philadelphia combined use about 90 ounces
a year. Are these large individual purchasers fit to
practice f Doctor, make your own answer.
A Reeking mni Small Minority
Now, these men are not all criminals at heart ; many
of them are of the class of individualists who are out
of step with the great majority of reputable and
capable men in the profession, who are ignorant and
who justify themselves on the basis of their so-called
medical prerogative to do as they jolly well please,
and it is no one's business what they do; and they
know very well that, soon as they get in trouble, sev-
eral decent doctors will come to their defense, and,
as well, the ward politicians. Yet they constitute a
reeking minority in the medical profession. It only
takes one dead rat between the walls of your house
to make it an unfit place to live, and you get that
corpse if you have to tear off half of the weather-
boarding to find it. The record on this desk shows at
least one dead rat in the medical profession in nearly
every town of ten thousand people in the state. Doc-
tor, do you do anything to "get" himt You do not.
And because you do not, and will not, that is why
people say nasty things about the medical profession;
and that is one reason why the cultists have such an
inning. This is not a pretty story, but the writer is
absolutely in position to know exactly what he is
talking about and has the names of these dead rats
in the profession and the facts concerning them. With-
out the help of the profession he has a hard task to
"get" these men; and he is threatened, cajoled and
sworn at whenever he does "get" them. But he should
worry! It is the reputable profession that should do
the worrying. Doctor, do you worry any over these
things t — you who get righteously indignant over the
bootlegger, the lay drug peddler, the crooked drug-
gist, the incompetent midwife, and any other crook
who does not have an M.D. after his name. Bring
your indignation closer home and you will accom-
plish more, especially if you will testify to what you
know and help to procure evidence. Also, when you
vote, do you ever cast your ballot for a crook t
The SplemiU Majority
There is not in any other profession, not even in
the Christian ministry, a more splendid majority than
is found today in the medical profession; and there
is no other profession that in the last forty years has
made such tremendous advances. The scientific bases
of medicine are proved, and, as well, many of the
clinical ones. We have every occasion to be enthu-
siastic over our calling and to defend it through thick
and thin. The splendid majority in modern medicine-
are men of personality, of force, of character and
(continued one leaf over.)
The American Physician]
An Honest Market Place 291
Bowel Torpor in the Elderly
is usually the result of a progressive atony of the bowel, with a
gradual decrease of the natural mucus and other secretions.
The loss of moisture dries the feces and interferes with their
free and easy passage. Under such conditions
INTEROL
serves as a safe and efficient substitute for the physiologic secretions. Fol-
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lubricated, and the feces are passed along and evacu-
ated in due time without straining, pain, or discomfort.
INTEROL thus constitutes an ideal medium for the
relief of bowel torpor in patients of advanced age.
DIRECTIONS:
In treating the el-
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empty stomach, in-
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ing as conditions re-
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i
The Dropsy of Chronic Bright 's
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secure prompt and prolonged action and effect without
danger of cumulative action or disturbance of gastric or
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indications present in loss of compensation from cardiac
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Lymphatic Leukemia — Goldstein
ul out-
ita own
i lesson
.ghtiug,
isolated
d faitb
lion of
ur pro-
unaiiti/,
!h with
'ou try
horities
» know
realize
re, how
e thing
nd sys-
aid of
of this
that in
iible to
• years.
i The
demon -
es both
ras not
roid extract, which caused an immediate and marked
amelioration of the myxedematous condition.
He emphasizes the diagnosis of acromegaly from
osteitis deformans (enlargement of skull and shafts
of the long bones), myxedema, and pulmonary osteo-
arthropathy.
Mullall) reported 3 cases of acromegaly with one
autopsy. The first case was a French -Canadian fe-
male aged 61 years — complaining chiefly of headache,
weakness, and deformity of features. She had 11
full-term children. Shortly after her menopause at
the age of 50 years, she observed a change in her
features, her nose and lower lip began to gradually
enlarge; nearly two years later her tongue began to
get longer and it gradually increased in size, and in-
terfered with photiation. Her skin became roughened
and coarse. Akyphosis of the upper dorsal region
was present, there were no ocular symptoms and
her thyroid was not enlarged.
Case 2. Female Galician, aged SO years. Com-
plained of changed features, cough, dyspneca, weak-
ness, palpitation, pain over the heart She had 10
children. The last was born at 34 years. She, her
husband and all the children (after reaching the
age of 10 years) had enlarged necks (goitrous dis-
trict). X-ray examinations showed evident enlarge-
ment of the Sella turcica.
Case 3. French-Canadian female, aged 64 years.
Complained of shortness of breath, palpitation, lump
in throat, deformity. She had two children. Shortly
after her menopause (at 45-50) she noticed enlarge-
ment of her features. Then her hands and feet got
larger. Her tongue enlarged and her speech became
thick. Headache and dyspncea were prominent symp-
toms. R. B. C. 7,380,000, Hb. 110%, W. B. C. 8.000.
At autopsy were found: enlarged pituitary, hyper-
trophy of adrenals and thyroid, myxedema of tissues
of body, acromegaly, enlargement of lungs and
bronchi, adenoma of adrenal. Fibrosed and cystic
ovaries. Dilated and hyper trop hied heart. Hands
large and spade-like ; fingers enlarged and resembled
sausages. Feet enlarged. The pituitary weighed 10
gms. (about 20 times larger than normal) and meas-
ured 4 cm. vertically and 2.5 cm. transversely. The
enlargement is made up entirely of the anterior lobe.
Microscopically there is evident a great hypertrophy
of the anterior lobe, merely an exaggeration of the
normal cellular arrangement. There is entire absence
of acidophilic cells, all the cells are basophilic. Cor-
pora amylacia are numerous and stain deeply. The
posterior lobe shows no abnormality. The thyroid is
greatly enlarged, weight 185 gms. (about 6 times
larger than normal). The lungs were voluminous,
edematous and slightly emphysematous. The acini
were dilated and their epithelium denuded. The heart
was very large, weight 615 gms. Liver weight 1660
gms., spleen weight 235 gms. and measured 12x8x5
cm. Left adrenal was bulky and weighed 18 gms.
The right adrenal weighed 7 gms. Large extra-cor-
tical adenomas were present. Sections of adrenal
showed uniform hypertrophy. The pancreas weighed
180 gms. and measured 21x4x1.5 cm.
In Ceddei cue, the patient was also a female, aged
50. The pituitary weighed 15.55 gms. (the normal
weight being 0.S gm.). The thyroid weighed 312
gms. being verv large and goitrous. Thymus was
not enlarged. The adrenals weighed: right 9 gms.
and the left 9.5 gms.. normal weight being 6 gms.
In this case the pituitary was 30 times the normal
size, the thvroid 10 times and the suprarenals were
increased 50^. The ovaries were small and ap-
parently functionless. The posterior pituitary was
(continued one leaf over.)
FnjrMcn&J
An Honest Market Place
293
| A frank talk about Postum
| to readers of
1 "The American Physician"
Every doctor and nurse knows that caffeine — under
certain conditions, or used to excess — may prove a source
of extreme detriment to the nervous organism, and to the
digestive function.
Caffeine* in overdoses, excites irritability of the sym-
pathetic nervous system and unduly stimulates the cerebral
cells.
The ordinary cup of tea or coffee carries anywhere from
1 Vi to 3 grains of caffeine — a maximum dose, even where
definite stimulation is required.
What its action is where sedation is demanded, or
where any stimulant action may be contra-indicated, has
been definitely determined by able clinicians, both in this
country and abroad.
If not the direct cause of various nervous abnormalities,
it is at least, an accessory factor.
Why not avoid the deleterious influences of tea and
coffee excess by giving your patient rich, delicious Postum
instead ?
Postum is a pure cereal beverage that is preferred by
many even to the finest coffee, for its flavor alone.
A few days' trial of Postum in neurasthenic cases may
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294
Acromegaly and Lymphatic Leukemia — Goldstein
[PhUa., April, 1922
apparently normal. The enlargement of the an-
terior lobe was due to simple hyperplasia, and not to
an adenoma.
Exner reported two cases where the pituitary had been
operated upon for the relief of acromegaly, and later
hypertrophy of thyroid occurred.
Marengli produced in rabbits, hypertrophy of the
pituitary by removal of the adrenals. Gemelli, Mul-
lally, Horsley, Ascoli, Aschner, Filney and others
consider the hypophysis unessential to life, and that
this small organ is not a vital centre.
Caselli, Panlesco, Livon, Pironne, Cushing, Gatta,
and others consider the pituitary as an essential or-
gan. In both the Geddes' and Mullally cases that
came to autopsy, there were present hypertrophied
pituitary, enlarged thyroid, and adrenals and atro-
phied ovaries.
Kaufmanris case was a young man aged 23 years.
He was anemic, the lips thick and prominent. (Bir-
mingham Med. Review, XLIII, 1898, pp. 308 and 360.)
Kyphosis was most pronounced. No central nor
peripheral defect of the field of vision was present.
Slight proptosis caused the outer field of each eye
to be increased in extent beyond the normal. No
enlargement of the thyroid gland was present. The
patient had a secondary anemia, which may have
dated from the lead-poisoning 50% R. B. C. and 50%
Hb. The patient's sexual function has been dimin-
ished. There was no disturbance of vision or hear-
ing. Headache was slight.
Charles Spencer Williamson (Med. Clinic of Chi-
cago, Vol. I, No. 5, March, 1916) reported a case
of acromegaly of long standing without subjective
symptoms. The man was a motion picture operator,
30 years of age. The man grew 5 to 6 inches in
height during a period of 12 years and gained 90
pounds in weight. At the time Williamson reported
the case, he weighed 230 pounds with a height of
5 feet 6l/2 inches. At no time has he had any sub-
jective symptoms of any sort; no loss of sexual de-
sire or power was complained of. The first thing
that attracted his attention was the progressive en-
largement of portions of his face, hands and feet.
The most noticeable thing about him was the shape
of his head, particularly the enlargement of the jaw,
the nose and the lips. The lower jaw protruded very
nearly an inch beyond the upper, and was well shown
in the x-ray picture.
Fraenkel (1901) reports four cases of acromegaly
with post-mortem findings. A tumor of the hypo-
physis was found in each case. The posterior lobe
was intact in all four cases. The hereditary char-
acter of acromegaly was evident in one case. One
case was not the complete type of acromegalia, but
seemed rather a transition between this and gigan-
tism.
Greene states that there can be no doubt concerning
the close relation of acromegaly to gigantism, and he
regards it as a sort of localized gigantism, due to
certain limitations in the pathologic seat and process,
or to the age at which it begins. Greene (1901) found
300 cases of acromegaly on record in the literature.
Hymanson (Med. Rec, July 1, 1899, pp. 14-15, Vol.
LVI, No. 1) reported a case of acromegaly in a
Russian Polish woman aged 39 years. She was
maimed at 19. Had 5 children, 4 living and well.
Spleen was normal. She was under his care for more
than two years. Striking improvement took place on
feeding with thyroid extract lA grain t. i. d. She
later also received pituitary extract grain I t. i. d.
He believes his case was one of acromegaly with
myxedema.
Bartlett (Arch. Int. Med., pp. 201-213, August, 1913,
No. 2, Vol. XII) reported a case died at the age of
25. A year before his death he noticed that his hands
were getting larger, he had slight headaches. Two
years prior to this, during his married life, he had
been extremely passionate. About 6 months before
his death he began to lose his sexual desire and soon
after became impotent. He became moody, forgetful
and irritable. Polyuria became marked. Diaphoresis
became very intense, soaking all the bed-clothes dur-
ing the night. Body was 6'3" long. The superficial
lymph-nodes were all slightly enlarged. The retro-
peritoneal and mesenteric lymph-nodes were mark-
edly enlarged. The mediastinal and cervical lymph
nodes were enlarged and quite firm. Thyroid gland
was twice the normal size (65 grams). Thymus was
persistent (weight 22 grams and total length is 85
mm.) Three small accessory thymi were found dis-
tributed among the cervical lymph-nodes. Liver
weighed 2100 gms. Spleen weighed 360 grams. Ad-
renals were normal. Parathyroids were slightly
larger than normal. A chromophil cell adenoma of
the anterior lobe of the hypophysis and enlargement
of the pineal gland, with atrophy of the cells of
Sertoli and of Leydog were noted. The pineal gland
was twice the normal size. Bartlett reviews some of
the cases of pineal tumor on record in the literature.
Chevalier Jackson (J. A. M. A., November 30, 1918.
Vol. LXXI, pp. 1787-1789), advises the systematic
examination of the larynx not only in every case of
acromegaly, but also in every case of hypophyseal
abnormality. He reports four cases to illustrate the
importance of recognizing laryngeal involvement in
acromegaly. He concludes that:
1. The larynx should be examined in every case
of hypophyseal abnormality.
2. The overgrowth characteristic of acromegaly in
some cases involves the laryngeal cartilages and soft
parts.
3. Acromegalic changes in the larynx may produce
stenosis sufficient to require tracheotomy to prevent
asphyxia, dyspnoea being added to by impairment of
the glottic movements, resulting in a defective bechic
cycle.
4. In three out of four cases, the laryngeal mucosa
was normal. In one, the chronic laryngitis present
was probably a coincidence.
5. In three of the four cases, the laryngeal image
was not symmetrical, though the laryngeal enlarge-
ment seemed so by external palpation.
6. In all cases of apparent hyperplasia of the
larynx, acromegalic overgrowth should be listed for
diagnostic exclusion.
7. Laryngeal examination should be recorded as
a routine in all cases of hypophyseal abnormality,
for the accumulation of data.
8. Altered voice in acromegaly may be due to
laryngeal changes as well as to alteration in the
resonating cavities, lingual enlargement, etc.
Loewenb erg's case was a white man aged 34 years, a
Bulgarian; a blacksmith. This was an (apparently)
acute case of acromegaly. The man had clubbing
of the fingers with well rounded finger nails. The
enlargements of the fingers and toes were acute in
onset. In this case, too, the ring on the ring finger
had to be sawed off in order to prevent necrosis of
his fingers. X-ray showed a calculus in the pituitary.
(continued one leaf over.)
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Mentioning The American Physician Insures Prompt, Careful Service
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Acromegaly and Lymphatic Leukemia — Goldstein
[Phila., April, 1922
The intermittent enlargement and infiltration of local
parts, as the hands and face, in Loewenberg's and
other reported cases, were undoubtedly due to
changes in the soft tissue covering the short and
flat bones, and not to osseoris changes.
Engelbach classified the disorders of the hypophysis
and he dwells also on the results of basal metab-
olism and carbohydrate tolerance studies in these
cases. The results in his cases were very variable
and indefinite. Thusr in the posterior lobe disturb-
ances, it appears that the basal metabolism was de~
creased in hypopituitarism and increased in hyper-
pituitarism, while the carbohydrate tolerance was
increased in hypopituitarism and decreased in hyper-
pituitarism. Geycosuria and hyperglycemia was ab-
sent in hypopituitarism and present in hyperpitui-
tarism.
In the simple anterior lobe dyscrasias, 7 cases of
his series had a metabolism (basal) rate varying from
the normal. In 5 cases it was decreased, varying
from 2 to 3% and in 2, it was increased 14 and 157c
respectively. In one case in 'which anterior lobe
extract was given therapeutically, the basal metab-
olism was increased from 30 to 80% during 6 weeks'
treatment, with a relief of other symptoms such as
muscular fatigue, loss of libido, headache, and mental
disability, etc. In the hyperactive conditions of the
anterior lobe in 4 cases, basal metabolism was normal
in 2, and increased in 2.
In 10 cases of anterior lobe dyscrasia, Engelbach
found 7 showed a decreased carbohydrate tolerance
and 3 an increased tolerance. Of the hypopituitarism
cases, 5 showed an increased and 2 a decreased sugar
tolerance.
In 53 of the 61 cases diagnosed as posterior lobe
disorders (58 of which were hypoactive posterior
cases) the sugar tolerance was increased, and in 5
decreased. It appears, therefore, that the influence
of the secretion of the posterior lobe upon metabo-
lism, from Engelbach's studies, was more definite in
its relationship than those changes of metabolism
associated with the simple anterior lobe dyscrasias.
Engelbach's case XI, a man aged 52, covers a
period of forty years — from the age of 12. Polyuria
was a prominent feature of the case. The maximum
amounts of urine varied from 10,000 to 20,000 cc.
daily. The diagnosis was bilobar pituitarism, prc-
adolescent, non-neoplastic type, heteroactivity. Origi-
nally this was a case of hyperactivity of both lobes
of the pituitary gland, followed recently by a hypo-
active period. The polyuria, polyphagia, and poly-
dipsia were all very favorably affected by a high alti-
tude. Pituitrin caused a marked increase in the poly-
uria. Sugar tolerance was decreased. This case
showed classical markings of acromegaly with the
onset and throughout the course of the polyuria, from
the age of 12 to 37. After a polyuria of 25 years'
duration, there occurred a glycosuria, hyperglycemia,
and decreased sugar tolerance. Engelbach states
this case presented evidence of associated anterior
lobe hyperf unction (acromegaly) during its initial
course, and a related hyperfunction (glycosuria and
hyperglycemia) of the pars nervosa during the late
course of the polyuria. Basal metabolism was de-
creased in this case (hyposecretion of the pars inter-
media). Adrenalin seemed to greatly intensify the
polyuria in this case.
Pituitrin, according to Engelbach, should be used
for polyuria (diabetes insipidus) in pituitary dis-
orders, only in cases where there is a definite hypo-
secretion or insufficiency of the infundibulum or the
posterior lobe of the hypophysis. In those cases in
which polyuria, etc., is associated with a hyperfunc-
tion of the gland, pituitrin would aggravate all symp-
toms as in the case just quoted. In these hyper-
active pituitary polyurias, X-ray, radium, and glandu-
lar substances physiologically antagonistic to the
hypophysis should be tried. Surgical intervention
may be advisable in very rebellious cases.
Schaefer, Webster, Jangeas, Cavazzini-Bergamo,
and others have reported very favorable results ob-
tained in tumors and hyperactive conditions of the hy-
physis. In Schaefer's series of 8 cases of hypo-
physeal tumors, with acromegaly, treated by X-ray.
6 showed definite improvement. Cavazzini-Bergamo
reported good results from X-ray therapy in 2 cases
of pituitary tumor with acromegaly.
Benedict, W. L. (Am! J. Ophthal., 1920, 3, 571-584).
says ocular phenomena develops early in cases of
pituitary tumor. My case is unusual, in that although
the sella is very large no ocular symptoms are pres-
ent. Tumors of the hydrophysis rarely metastasize
elsewhere (Budde-Munchen, Med. Wchnschr., 1920,
67, 820-827); in Budde's case of hypophyseal carci-
noma with glandular and pulmonary metastases there
were observed symptoms of increased brain pressure
and other changes, but symptoms caused by the
metastasis were observed preceding those from the
hypophyseal. No acromegalic changes were noted.
The cancer destroyed the whole gland.
In Herman Feit's case of "Hypophyseal Cachexia"
(Med. Klin., Berlin, 1920, XVI, 421-422), due to
syphilis, there were symptoms of hypopituitarism and
cachexia. The patient was beardless, and his face
yellow, he had a boyish voice, and he had undevel-
oped genitals, polyuria and polydipsia. His blood
snowed 50% small lymphocytes, 5% large lymphs..
43% polys, and 2% eosinos. No changes in the
sella were seen, and no acromegalic changes noted.
Although the symptoms improved after two salvar-
san injections, the increased lymphocyte count was
not reduced.
Oberndorfer (Munchen. Med. Wchnschr., 1920. 67,
946-948) describes some cases of hypophyseal and
adjacent tumors. He mentions a case of rudimentary
acromegaly in a man aged 40 years who died from
acute yellow atrophy of the liver. He had two
enormous toes. Autopsy showed an enlarged pos-
terior pituitary lobe, the eosinophil cells invading the
posterior lobe. He describes a case of acromegaly
with dystrophia adiposogenitalis, in a man aged 21
years. No trace was found of hypophyseal tissue.
The gland had been replaced by hen's egg size tumor.
In addition, he reports several cases of dystrophia
adiposogenitalis due to tumor of the pituitary. Three
were women, aged 21, 39, and 63 and a man aged 55
years. No acromegalic changes were noted in these
cases.
Foerster's (Deutsche Med. Wchnschr., Berlin, 1920.
46, 1066) case showed an enlargement of the sella
turcica without acromegalic changes. Patient was a
man aged 37, suffering from dystrophia adiposo-
genitalis.
In Semerak's (Trans. Chicago Path. Society, XI.
June 1, 1920. No. 3, pp. 87-98), three cases of tumors
of the hypophysis, acromegaly was not present In
his first case, that of a Polish laborer, aged 28 years,
the large feet and long extremities would indicate
hyperfunction, which later was followed by dys-
trophy, but Semerak states that the length of the
extremities may also be ascribed to the atrophy of
the genital glands before puberty (Brown-Sequard)
and in this case the testes were very small. Semerak
remarks that according to Benda, Erdheim and Lewis,
it is only the increase in eosinophile cells which
gives rise to acromegalv. He gives this as the rea-
( continued one leaf over.)
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j The Management of an Infant's Diet
Constipation
Constipation in infancy is a symptom that should not be passed over
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cially if allowed to become chronic, may lead to digestive disorders diffi-
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Mentioning The American Physician Insures Prompt, Careful Service
298
Acromegaly and Lymphatic Leukemia — Goldstein
[Phil*., April, 1922
son for the lack of changes of the bones in his third
case, notwithstanding the marked hyperplasia of the
anterior lobe. This patient was a man aged 52 years,
weight 143 pounds, who had a tumor of the hypo-
physis cerebri, diagnosed as a basophile-cell adenoma.
In Jewesbury's case (Lancet, April 26, 1913, p. 1169,
I), a woman aged 36 years, although the sella tor-
cica was very much enlarged, and there was absorp-
tion of the posterior clinoid processes, ocular symp-
toms were absent. The discs were normal and there
was no diminution of visual fields. She was free
from headache. The thyroid gland was very defi-
nitely and uniformly enlarged. No glycosuria was
present. There were marked scoliosis and kyphosis,
the hands and feet were very large, and she had a
"Punchinello chest."
T. Reuell Atkinson was able to study his case of
acromegaly for eleven years (Brit. Med. Jour., p. 1111,
May 13, 1911, and p. 270, February 2, 1901). In his
case, sight continued to be normal. No hemianopia
was present. He was drowsy, and perspired freely.
He became somewhat bow-legged, especially on the
left side.
Howard reports four cases of acromegaly with
symptoms of hyperpituitarism, and adrenalin tests
that suggested hypoadrenalism. He also includes in
his paper two cases of dystrophia adiposogenitalis
(Froehlich Syndrome). He emphasizes the import-
ance of the role of the hypophysis in carbohydrate
metabolism, and states that it seems definitely estab-
lished that the pars intermedia is directly concerned
in carbohydrate metabolism and that hypertrophy,
if it causes polyuria, diminished carbohydrate toler-
ance, or even frank glycosuria, while hypoplasia or
degeneration of the pars intermedia will result in a
high degree of sugar tolerance. In the early stages
of acromegaly, therefore, it is common to find a de-
creased sugar tolerance; in the latter stages of hypo-
physeal disease, when the pars intermedia has been
destroyed by pressure or by invasion, increased sugar
tolerance is to be expected. He considers the deter-
mination of the sugar tolerance as the most accurate
and only scientific method for an estimation of the
activity of the internal secretion of the hypophysis,
thyroid gland, and pancreas.
Karl Csdpai (1914) suggested the conjunctival instilla-
tion of adrenalin or pituitrin and the subcutaneous
injection of both — for the study of the diseases of
the endocrine glands. Csepai noted that exaggeration
of the reaction indicates diminished function of the
adrenals, and that in cases in which adrenalin reac-
tion was positive (i. e., the blanching was prolonged),
the carbohydrate tolerance was increased or normal.
Csepai found that adrenalin given subcutaneously
in hypophyseal cases, caused either no increase or,
at the most, a slight increase in the total leukocytes,
v/ith, however, a slight relative increase of the neutro-
phils at the expense of the mononuclears and to a
less extent of the eosinophiles. He concluded, there-
fore, that any variation from the leukocytosis indi-
cates pituitary (or disease of the ductless glands).
Falta pointed out that the subcutaneous administra-
tion of adrenalin causes a distinct leukocytosis, with
an increase in the neutrophils at the expense of
the mononuclear and eosinophilic cells.
(Note: Normally. Csepai has shown that three
drops of a 1 to 1000 adrenalin solution will cause in a
few minutes a slight or moderate blanching of the
conjunctival sac. which will persist for 10 to 20 min-
utes. He also found, in normal cases, that after the
subcutaneous injection of 5 mg. of adrenalin, there
was a marked increase of the systolic blood pressure
of 30-60 mm. In the hypophyseal, and other endo-
crine diseases, he found no such increase in the blood-
pressure — in all of these, the conjunctival reaction
or blanching was prolonged. Howard's results were
quite different, however, in the study of his six case*.
Howard concludes that: a secondary hyperpitui-
tarism may result from a greatly or rapidly increas-
ing intracranial pressure; that the determination of a
decrease in the sugar tolerance in the presence of
other symptoms of disturbance of pituitary function
justifies a diagnosis of increased activity of the pars
intermedia; that the adrenalin conjunctival test may
be of positive value in certain cases of dyspituitarism
in showing a hypofunction of the chromaffin system;
that the internal administration of the pituitary ex-
tract of either the whole gland or the anterior or the
posterior lobes appears to be without any definite
influence.
Labbe's patient was a miner aged 48, who had hyper-
trophy of the pituitary and acromegaly with diabetes.
The glycosuria was greatly improved by pituitary
treatment. There is probably some irritation of some
centre in the base of the brain that is responsible
for the diabetes and the polyuria in these cases. The
pituitary treatment did not relieve the polyuria in
Labbe's case. It suggests that the sugar metabolism
is under the control of a complex physiologic appa-
ratus that comprises the liver, the pancreas, the
nervous system and the ductless glands. Disease in
any part of this apparatus may suffice to bring on
diabetes. The diabetes occurring in some acromeg-
aly cases is a type of nervous diabetes in which the
disturbance in the control of sugar metabolism seems
to be of the same nature as in liver or pancreas
diabetes.
Principles of Medical Treatment
By George Cheever Shattuck, M.D., A.M., As-
sistant Professor of Tropical Medicine, Harvard Med-
ical School, Formerly Assistant Visiting Physician,
Massachusetts General Hospital. Fifth revised edi-
tion. With contributions by the following authors:
"Tuberculosis," John B. Hawes, 2d, M.D., Assistant
Visiting Physician and Director of the Clinic for Pul-
monary Diseases, Massachusetts General Hospital,
Consultant for Diseases of the Chest for the New
England District of the United States Public Health
Service; "Acute Infectious Diseases Most Common
in Childhood," Edwin H. Place, M.D., Physician in
Chief of South (Contagious) Department, Boston
City Hospital, Assistant Professor of Pediatrics. Har-
vard Medical School; "Influenza," Gerald Blake,
M.D., Associate in Medicine, Massachusetts General
Hospital, Instructor in Medicine, Harvard Medical
School; "Diabetes Mellitus." Benjamin H. Ragle.
M.D., Assistant Physician to Out-Patients, Massa-
chusetts General Hospital; "Serum Treatment of
Pneumonia," Henry M. Thomas, Jr., M.D., Resident
Physician John Hopkins Hospital. W. M. Leonard,
Inc.. Publishers. Boston. 1921.
"Principles of Medical Treatment" is essentially a
compend. It covers a good deal, but briefly — too
briefly perhaps to justify its title. In spite of the
fact that this is the fifth revised edition, and that, as
the respective forewords announced each succeeding
edition has been improved and enlarged — the student
— compend type of tabulated brevity still predomi-
(Book Reviews continued one leaf over)
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Mentioning The American Physician Insures Prompt, Careful Service
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Helpful Points
[Phil*., April, 1922
nates. Otherwise the book covers the ground real
well. Those who prefer words and statements to
paragraphs and chapters will, no doubt, find here
what they want, and plenty of it.
The Blood Supply to the Heart— In Its Anatomical
and Clinical Aspects
By Louis Gross, M.D., CM., Douglas Fellow in
Pathology, McGill University, and Research Asso-
ciate, Royal Victoria Hospital, Montreal With an
introduction by Horst Oertel, Strathcona Professor
of Pathology, McGill University, Montreal. With
twenty-nine full-page plates and six text illustrations.
Paul B. Hoeber, New York.
This is an excellent work on the blood supply of
the heart and of undoubted anatomical and clinical
value. It is presented from rather an original angle
and covers its ground admirably well.
E$s*ntimU W Lmforatwy Dmgnm$U
By Francis Ashley Faught, M.D., formerly Director
of the Laboratory of the Department of Clinical Medi-
cine, Medico-Chirurgical College, Philadelphia. Seventh
revised and enlarged edition. Cloth, 523 pages, elab-
orately illustrated. F. A. Davis Company, publishers,
Philadelphia, Pa. Price, $4.50 net.
This work has been a standard for practitioners and
students since 1909, but the advance of the subject has
been so rapid that each new edition has practically been
rewritten, as is the case with this seventh edition. The
book has expanded and should be given a new name,
since it is no longer a mere compend on "essentials"
but is a fairly complete guide to the whole subject of
laboratory diagnosis. Yet the volume still seems famil-
iar, since it aims to keep within the limitations of the
practitioner of modern training and chemical dexterity.
We heartily commend the book to the profession.
Awtttniic
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pathology of Onanism — By K. Menzies, with a Foreword
by Dr. Ernest Jones— Second Edition— $1.50— Paul B.
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The pendulum of sexual knowledge of our day seems
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"libidio" and the like, with which the little book is
sprinkled, color it much with "psychoanalytical" and
Freudian paint Apparently the author is carried freely
by the waves of this ultra-modern school. With all said,
the little volume is undoubtedly earnest and fairly inter-
esting, and while presenting nothing new, has neverthe-
less a compilation of facts well worth reviewing.— Efc
By Frederick Taylor Lord, A.B., M.D., Massachusetts
General Hospital. Cloth, 70 pages. Harvard University
Press, Cambridge, Mass. Price, $1.00.
This little book is one of the series of Harvard Health
Talks and is a non-technical presentation of the whole
subject of pneumonia in such manner as to be useful to
intelligent laymen and to the profession. Naturally, the
element of prevention is stressed. The whole series is
admirable and may be procured at the price of $9.00
from Randall Hall, at Cambridge, or from the Harvard
University Press, at 15 West Forty-fourth Street, New
York City.
(Helpful Points continued one leaf over.)
FIDELITY TO AN IDEAL
has won
PROFESSIONAL COMMENDATION
for
MANSFIELD AGAR AGAR WAFERS
A DRUGLESS LAXATIVE FOOD
Originally produced at the suggestion of physicians, these wafers have
been manufactured for ten years wjth a persistent endeavor to merit the
confidence and approval of the medical profession. That we have succeeded
is demonstrated by continued and increasing sales, unstimulated by any
advertising during the last four years.
We believe that the hygroscopic properties of agar and the vitalizing
qualities of the entire wheat grain, combined, have resulted in a product of
proven value in the treatment of constipation due to intestinal atony. As
evidence of this belief, we gladly offer any physician a package of the wafers.
THE MANSFIELD LABORATORIES, Inc.
18 CHANDLER STREET BOSTON, MASS.
You can buy with Confidence — See "Service Guarantee to Readers" on page 316
The American Physician]
An Honest Market Place
301
nniiiim^
CHLORYLEN 1
A New Treatment for Trigeminal Neuralgia g
Chlorylen is used with marked success in the treatment of tri- facial neuralgia. 1
It has a specific action on the sensitive Trigeminus, gives immediate relief and the [j
pain disappears after a few treatments. fj
Chlorylen is applied by inhalation. 20 to 30 drops are placed on cotton or g
the handkerchief and inhaled through the nostrils, until the odor disappears. It 1
is a volatile liquid with a pleasing odor and is obtainable in bottles of 25 grams each. fj
NEUTRALON
A substitute for the Bismuth saits,
Sodium Bicarbonate, Silver Nitrate,
etc., in the treatment of Hyperchlor-
hydria, Hypersecretion, Ulcus Ven-
triculi, etc. A white, tasteless, odorless
powder; supplied in packages of 100
grams each. The dose is one teaspoon-
ful in a glass of water before food.
VALAM1N
A sedative and soporific for use in
the treatment of Neurasthenia, In-
somnia, Hysteria, Palpitation of the
Heart, etc. It is a Valerian and Amy-
lene combination, is easily absorbed
and acts promptly. Valamin is mar-
keted in packages containing 25 cap-
sules of 4 grains each. The dose is
one or two capsules after meals. In
nervous insomnia, two to four capsules
should be taken before retiring.
For further information and literature address:
KIRBACH, Inc., General Agents, 227-229 Fulton St.,
NEW YORK
"Smnwmmsmmmmmmmwmn
ramiEiS'
liKIIIH!!!
IHHBEIIi:
rnniii
High Blood Pressure — A Danger Signal
Its meaning should be carefully considered. Its reduc-
tion by safe methods is always a therapeutic necessity.
J*uIvoids Natrium Compound
(High Tension Dr. M. C. Thrush)
~ugar coated green color, dissolves in intestinal tract; is a safe, reliable, non-irritating,
-on-toxic combination of potassium nitrate, sodium nitrate, sodium bicarbonate, nitro-
glycerin and Crataegus oxyacantha, prompt to act, prolonged in effect. Send for booklet
<^>*i High Blood Pressure; also for "Drug Products," a periodical devoted to hypertension
«-»*d allied subjects.
'* you dispense, ask for catalogue and price list of Pulvoids, Wafoids, Salvarols, Vita-
ftat. Organic products, etc.
Special Offer to Physicians and Hospitals Only
200 Pulvoids Natrium Comp., $1.00. One time only. 1000 Pulvoids
Natrium Comp., $5.00 on 60 days' trial; money back if not satisfied.
Mailed free for cash with order, or sent C. O. D.» mailing and collection
charges extra.
THE DRUG PRODUCTS CO., Inc.
Meadow Street Long Island City, New York
Mentioning The American Physician Insures Prompt, Careful Service
302
Helpful Points
[Phila., April, 1922
The Remedy for Hemorrhages
Many physicians have found Styptysate the effective
remedy for hemorrhages. It is of particular advantage
in menorrhagia and metrorrhagia, and has also been
found to be of great value in vesical hemorrhages and
hemorrhages from mucous membranes in general.
Results in many cases have been surprising; there are
no secondary ill-effects upon circulation or respiration;
Styptysate is therefore a safe remedy. Turn to page 251
and see special introductory offer.
Write for This
The grinding surfaces of teeth are the most subject
to decay, and it is here that cleanliness is of the utmost
importance. Dr. R. B. Waite's Anti-Py-0 Dental
Cream contains vegetable soap which forms a fine lather
and quickly enters all the finest interstices. Special
sample tubes and a full-size tube for your personal use
will be sent to American Physician readers. Turn to
page 254 and send in the coupon.
The Value of Liquid Petroleum
A prominent authority of international reputation who
has made an exhaustive study of the therapeutic value
of liquid petrolatum, says that laxatives of all sorts in-
crease the spasticity of the intestine, whereas liquid
petrolatum lubricates and protects the sensitive surface
of the spastic bowel, at the same time softening the
intestinal contents so as to permit passage through the
bowel without mechanical irritation.
Nujol is especially suitable for all forms of intestinal
constipation. It is the achievement of an organization
of fifty years' experience in the making of similar prod-
ucts. Interesting booklets will be sent to physicians,
turn to page 307 and send in the coupon.
Worth Your While to Look Imto This
If you have a case of spinal weakness or deformity
under treatment now — no matter whether it is an incipi-
ent case or one seriously developed, it will be worth
your while to look into the Philo Burt Appliance. The
scientific Philo Burt method, which allows absolute free-
dom of action, and which lifts the weight of the head
and shoulders of the spine and corrects deflections, has
benefited thousands of spinal cases. You owe it to
yourself and your patient to give it a trial, which by
the very liberal policy of the makers can be made at
their expense. Appliance is made to measure for your
case, and thirty days' trial is given, money returned ii
not satisfactory. Write today for Physicians' Portfolio
and illustrated booklet and plan of co-operation with
physician — there is no charge. Address: Philo Burt
Company, 115-16 Odd Fellows' Temple, Jamestown,
N. Y.
When Appetite L*g$
Every physician has been up against the problem
of tempting the appetite, especially the fickle appetite
of convalescence.
But some of us have not known that few fruit-
foods offer the same rousing flavor—the tart, tangy
"relish" characteristic of dried apricots. Nutrition
tests show that the salts and organic acids in dried
apricots improve the quality of the blood and react
favorably on the secretions.
Many appealing, appetizing and nutritive dishes can
be easily made from this year 'round fruit. The Sun-
sweet Recipe Packet gives them and is yours for the
asking. Address: California Prune and Apricot
Growers, Inc., 480 Market Street, San Jose, California.
(Helpful Points continued one leaf over.)
ANUSOL
(Trade-Mark)
Hemorrhoidal
SUPPOSITORIES
'Efficient and
Safe to Use At
Any Time of Life
yy
The outstanding characteristic of Anusol Suppositories, and the one
enthusiastically commented upon ever anew by physician and
patient alike, is
Their ability to allay and check the distressing pain and inflamma-
tion of Hemorrhoids so promptly and completely,
In the total absence of narcotic, or any other habit-forming, or
injurious ingredients.
We guarantee it. Besides, the formula is on every label.
That* 8 why you can employ Anusol Suppositories from childhood
to old age, with absolute peace of mind.
Ample Trial Quantity and Literature from
SCHERING & GLATZ, INC, 150 Maiden Lane, New York
You can buy with Confidence — See "Service Guarantee to Readers" on page 316
An Monesl Market Place
Benzylets
take the place of opium
in so many pathologic conditions that their
use in "the morphine habit" seems quite
logical and the reported results are in the
main good.
The dosage depends upon conditions, the
rule seems to be to begin with two or three
and repeat as often as required.
Benzylets
in boxes of 24
at your druggist's
SHARP & DOHME
EVERY DAY doctors are advising a rest, a trip to a sanitarium, a visit to
a specialist, an operation — anything to get rid of their old, stubborn cases of
Prostatic Disease and Impotence
Maybe jou are doing, or are about to do thii very thing. You iif losing possibilities of dollars and prestige,
10 joy nothing of tht tolitfaction of having huh a hard fight.
Too many of these can are passed up by good doctors, only to fall into tbe hands of unscrupulous men who
offer do tiling but promises and frequently give less.
YOU CAN GET RESULTS
■ughly in t
in many of tbese case.. If you will try SUPPOS. PROSTANS
convince yourself and will thereafter kief tlu bxiinett ynw'vt be... .- , ..
There ia nothing secret about Suffoi. Proliant— form-jla with each to.
agree to refund your money upon request. This offer places the burden of r
Remember, Doctor, that your immediate order means a clear saving
your patients to mail this before other matters cause you to lay it aside,
^Fill out the coupon now. Sincerely,
REGENT DRUG COMPANY.
Thii Coupon Mean, Sue
and Money Saved
REGENT DRUG COMPANY,
3)52 Woodward Ave., Detroit, Micb.
1 enclose $5.00, aend me aix boxes of
Suppoa. Proatana (worth $9.00) alio
the above book and "Succeaaful Proata-
tic Therapy" — free.
i Wilt, Fill It Out. Send Today
Tbo Burden of Proof ftaata Upon
Mentioning The American Physician Insures Prompt, Careful Servict
ul Points [Pha»., Apia, i«i
"The food value, therapeutic value, manufacture, physf-
[. ology and chemistry of yeast, also a symposium on nii-
s mins," written by a physician for physicians.
J The Fleischmann Company, Dept. S 4, 701 Washington
' Street, New York, will gladly send a copy of this took
to you, free of charge. You will find this information
valuable to you in your practice, write for your copy
11 Begin JTm> m Hay Fever Petitmtt
n Now is the time to do what you can for your hay
s. fever patients with pollen extracts for cutaneous tests
r and treatment.
Arlco-Pollen Extracts, for cutaneous tests and treat-
ment, cover early and late spring types, also summer and
autumn types. Literature and list of pollens will be sent
._ to American Physician readers, address: The Arling-
ton Chemical Company, Yonkers, New York.
tfwifi Y«*t AtttMion
Instant Postum is a product which merits your at-
tention. There are cases where tea and coffee ate
contra-indicated, where they are the cause of real injury
to the patient.
You will find it much easier to get your instructions
carried out if you can, at the same time, direct the
patient to a pleasing beverage in place of the interdicted
Postum is a pure cereal beverage, that has a particu-
larly satisfying flavor. A few days' trial in neurasthenic
cases, for example, may show you some very interesting
and definite results.
Samples of Instant Postum, with full information, for
personal or clinical trial will be sent upon request, ad-
dress: Postum Cereal Company, Inc., Battle Creek,
Mich.
(Helpful Points continued one leaf over)
Clinical Evidence
proves the most satisfying
results are obtained by pre-
scribing
Pluto Water
in cases of habitual consti-
pation, gout, rheumatism
and all cases when a uric
acid solvent is desired.
Many practitioners direct
convalescent patients to the
spring for rest and complete
treatment where can be
found two well-known
members of the American
Medical Association with
trained
f
French Lick Springs Hotel Co,
French Lick, led.
Service Guarantee to Reader/' on page 316
The American Physician]
An Honest Market Place
305
i
A rational
measure in the treatment
of INFLUENZA is to en-
courage the invariably de-
pleted adrenals by using
ADRENO-SPERMIN CO.
(Harrower)
One, q. i. d; in acute con-
ditions 2, t. i. d. is proved
to be rational because it is
effective. It opposes the
asthenia, hypotension and
peplessness that is so com-
mon.
r :
I Have You Made Your Reservation
I for a copy of the new third edition of Harrower's
"Practical Organotherapy?"
The present edition contains most of the old fea-
tures and many new ones — fifty new chapters;
larger page; larger type; better in every way.
This New Book is Ready for Immediate Delivery
Send your order for a copy at once— enclose a dollar bill;
and if this big, new, cloth bound, 416-page book does not "suit
you to a 'T " your money will be promptly returned on request.
The regular price of this book should be $4.50, but a dollar
represents the entire cost to you and the book will be sent on
approval if you prefer.
The Harrower Laboratory
Box 68, Gkadale, Calif.
Creo-Tussin in Whooping Cough
IF YOU ONLY KNEW the excellent results physicians are getting from
the use of Creo-Tussin in whooping cough you would not be without it for,
as one physician stated, "good results are evident the first night.'
»
Physicians who are unfamiliar with Creo-Tussin are
requested to write us for sample and literature. Please
use attached coupon.
The Maltbie Chemical Company, Newark, New Jersey
Creo-Tussin
is a palatable solution of creosote, %
gelsemium, passiflora, yerba santa, .
menthol and aromatics. Conveniently J
put up in 2 oz. bottles with blank la- J
bels for directions, each bottle in!
plain carton. ■
Price— Dosen 2 oz. $4.00, Pint, $2.40 i
■-- - - —.Cut Here and Mail Today. __ _ _
i
' THE MALTBIE CHEMICAL CO., Newark, N. J.
Please mail sample Creo-Tussin to
M.D.
I A. P. 422
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
Your Infant
Feeding Problems
Nestle's Milk Food offers the
practitioner a modified cow's
milk — in powdered form —
that is so simple and conveni-
ent in its preparation for use,
that all danger of error or
incidental contamination is re-
duced to a minimum. All that
it requires is the addition of
the requisite amount of water
to a given quantity of the Food,
and boiling for one minute.
NESTLES
MILK
FOOD
A liberal supply of samples for professional
use and copies of'The Mother Book" for dis-
tribution to your patients sent on request.
Nestle's Food Company
Nenle Dulldlm MZMaiket Street
d m DMtmU C«i
Many physicians have not been satisfied with thera-
peutic results in their cases of whooping cough; and also
it has been difficult to give relief in asthma and bron-
chitis. In this regard it is interesting to note the results
some clinicians have been getting .with Diatussin. A
Detroit physician says : "Diatussin positively relieves,
and comes as near a specific as I would wish in whoop-
ing cough."
You will find it, as have others, a most efficacious
therapeutic aid in the treatment of asthma, bronchitis
and whooping cough, for children or adults.
Ernst BischofT Co., Inc., 85 West Broadway, New
York, will send you a sufficient trial quantity of this
excellent product, so that you can prove its efficiency
yourself, also interesting literature giving case histories.
Write them today for samples and literature.
Ntw Bulletin H Xtrobarterliu
We have recently seen a copy of the latest edition (the
fifth) of Mulford Working Bulletin No. 18, on the sub-
ject of "Serobacterins."
The text is illuminated with several diagrams and
charts, which are very helpful in conveying a clear idea
on some of the points and advantages claimed for these
products. There are also a number of authoritative
reports, covering both experimental results on labora-
tory animals and clinical results in actual practice, to-
gether with a comprehensive bibliography, suggestions
for dosage, etc., all calculated to prove interesting and
helpful to the medical and pharmaceutical professions.
Copies of this new bulletin may be had by addressing
H, K. Mulford Company, Philadelphia, Pa., and men-
tioning The American Physician.
Standard Synthetic Improved
Atophan has been manufactured for quite some time
past in the manufacturing plant of Schering & Glaiz,
Inc.. at Bloomfield, N. J.
The product is made by a special process, which en-
tirely eliminates the possibility of unpleasant empyreu-
matic admixtures, and thus still further improves this
standard synthetic in the treatment of rheumatism, gout,
neuralgia, neuritis, sciatica, migraine and "retention"
headaches.
Schering & Glatz, Inc.. 150 Maiden Lane, New York
City, will be glad to send a trial box of Atophan Tab-
lets to American Physician readers on request.
Are Yon Treating Heie Com?
If you have been turning away stubborn cases of
prostatic diseases and impotence, feeling that you had
not a treatment that would give a reasonable expectation
of success — you will be interested in the advertisement
of the Regent Drug Company, on page — . The com-
pany is making a special offer, but more than that, they
guarantee to refund all money — if after a clinical test
the treatment, in your opinion, does not give results.
Which means that the burden of proof rests on them.
ReialU Evident the Fint Ni/ikt
It you knew, as many physicians have learned from
experience, the excellent results from Creo-Tussin in
whooping cough, you would not be without it The
good results are evident the first night.
It is made very easy for you to try this excellent
product, with no expense and the least possible trouble
to you. Sample and literature will be sent gladly. Just
turn to page 305 and send in the coupon.
(Helpful Points continued one leaf over.)
You can buy with Confidence — See "Service Guarantee to Readers" on page 316
An Honest Market Place
Lubrication and diet
in intestinal stasis
A recognized authority sayi that the adm in iitra lion
of liquid petrolatum adds to the effectiveness of the
routine treatment of intestinal itaiii (juch as diet,
etc.) by lubricating the bowel, loftcning the fecal
mass, and easing its passage to the rectum and
final expulsion.
NUJOL is the most effective liquid
petrolatum for use in the treat-
ment of intestinal stasis. Its capacity
for penetration and lubrication of the
feces is unsurpassed.
In determining a viscosity best adapted
a Norm.1 cd™ to general requirements, the makers of
Nujol tried consistencies ranging from
a water-like fluid to a jelly. The viscosity
of Nujol was fixed upon after exhaust-
ive clinical test and research and is in
accord with highest medical opinion.
Sample and authoritative literature dealing
with the general and special uses of Nujol will
be sent gratis. See coupon below.
Nujol
A Lubricant, not a Laxative
Pk
ol Labontnrict. Siandmd Oil Co. (New J
Room KS. 44 Be.ver Sireei, New York
ui >end booklet! marked :
D "In General PrKttce"
□ "A Surgical Aulilant"
a
iiVn
rTrV
d Children'
Mentioning The A;
Physician Insures Prompt, Cartful Service
Htlpful Points
[Plitt*., April, 1KJ
USOL1NF. m tin fir.t miner*] „il put
en the market IB thi. country. It U.
never been extenelvelr .dvartiwd. and
uagB/eiated claim* have never been ma da
>»r ft. therefore phy.1ci.ne have been
■ teadily and m<:re..ing!y prescribing It
Wa Win pre.cnt to you USOL1NE a
a high yrefined 100% Imported Rua.li
Mineral Oil. with properly adjnated a- rev
Ity end vlacoalty; containing no tulphu
&£
i. letllt ef VSOLINB
OIL PRODUCTS CO., Ine.
M Ualnn Square, Naw York, N. Y.
ICtU,
The experience of the past three or four years has
definitely shown the great importance of painstaking at-
tention to the personal hygiene in preventing influenzal
infections. Especially important in this direction is fre-
quent disinfection of the nose and mouth, together with
thorough cleansing of the hands several times a day.
For these purposes there is no antiseptic or disin-
fectant more serviceable and effective than Dioxogeii.
For nose and mouth infection, one part Dioxogeii to
six or seven parts of warm saline solution will be found
remarkably effective used as a gargle or nasal douche.
To cleanse the hands, wash thoroughly with soap and
water, after which apply a solution- of Dioxogen and
warm water— -equal parts, rubbing this in well, espe-
cially around the nails.
Dioxogen thus employed has been conclusively proven
of invaluable aid in preventing the development of in-
fluenza and other acute infectious diseases.
Tkt Treatau
It af Mrnstrmal IrTtfUritiii
ied functional disorders of the fe-
male generative organs will nearly always yield to per-
sistent treatment with Genitone (Viburnum Compound
— Merrell) because this remedy provides a most pal'
atable uterine tonic and these troubles are usually due
to atonicity. Amenorrhea, dysmenorrhea, and menstrual
hysteria require prolonged treatment, but eventually
yield if the use of Genitone in one or two teaspoon jul
doses three times a day is persisted in. For threatened
abortion, the patient should be given one teaspoon ful of
Genitone in hot water every hour until the danger is
past. Many helpful suggestions regarding the treatment
{Helpful Points continued one leaf over.)
Jr
%
TAUROCOL COMPOUND TABLETS
\=
THE PAUL PLESSNER CO.
J"
A Stand-By in
Uterine Troubles
VIBURNO
(BEACH)
The best evidence of this is the
repeat orders received from physi-
cians and druggists.
Nervine-Tonic and Anticongest-
ive, with calmative and corrective
action on the bladder. Employed
with much satisfaction in ovarian
congestion and congestive dysmenor-
rhea; weak pregnancy and deficient
lactation; menopause and its phe-
nomena, including hallucinations, hot
flushes, etc.; nervous and menstrua]
derangements after "flu," and the
troubles of adolescent girls. Sterility
often responds after 2 or 3 bottles if
no lesion exists.
Unlike aimilar product*, VIBURNO
u pa.Uta.ble; and plaaaut la taJk*.
Domi 2 ten.p. (nadilutod) Li.dL
before iwa.lt,
Put up in II ob. bottle*
Sample and Formula en Renewal
THE VIBURNO COMPANY
US Maiden Lm, New York
i buy with Confidence— See "Service Guarantee to Readers" on page 316
The American Physician
A TESTOGAN THELYGAN a
For Hen
For Women
Formula of Dr. /wo* Block
After seven yean' clinical experience these products itand as proven specific!.
INDICATED IN SEXUAL IMPOTENCE AND INSUFFICIENCY
OF THE SEXUAL HORMONES
They contain SEXUAL HORMONES. L e, the hormones of
the reproductive glands and of the glands of internal secretion.
Sftcioi Indications for Testogan:
Sexual infantilism and eunuchoidism in the
anak. Impotence and sexual weakness.
i virile. Neurasthenia, hypo-
Special Indications for Tkelygan:
Infantile sterility. Underdeveloped mam-
mae, etc. Frigidity. Sexual disturbances in
obesity and Other metabolic disorders. Cli-
macteric symptoms, amenorrhea, neurasthe-
nia, hypochondria, dysmenorrhea.
haafcael b TABUT1 fer Unl — , mi b AHrOOUS, f.
tntm T+hM.*hi*hm.Um*mmni.nuiAhm,toM.
EXTENSIVE LITERATURE ON REQUEST.
CAVENDISH CHEMICAL CORPORATION
Salt Agents.
JJM Paacl Stnat
Established 1905
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
For Cleanliness
Marvel Whirling Spray
MARVEL COMPANY
25 W. 45th Street New York
of menstrual irregularities are given in the booklet on
Genitone, which will be sent to American Physician
readers on application by The William S. Merrell Com-
pany, Cincinnati, O.
Constipation in Old Age
The prevalence of constipation among the aged is
well known — a condition that demands considerable
attention. In old-age cases, as well as those that
are bed-ridden, KelloRg's Bran, thoroughly cooked
and krumbled, affords a natural and very satisfac-
tory measure of relief. Kellogg's Bran is particu-
larly pleasing in flavor and in edibility; unlike com-
mon brans, it is thoroughly cooked and krumbled,
and does not become tiresome to the patient. Id
fact, as a cereal with milk or cream, or on the
patient's favorite cereal, it is most appetizing, or
used in baking products will be found particularly
appealing to the most sensitive appetite.
Physicians are finding that for both mild and
chronic cases, prescribing Kellogg's Bran gives the
desired result. A large package will be sent to
American Physician readers without obligation, so
that you may personally know the value of this
product. Address: Kellogg Toasted Corn Flake
Co., Battle Creek, Mich.
Strength for the Asthenic
Suprarenal insufficiency is one of the marked features
of the asthenias. The blood pressure in these individ-
uals is almost always low and the circulation poor. The
activities of other glands of internal secretion are
always impaired. That is why pluriglandular therapy
gives better results than suprarenal substance given
alone. (Helpful Points continued one leaf over")
To ALLEVIATE PAIN, to PROMOTE DIURESIS
and to PROTECT the membrane of the urethra, especially
THE POSTERIOR PORTION— these .re the important
objects of the treatment of acute cases of Gonorrhea,
The entire urinary tract should be influenced by means
of proper internal medication. Local injections alone will
not be sufficient
This is the rationale of GONOSAN.
R1EDEL & CO., Inc.
104-114 South Fourth St. Brooklyn, N. Y.
LISTERS DIABETIC FLOUR
IA
Strictly Starch-free. Produces Bread,
Muffins. Pastry that makes the
. I .distressing features
I
TES
Grow
Less and
Less •
Litters prepared casein Diabetic Flour — self rising. A mouth's supply of 30 boxes $4.85
LISTER BROS. Inc., 405 Lexington Avenue, New York Ci<y
You can buy with Confidence — See "Service Guarantee to Readers" on page 316
The American Physician
Specialties for
Tonsillitis
r
Benzomint
INTERNAL REMEDY
Compound of Sodium
Benzoate with Alka-
O/ifhen appetites
must be born agim"
loids of Calisaya
A TIME-TESTED, highly
/-\ therapeutic formula which
has proved a veritable
Getting well is a process of re-creation.
The patient's appetite, no less than any
wonder worker in many thou-
other body function, must be reborn
lands of cases of Tonsillitis.
and rebuilt. Trite, commonplace dishes
— no matter how high in caloric value —
Benzomint has pronounced anti-
septic and antipyretic properties.
won't do it New flavors are needed
It soothes instantly the intense
— new sensations for the eye, the pal'
pain from swollen, inflamed
ate, the taste-nerves.
glands, and quickly counteracts
Few fruit-foods offer the same re'
both local and systemic infection.
freshing possibilities as Sunsweet Dried
Apricots. No fruit offers the same rous-
ing flavor — the tart, tangy "relish"
characteristic of dried apricots! More
Glycodin
over, nutrition tests show that the salts
(GARGLE)
. and organic acids in dried apricots im-
prove the quality of the blood and react
favorably on the secretions.
A N efficacious astringent
J-\ and antiseptic gargle of
great value in the treat-
The enticing apricot whip pictured
above is but one of a score of appeal-
ment of Tonsillitis.
ing, nutritive dishes that can be easily
made from this year 'round fruit. Our
Pint, Sl.OO; Fin Pint., W-BO;
Sunsweet Recipe Packet shows many
Gallon, Se.OO. Eilli.r preparation.
more — it is yours for the asking. Cali-
Sad far Mnpln and Htar.tura
fornia Prune &* Apricot Growers Inc.,
480 Market St., San Jose, California.
THROAT SPECIALTIES
LABORATORIES
SUNSWEET
(MJLBURN PHARMACAL CO.. INC.)
CALIFORN1AS NATURE-FLAVORED
BALDWIN, L. I. NEW YORK
0AiA> APRICOTS
McKhiod * Rabbis*
Whnl.Hj. Dlatrlbutora
V^*
N*w York City
Mentioning The American Physician Insures Prompt. Careful Service
Helpful Points
[Phila.. April, 1922
Amenorrhoea
Dysmenorrhoea
and other disturbances of the
menstrual (unction call for the
t'ue active principle of Parsley :
It Secures Results
by acting directly upon the uterine
nerve endings and producing ovarian
hyperemia, but without disturbing
gastric or renal functions.
Avoid impure or unreliable nibititutc*.
Prescribe original omit of 24 capsules.
Laboratory of
Dr. Ph. Chapdie, New York-Paris
Physicians' sample and literature on request to
E. Fougera & Co., Inc., American Agent!
90 BhIdhu Street, New York
Canada: Lyman. Limited, Men tree]
H or mo tone is a combination of thyroid (1-10 gr.)
entire pituitary (1-20 gr.) ovary and testis, and pro-
motes oxidation, increases blood pressure and enhances
metabolism by producing suprarenal efficiency.
For full information, American Physician readers
should address: G. W. Camrick Company, 419 Canal
Street, New York.
Vara a Uric Acid Solawmt it Desired
In all cases where a uric acid solvent is desired,
habitual constipation, gout, rheumatism, etc., you will
find that Pluto Water gives particularly gratifying re-
sults. The clinical evidence of many practitioners has
proven this.
Produces Complete Vaginal Ant'sepsis
"Aseptikons" (vaginal suppositories) produce com-
plete antisepsis and are non-poisonous, non -irritating
and produce no injury to membranes. They are in-
dicated in cervicitis, leucorrhea, specific and non-
specific vulvo- vaginitis in all cases where complete
vaginal antisepsis is desired.
For further information, address; Parmele Phar-
macal Company, 47-49 West Street. New York.
Intravenous Administration of Mercury
Locser's Intravenous Solution of Mercury Oxj-
cyanidc is the result of years of study of the chem-
ical, physical and clinical properties of mercury salts
employed in syphilis.
Interesting descriptive literature, price list, and
"Journal of Intravenous Therapy" will be sent to
American Physician readers on request. Address:
New York Intravenous Laboratory 100 West 21st
Street. New York City.
Woodlawn
Maternity Home
:, nuriing and protection. A home found
for the infant by adoption if deiired. All
publicity avoided. Price, reasonable. For
WOODLAWN, OWECO,' Tloia Co™ N, Y.
MORPHINE
NEW HOME TREATMENT
DR. CRIBBLE'S SANITARIUM
Formerly at Lebanon, Tenn., for
DRUG, ALCOHOL and TOBACCO ADDICTIONS
Established IS veers.
A quiet, home-like institution. Only refined ohi accepted. Over 5000 c*
rented. For references address
DR. POWER CRIBBLE, 1519 McGavock Street. Nashville, Tenn.
Increase
Your
Income
Unsurpassed In enteroptei
lot kidney and poat-nnerntl
draiglug nn the solar planus.
The New
Abdominal-U
Supporter
"NEVERSSUP"
_ I Full supply for thirty cases at only a nickel each. Send us $1.50
r, „ „,,, and will ship at once prepaid.
HUSTON BROS. CO. Atlas American Bldg., Chicago
You can buy with Confidence— See "Service Guarantee to Readers" on page 316
The American Physician]
An Honest Market Place
313
"It is More Unfortunate to be Left-Minded
Than Left-Handed!
99
Only left mindedness can ignore the practical value and demonstrable
efficiency of ALKALOL. Since the best antiseptic for an irritated or
inflamed mucous membrane is the natural secretion of its healthy cells, the
best application is that which soonest and best restores such cells to normal.
ALKALOL does this, by virtue of its correct salinity, its proper alka-
linity, its hypotonicity, and because it feeds depleted or exhausted cells with
needed physiological salts to restore natural secretion.
In the eye, ear, nose, throat, bladder, vagina, urethra, rectum, on the
skin and internally, ALKALOL rs corrective, restorative, soothing and
healing.
ALKALOL is alkaline, but it stands the acid test of time and trial.
Send for sample and literature.
THE ALKALOL COMPANY
Taunton, Mass.
RHINOL
in Ail Affections of the Nose and Throat
The Rhinol Company, Inc.,
Dear Sirs:
Permit me to state that we have used Rhtnol
at the Quality Hill Sanatorium with several of
our patients that were suffering from Hay fever.
The results were indeed good and pleasing.
Will be glad to have you publish this state-
ment for the benefit of the medical profession.
(Signed)
J. S. MASSEY. M.D..
Physician and Surgeon.
July 0. 1921.
The Rhinol Company, Inc.,
Gentlemen:
1 want to inform you that during the last year
1 have treated a large number of patients suffer-
ing from Coryza, Chronic Rhinitis, Pharyngitis,
Laryngitis and Hayfever with your Rhinol, and It
gives me great pleasure to state that the reeulta
have been very satisfactory in each instance.
Rhinol is one of my standbys in my practioa
and now that 1 have realized its great therapeu-
tic value in the treatment of the above named
conditions, 1 could not do without it. You may
make any use of this letter in any way you may
desire.
Sincerely yours,
(Signed) CHAS. B. GRAF, M.D.,
Physician and Surgeon.
230 E. 15th St., New York City.
Enclosed please find check for three dollars for which send me one complete Rhinol outfit. Yon
have a very superior preparation, and 1 was aetounded at the quick result* produced.
1 am very much disappointed that you cannot or will not supply my druggist, Theo. Metcalf
Co., as 1 would like to prescribe your outfit for some of my patients. 1 cleared up my own acuta
frontal sinusitis in a few days, then gave it to a hayfever patient who has been more relieved than
by anything aha has ever used. 1 dread being without the outfit for fear 1 may have another attack
off sinusitis. Hoping for an outfit by return mail, 1 am, gratefully yours,
(Signed) JACOB D. SNYDER, M.D.
542 Boylston St., Boston, Mass.
Price Complete, $3.00— Refilled Packages, $2.50
RHINOL COMPANY, Inc. 1416 Broadways New York
Quality Hill Sanatorium,
Monroe, N. C
The Rhinol Company, Inc.,
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Poinh
[Philn., April. 1922
THE STORM BINDER
AND ABDOMINAL SUPPORTER
THE STORM BINDER IS FOB GENERAL
SUPPORT IN ViKcrootmii, Obeaitr, etc., nc.
THE STORM BINDER IS FOR SPECIAL
SUPPORT la hernia, rloaun* kidney. descent of
no mack, etc, etc
THE STORM BINDER IS FOR POST-
OPERATIVE SUPPORT of incioom in upper,
middle and loner abdomen.
THE STORM BINDER IS POR MATERNITY
CASES. rtUevbw Che nauaea and discomfort* of
■reguna*.
Aak for Illustrated folder.
Order* tiled In Philadelphia only — in 24 honra
and sent by parcel pott.
•CATHERINE L. STORM, M.D.
ITOt Diamond Strut Phlladalphln
The se Advertismg Paget are am
Honest Market -Puce
Our Advertising Standards ■
Advertisements mutt give honest service to our read-
ers and thetr patients— is the basic principle for these
standards and for the conduct of Tbb A-iniCAB
Physician's advertising pages.
Our attitude in applying these standards is not one
of narrow technicality but of practical service —
Advertisements must give honest service to out read*
ers and their patients.
Advertisements of the following classes are *ol
acceptable for the pages of The American Physician:
Fraudulent pharmaceuticals; those making dishonest
Pharmaceuticals charging excessive price; price not
warranted by content and by trade conditions-
Pharmaceuticals and other mixtures containing nar-
cotics or other habit-inducing drugs in quantities suffi-
cient to promote their repetition on prescription
(chloral-bearing proprietaries, etc.).
Potent pharmaceuticals which justly merit profes-
sional disapproval because of their lay advertising or
manifestly unethical exploitation.
Financial advertisements that claim returns not com-
patible with conservative investment Only conserva-
tive investments are advertised.
Further
Advertising copy is subject to revision by the
editorial staff.
The American Physician agrees heartily with the
principle! of the Council on Pharmacy and Chemistry
of the American Medical Association and we exclude
from our advertising pages such pharmaceutical prod-
ucts as they have definitely shown to be unworthy of
professional confidence and the manufacturers of which
have not removed the cause of objection; but we do
not accept such findings as are based on academic data
without due recognition of general clinical experience.
Concerning formula?, The Ahemcan Physician is
urging pharmaceutical manufacturers to give full thera-
peutic data regarding formula;, stating quantitatively
active medicinal content, in order that physicians may
intelligently prescribe. We do not accept advertising
of secret pharmacueticals.
But We do not Decline - - -
Advertising of original drugs, compounds or preparation! imi-
tated in current editions of the U. S. Pharmacopoeia or National
Formulary (except habit- inducing; preparations) ; new prodnet*
that seem lo be honest and valuable, but which bavi
reported upon by the Council on Pharmacy and Chi
similar product! whole manufacturers have not ret sot
same to them for approval or rejection. We use oar
merit in these cases, but will always condd« prop>
limited number of druf s
dried' t»
'.Cantmued p
bar o
i buy with Confidences — See "Service Guarantee to Readers" on page 316
Tkt American Phyncun]
An /Zonal Mark* PUu
HA
o;
P YRAMIDON
After alma*! thirty jean of tervice ihn diu| >tmiii* out pre-eminent ai an
antipyretic, analgetic, antineuralgic and tedative.
Pjnmidou i> supplied is powder form in I 07., % lb. and I lb. cartoni and
in tablet! of S grami in aluminum tube* of 10, and in bottle* of 100 tablet*.
Price* to phytician* are $120 per ounce. 40c per tube of 10 tablet!, and
$3.00 per bottle of 100 tablet).
ORTHOFORM
Ublixablc a* a local antithetic for the relief of pain from wound*, bum*,
nicer*, excorialioni and alt exposed nerve-ending*. Ortbofomi 11 u*ed a* a
powder in imufflation. ai an emuliioa, or in tablet form. It ii given in-
ternally for the relief of pain in gailric ulcer and gutralgia.
Orthoform ii dupeaied in I 01. bottle* which tell to the phytician at $4.50
and in 5 gram viali at 90c per vial.
ORTHO TROCHES
Are employed for the alienation of pain and the mollification of irritation
following all operative procedure* on the throat. The]' dimolve ilowlj,
thu* producing a prolonged anesthetic effect. They are diapenied in bottle*
of I0O tablet* of one-quartet grain each or of one grain each at $IjQ0 and
$1.75 par bottle, rcapecbvely.
I.Hrral*'*
* b* oblainid fret
JfAMETZ IABOR/WMIESM
One-7*Amty-7u)o Hudson Street, NniybrL
GERMICIDE--CICATRIZANT--DISINFEGTANT.
These words express the therapeutic powers of
CA MPHO-PHENIQ UE
And indicate it* utility in urinary practrice. The
urinary surgeon who put* CAMPHO-PHENIQUE to
the most rigid teste and thereby learns its depend-
able qualities will assign to it first place among
agents of its class.
PUT IT TO THE TEST.
CAMPHO-PHENIQUE LIQUID ama/iais* 30c, larg. nine * 1.20
CAMPHO-PHENIQUE POWDER, .matt *.« 30c, larg. aba 75c
£*BH*rfaa eutaT LUtralmrm on nouuf.
Campho-Phenique Co., St. Louis, Mo., U. S. A.
Mtntummg Th* Amtrke* Pkyricia* Ituwts Prompt, Cartful Swvict
Helpful Points
[PHila,. April, IK!
New Prices on
Herz Santal Comp.
Capsules
DISPENSING PHYSICIANS CAN BUY
OF US DIRECT
10 Minim Elastic Capsules, box of 100
AIm bona* •( 12 u< asaa* oi M
S Minim Perle* bottleof 36
| « " bottleof 600
» *» » bottleoflOOO
Unsurpassed for happy effect in Urethritis,
Cystitis, Prostatic Troubles, difficult mic-
turition, etc.
FXICE3 AND SAMPLES UPON APPLICATION
THE MERZ CAPSULE CO.
DETROIT. MICH.
On- AdVertMJBf Standards
[CmhMfJ evtr from prtcidmg r»*»l
tore and in *uch lorn u may parallel * prescription
floaagc, provided these drugs ha
sands of physicians esteem tb
urged *fain*t them.
Minor antiseptic*, aoapi and toilet article* honestly adTerrisoi
to both physicians and laymen without false or fraudulent state
men!: honestly advertised mineral water* and minor purgative*,
food product*, malt tonic*, etc.
Uce in medical bura-
: pharmacologic data
Service Guarantee to Readers
IP YOU HAVE ANY UNSATISFACTORY
DEALING WITH AN ADVERTISER IN THE
AMERICAN PHYSICIAN, WRITE US THE
PARTICULARS AT ONCE.
WE WILL IMMEDIATELY TAKE THE MAT-
TER UP WITH THE ADVERTISER AND SEE
THAT THE ADVERTISER EITHER MAKES
GOOD, OR HIS ADVERTISEMENT IS EUMI-
NATED PROM THE AMERICAN PHYSICIAN'S
PAGES.
*t)H
IHIL.
Forgetting
the
Facts?
Refresh jour
mcmorji —
Brush uO m
ANATOMY—
Vtth the
P1LZ ANATOMICAL MANIKIN
(Uft-iisr—cemplrle in ettty dttail)
Better than the usual chart because each part
i* reproduced in natural color. Bap upon flap.
in exact poaition.
S' 8" high
{complete with obstetrical attachment*)
Dr. Minder1* Manikin— 20" *8"
Sent on receipt of N. Y. check or C O. D. Through
all dealer*. Money-back guarantee.
Write «ew for frit Booiltt.
AMERICAN THERMO-WARE CO.
10 B Warns Street New Vara CM*
Yon can buy with Confidence !
Set "Serr ice Guarantee to Rtadtrt," top of thi* p
"An Honed Jt/arfrf Fleet
"«"" hAwJy*
Pneumo-Phthysine
The best remedy (Pneumo-Phthysine)
misapplied, may defeat the combined
■kill of all who have contributed to it?
success. More especially in the treatment
of pneumonia, the unconquered foe of
medical science.
If PNEUMO-PHTHYSINE has failed
you, there is a reason.
How to Apply in PNEUMONIA
Apply ■ thin lajer, thickn™ at tilver dollar, to
cneeMclotb, cut to cover front of ctaeit, including
npr»daV -
eluding tl
evaporation of Gnu
pyretic **—
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
[Phil a.. April, 1923
* jjatgi
md a tmbicriptitm bill
NOTE— U yon hive ]
icloaed hare, pleaae lent
through, be finally I
■t recently remitted and * bill k
e It. With ■ lutncrlpUon Hit .■
■ few days (or a auhacrlption to pan
idlted and the atencil trnmfermd fnai
He Compares Us to Old Wine!
And prophesies tha
old wine does — that's
this month.
But as for improving — he is dead right. We are going
to go right on improving; bringing to you a better and
better journal each month, full of the kind of practical
medical material you can use in your every-day work.
read it will improve. Because in the months to come,
this journal is going to be a very real aid to the earnest
physician in making a greater success in his practice.
But Brother, it takes money to publish a journal, and
our profit is figured very small, so that delayed payment
means a real hardship. So we are hoping you will let us
hear from you this time.
Just slip $3.00— for .two years— (check or bills) in the
safe money carrier here — you don't even have to write
your name, and we take all risk of safe carriage. But
let us hear from you this time, Brother. Thank yon,
C. C. Taylo*
Sal Hepatica
THE
STANDARD SALINE
LAXATIVE
Brittol-Myers Co.
NEW YORK
GRIFFITH'S CMPOUIID NHXTUflE
of Guaiac, Stjllingia, ate.
A Powerful Alterative — Compoacd of Guaiat,
Stillingia, Prickly Abb.. Turkey Corn,
Black Cohoih. Sarananlla, Salicylate! ot ue n
I and other well known K
bined ii
by .11 .__ , ..... _....
Lumbago. Neuralgia. Sciatica, etc
Fraacrina tt far "That Stubborn Caaa"
To Pkyiiciant only — wc will upon request, aeaa 1
regular eight ounce bottle ($1.25 ause), for trial, ana
receipt of 25 centa for expreu charges,
Griffiths Rheumatic Remedy Compaijr
Newburgh, N«w York
Pond'sExtraci
The following ia a remarkably aoothlns and e
tlva eye-waah that can be relied on to afford rt
without delay from conjunctival Inflammation
Pond's Extract dr. VI
Aq. Camnh ox. f~
Aq. Roue q ltd ox. IV
M et SIg. — Ten drops In eyaa every 2 or B h
PONDS EXTRACT CO., New York and Lor
b:
Conjunctivitis
TktAHkaPVrM.]
An Honest Market Place
Acute Infections of the Nose and Throat
Every Winter and Spring bring their quota of nasopharyngeal infec-
tions. The great dangers of these extending to the various sinuses and ears,
or of being the fore-runner of graver respiratory diseases, particularly
pneumonia, make painstaking and effective treatment of even the simplest
cold both urgent and necessary.
The ease with which Dioxogvn, when used as suggested, will quickly
control the great majority of colds, and not only avoid their obvious
dangers, but give the patient gratifying relief from local congestion, with
its often severe discomfort and distress,
emphasize the desirability of employing
it at the earliest evidence of an infection.
Owing its efficiency in overcoming in-
fections of the upper air passages to the
liberation of pure active oxygen — Nature's
own antiseptic — it is no wonder Dioxogen
fills the place it does in the treatment and
prophylaxis of nose and throat colds.
The Oakland Chemical Co.
59 Fwrtk Ave., New York
'Two to four tttupoonfub of Dioxogen
to a half glass of warm water makes
an Meat gargle or natal spray."
THE DIOXOGEN TREATMENT
OF NOSE AND TBBOAT
COLDS
a ruth back of Ih* furial J>ll
in. II th* taaJKaM baakmja.
> Htara infartlen. thta i
., Ik* MH^WJ thl
i atrwwth ■(
inula NMnl ul Ik* InfactlH
Mentioning The American Physician Insures Prompt, Careful Service
The American Physician
{ Fhita., May. "22
Here's where genuine Atopkan is
manufactured by a special process
completely precluding the possibility
of unpleasant empyreumatic admix-
tures
This means a still further im-
proved Atophan for your cases
of Rheumatism, Gout, Neural'
gia. Neuritis, Sciatica, Lumbago
and "Retention" Headaches.
Ample trial quantity and literature
Schering & Glatz, Inc.
150-152 Maiden Lane New York
AN IDEAL ARSENICAL
SODIUM DIARSENOL
SODIUM ARSPHENAMINE
Sodium Diarsenol marks a distinct advance in syphilology. It dissolves
very quickly in water, giving a solution ready for immediate injection. No
addition of sodium hydroxide is necessary. It has the therapeutic advantage
of arsphenamine with the solubility and convenience of neoarsphenamine,
and gives clinical results equal to or better than either of the two latter com-
pounds. Neutralization with alkali being obviated, there is no undue hand-
ling and consequent decomposition of the highly reactive solution.
SODIUM DIARSENOL has been accepted by the Council on Pharmacy and
Chemistry of the American Medical Association for inclusion in "New and Non-
official Remedies."
1
Manufactured by DUrieool Labormt oriel. Inc., Buffalo,
Foundation. Inc., i
DIARSENOL COMPANY, Inc.
BUFFALO BOSTON ATLANTA
You can buy with Confidence — See "Service Guarantee to Readers" o:
An Honest Market Place
UUr—Tha Taylert; C. C. Taylor, Publish,
[J, itot, at thr ton alter et PkUodrtpkia, Pa.,
'iotlj Circulated Medical Menlhly/' cn>(in«in# Ike
by Tha Ttyltrt, Publiihtrs; *M W'- ' "'
J. Taylor, Ei. Mar. E*
i ei March 3,'l79- Tha A
'Philadtiphia, U. S. A. A* riahu mania
An Honest Market Place
LOESER'S INTRAVENOUS SOLUTIONS
Mentioning The American Physician insures Prompt, Cartful Service
The American Physician.]
An Honest Market Place
327
STYPTYSATE
THE REMEDY FOR HEMORRHAGES
Not Subject to Narcotic Law
The least disappointing remedy in uterine hemorrages. Very often acts
where Ergot and Hydrastis faiL Dose gtts.x-xv. Prescribed in 10 cc bottles.
Sold on prescription only.
A Few Short Clinical Reports WiD Prore Interesting
W. H. Age 23. Menstruated regularly up to a year ago. Twice then every 10 day* —
profuse hemorrhage. After Styptysate, duration and quantity of flow considerably lessened.
T. V. Age 25. Menses every 3 weeks, very profuse during the last months — Styptysate
reduced the amount of flow to normal quantity.
L. A. Age 28. Menstruated regularly; duration 5 days. However, for the last several
months menses were irregular, and the flow, lasting 8 days, was very profuse. Styptysate
shortened the periods and reduced the flow.
E. T. Age 28. Menstruated first at the age of 14. Menses regularly up to about 10 weeks
ago, when they appeared every 2 weeks— accompanied by severe backache. After the use of
Styptysate the frequency of the periods was lengthened and the action of the drug regarding
the amount of the flow was surprisingly prompt.
A. Sch. Age 24. Menstruated formerly regularly; since 3 years very profuse flow lasting
3 days and appearing every 2 weeks. The hemostatic action of Styptysate manifested itself
after every administration in a surprisingly favorable manner.
A. W. Age 35. Menses appear regularly, but are of long duration, the last having per-
sisted for 3 weeks. Styptysate treatment for 3 days limited the flow to 4 days. Lasting result
T. M. Age 49. Menses every 4 weeks, but very profuse flow of 8 days' duration. After
Styptysate medication a lasting limitation of the flow to from 3 to 4 days.
In all these cases, in spite of the difference in the ages of the patients, the dis-
turbance apparently was a functional one only, as the gynecological status was
normal, judged from the pathological point of view. However, the excellent results
obtained led Krummacher to employ Styptysate also in pathological conditions. In
particular does he mention a case of myoma, the size of a child's head, in a 43 year
old virgin. Frequent and very profuse hemorrhages — lasting 8 days or longer—
were not influenced by Hydrastis or various Ergot preparations, but were favorably
acted upon by Styptysate, so much so in fact, that the patient herself described the
action of the drug as unbelievable. In this case, Styptysate was given in doses of
gtts. XV t. i. d. and limited the hemorrhage, moderate in amount, to 3 days. It is
of importance to observe that Styptysate does not have any influence upon heart
action or respiration, although it has occasionally been given in massive doses (up
to gtts. XXXV single dose). The gynecologist as well as the obstetrician and
general practitioner will, therefore, find in Styptysate a safe, reliable and active
hemostatic
Samples and literature on request
INTRODUCTORY OFFER
One-half Dozen Bottles of STYPTYSATE for $2.50
(Regular Price $3.75)
Fill out, detach and mail the corner coupon with N. Y.
draft for $5.00, and we will send you one dozen bottles
of Styptysate.
Ernst Bischoff
Co., Inc.
SB W. Broadwmy,
New York
ERNST BISCHOFF CO., Inc.
For $2.50 remittance enn
. closed send one-half dozen
bottles of Styptysate as per your
Introductory Offer.
Name.
85 West Broadway
New York
Address.
Hfentioning The American Physician Insures Prompt, Careful Service
ontents
by Tht 1'tylort. All righli rtttrvtd.
1 Medical Diathermy.
'343
as often
■i Lculnrl}'
bleb can
periodic
equipped
( Folkmar. M.Ph.. D.S.S., M.D. »l
.ueuicoi iiintueruiy is nut a panacea for all diaeaiea.
Yet Its Indications are many, and It is a most exutlltni
adjuvant to other therapeutic measures. In many cam
It Is the indicated therapeutic agent par excellence. For
diathermy la heat, and beat is necessary to life, to
health, to function, to repair In injury, and to the
diathermy furnishes the needed deal where it la wanted
Tills flrst Installment goes thoroughly Into dell nil ion.
< L 1 1 ■ r : i 1 ■ i ■ 1 1 1 1 ■ - ludlralioiLH. We hope you "ill i:'-t hh c -Ii
of 11 Htimulua aa we did from reading Dr. Polkaur'a
Dlbromin — An Ideal Moist Dressing.
By David Ynndell Roberta, M.D\, F.A.C.8 JS5
The author has used dlbromin, in more than eighty bm
of surgical Infection In the past year, with uniformly
good results. It la an active germicide, at least equal
(0 the chlorine compounds, and baa met all the require-
ments of a surgical bactericide, because of Its ease of
preparation, Its efficacy, and the absence of Irritation.
odor and color. Particularly baa It proved Ideal la
those cases requiring Irrigation and where a continuous
moist dreaslng was. desired.
The Greedy Colon.
By N'orris W. Gl
If your patient
ills colon 1 There are «uou Burgeon*, win Kooa mm
who do. Rend Dr. (llllette's paper and see whether ji
« contotnmd on pof 330)
\OSOL
EPTIC, SOMEWHAT STRONGER IN
MERCURIC CHLORIDE AND CONSID-
1AN PHENOL."
(COUNCIL ON PHARM. AND CHEM. A. M. A.)
. VAGINAL \
suppositories/
omplete antisepsis
But
-ritating and No Injury to membranes
Indicated in cervicitis, leucorrhea,
specific vulvo-vaginiti*, in all cases
aginal antisepsis is desired.
PAR MEL E PHARMACAL CO., 4T-49 W£a*r street, ncwyomc
—See "Service Guarantee to Reodtrs" on page 392
NS" (
The American PbyncUn]
An Honest Market Place
329
New discussion of the value
of yeast treatment in
suppurative skin diseases
IN a chapter entitled "Boils, Fur-
unculosis, Carbuncles, Acne"
fresh light is thrown on the ques-
tion of yeast therapy in relation to
these and other suppurative skin
diseases.
Up-to-date sources and authori-
ties are quoted so that the physi-
cian, if he wishes, can follow up the
condensed material of this chapter
by further reading and research.
The author says in the opening
paragraph of the chapter:
"The use of yeast internally,
while usually effective alone, should
always be considered supplemen-
tary to any necessary local treat-
ment. And boils that have reached
the suppurative stage at the begin-
ning of treatment should of course
be opened with the necessary sur-
gical precautions and after treat-
ment. It will usually be found that
boils just starting will abort, and
one of the great advantages of the
use of yeast is the prevention of
recurrence. The rapidity with
which a group of boils in various
stages of advancement will often
dry up and disappear is astonishing.
When surgical intervention is nec-
essary, the use of yeast will shorten
the period of discharge and hasten
the healing process.
"It is better to start at once with
three cakes a day taken before
meals. Yeast may be administered
plain or with salt, on crackers,toast,
in milk, water or fruit juices.
"It is important that the bowels
should be kept freely open. This
is accomplished by the yeast, but
if this action becomes excessive the
dose should be diminished. For
the prevention of recurrence and
in order to raise the resistance of
*
the body to a normal level the
yeast should be continued for sev-
eral weeks after a cure has been
effected."
The book from which the foregoing paragraphs are taken, gives in
compact form the result of modern study of yeast. It is published
by The Fleischmann Company and is distributed free to physiologi-
cal chemists, doctors and hospitals. Write for a copy, addressing
Thb Fleischmann Company, Dept.S-5, 701 Washington St., New York
Mentioning The American Physician Insures Prompt, Careful Serine e
aican Physician lPbam., u.Ti ,,
Contents — «,nj/n«j/™» »,
-.328
The Therapeutic Value of the lea Bag In Acute Inflam-
matory Condition*.
By Albert J. Colton, M.D 35)
The use of cold in attempted reduction of dented
temperature lo as old aa man. The feverish uimil
Instinctively plunges Into cold water to obtain relief
Just aa the feverish human applies the we' kerchief to
relieve headache. Still Dr. Colton brings out new ud
Interesting points on tbe utility of this excellent remedj.
You will agree with as that It la a paper worth reading
—and you will be surprised at the extent of the use to
which you can put this good, old-fashioned Ice bsg-
Morbldlty In Obstetric*.
dlty li
7 Geoi
ge E. Nour, M.D.
Acid Fruit In Typhoid.
By C H. Mitchell, M.D Xt
Our Pedigreed Stock.
By Roland C. Evans. A.M.. M.D MS
Our Medical Schools Over- Manned.
By Leon Thurston, M.D MS
Polyneuritis of Infectious Origin — Author's Abstract.
By Tom A. Williams, M.S.. CM. M4
Efficient Future) of Medical Practice
Too Much Complexity Making Ducks and Drake* of Our
Civilization, Business and Medical Practice MS
Long Distance Weather Prognosticating Mi
Medical Fellowship* Ml
Board to Administer the Medical Fellowships J70
Cancer Work Budget for 1982 WO
The Laskar Memorial SM
Book Reviews
The Gland* Regulating Personality SID
The Blood Supply to the Heart In Its Anatomical and
Clinical Aspects 370
Atlaa for Electro- Diagnosis and Therapeutic* HO
Disease* of the Skin J72
Money Back Guarantee to Subscriber*
Miaicaa Phv*ici*h is published for eu and only —
- -to give the gtntrat praclititmrr the efficiently frerlictl
■«•><*: really htlpful in the problem* of everyday practice, and
to pTomolt and prottct the c-pportnnitiu and inttrttts of the
gmral practitioner in tvtry possible way; and, ■/ law mark be
will don,, to be financially aclf-iupporting and to im a reason-
It ta conpltttly free from any outside Inflow
itsnglement in any a»y with ttthtr.
riber, at any lime, feels that Tfttl
ot giving him fnil measure ("pressed
of such service, or i* dissatisfied for 4 .
us we will eheerfnUy refnni, without question.
;sid for the y tar's tnbscriptien, even if he hu|
seeks only sstisl
Practically all of oar subscribers, a* a matter of com
dttir* subscription to be continued, to avoid missing- issues
cannot jiMh back m-ri). and to be bulrd when subscription it
due (yearly in advance, unless, of course, paid ahead for longer
""where this is net the subscriber's desire. It is <*"*f*jb ■"* .,
is »°*"es%ea\ V nottfcltic0" i* sent promptly upon receipt ot
subscription bill, it will be discontinued (el once, of Bourse),
with no charge for the copies sent after aspiration.
Tan Amikicak Phybiciah does not distribute tempi* copies oi
free eopiea of any kind.
Sabtcription Price
Fiftr cents a copy current issue (beck issues $1.00 a oooy—
bmTUSm aranabl.); VM for One Year; « 0O foT^-c
Yean (*l SO a year); tS.OO for Four Years (I1.2S a y**0;
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Mexico. Canada and Foreign, SOe additiontl each year.
Aiirett si/ cemmnnicotumt sad *■*»# »B fundi fyaUt H—
Thi American Phyttcum,
4M fC.Ji.nt Street, PhiltdtlHut, U. S. A.
"Service Guarantee to Readers" on page 3
An HoneU Market Place
Hay Fever Memoranda —
Late Spring Type. Patieats whose hay fever develops in the
latter part of May, during June or early July, should be tested
with the pollens of sweet vernal grass, June grass, orchard grass,
timothy and red top. The one giving the major reaction should
be selected for treatment to the group. The unrelated rose
pollinates simultaneously and is the primary or secondary cause
in an occasional case — hence, should be included in tests especially
where direct exposure exists. The same is true of dandelion,
daisy and in some sections alfalfa.
Late Summer Type. Patients whose hay fever develops in mid-
August and continues until frost should be tested with pollens of
local importance — primacy being given to the long distance wind
pollinated plants, e. g., ragweed. However, where contact is
unavoidable, as on a farm, the short distance wind pollinated
plants, e. g., corn — and the insect pollinated plants, e. g., sun-
flower, which are also atmospheric — cannot safely be ignored.
ARLCO-POLLEN EXTRACTS
For Cutaneous Tests and Treatment cover early
and late spring; also summer and autumn.
Literature and Litt of Pollem on Request
THE ARLINGTON CHEMICAL CO., Yonkers, N. Y.
I SPRING HAY FEVER
Use Proteogen No. 4
united States Public Health Service statistics show
that the season for spring hay fever ranges from April
1 5 to July 27, depending upon the section of the country.
The immunizing treatment with Proteogen No. 4
should be begun from four to six weeks before the
customary onset of the hay fever symptoms.
Proteogen No. 4 has given very gratifying results both
in the curative and prophylactic treatmentof hay fever.
It is a safe, simple and rational treatment which is aimed
at the underlying cause of the disease.
Supplied in boxes of 12 ampoules.
Send for our booklet on the Proteogen treatment of Hay Fever.
Give your hay fever patients the benefit of Proteogen
treatment this year.
THEWBS.I
M FOUNDED ISIS
ERRELLcohmny
CHCHttTL U 5. A.
Mentioning The American Physician Insures Prompt, Careful Service
)'Silvol
the treatment of
inflammations
silver preparations
g bid for distinction.
: white in color, and
descent hue. This
can apply effective
is membranes with-
thin reach with the
color of other silver
x colloidal form of
I silver proteid that
he practice of many
er hand, a colloidal
This explains the
and NeO'Silvol are
cated in solutions of
treatment of inflam-
micous membranes,
z, ear, nose, throat,
Mid rectum.
l Company
o Readers" on page 392
The American Physician. ]
An Honest Market Place
333
DIATUSSIN
One of die moat eflkaorai and best known remedies
FOR
ASTHMA, BRONCHITIS AND WHOOPING COUGH
For children or adults. Sold on prescription only
A FEW CASE REPORTS OF INTEREST
"Some time ago I received a sample bottle of Diatussin which you sent me at my request, for clinical
teat. I at once put the Diatussin to work in my three cases of whooping cough, with immediate and
gratifying results. All three cases showed marked improvement from the very beginning of the treatment
with Diatussin, the paroxysms being diminished both in tensity and frequency. I shall be pleased to use
Diatussin in all cases of Pertussis in the future. You have my permission to use this letter in any
way you may see fit." — W. C. Wolverton, MJ)., Linton, N. D.
"As to the value of Diatussin — you can quote me if you choose — it positively relieves and comes
aa near a specific as I would wish in whooping cough"— iDr. $. Kahn, Detroit, Mich.
"I take pleasure in saying that while I have had the opportunity to test the drug in only two cases
of whooping cough, the results in both cases were so gratifying that I will undoubtedly prescribe the
drug in future cases. From the limited experience I have had with it, I regard it of extreme value in
allaying the cough and paroxysms of this stubborn disease." — Dr. B. R., Brooklyn, N. Y.
•«i
'I hereby report to you the following three cases of whooping cough and the succcssfulness of Diatussin:
"a. Child of I. C, 7 months old, 99 Bay 34th St., Brooklyn, 54 to 1 drop twice, daily and relieved
in a week and cured in about 4 weeks.
"b. Two children of Q. M., 980 Prospect Ave., Bronx, 4 and 5 years of age. Paroxysms relieved
and recovering rapidly. (1 to 2 drops morning and evening)
"c. Child of Dr. I. T., Dentist, 2 West 119th St., N. Y. C, 18 months of age, paroxysms relieved
and recovering rapidly. (One drop twice daily.) — L. C, M.D., N. Y. C.
"As I have been so well pleased with the results obtained from Diatussin in the case of a little girl,
will give you a brief history. F. H., female, 7 years, 3 weeks after developing whooping cough was
brought to me for treatment. At that time she was suffering from 20-30 paroxysms in 24 hours, vomiting
and loss of weight and sleep. I put the child on antipyrine and bromides, the paroxysms increased in
number and severity. The lungs on ausculation revealed rales over the upper portion. I placed the
patient upon one drop of the new remedy for whooping cough, 'Diatussin' night and morning and in three
days the paroxysms were reduced to 2-4 in 24 hours and less severe, vomiting decreased and the child
slept all night. The dose was then increased to 2 drops night and morning, then 3 drops with the result
that at the end of two weeks from the time the first dose of Diatussin was given, the mother stated that
the child had improved to the extent that she considered her cured. I wish to give Diatussin a thorough
trial and if it proves to be as serviceable in my future cases as the one mentioned above, I assure you
it will be a very valuable preparation to me." — Dr. E. H. C, Johnstown, Ohio.
Child D., 6 years, well developed boy, suffering from annoying cough, especially during the night.
General condition good, lungs normal, no whooping cough. After taking Diatussin 3 gtts. t.i.d. for 3 days,
cough disappeared completely.
Mrs. K., 38 years, always healthy up to some time ago, when she began to suffer from persistent
spasmodic coughs, which became particularly aggravated at night on retiring. Codein and Paracodein
gave only temporary relief. Examination of the lungs revealed no pathological lesion. Diatussin in doses
of gtts. V-VI in the evening eliminated the night attacks for a long time.
Mrs. H„ 71 years, well preserved, healthy respiratory organs, suffered attack of influenza. No
pulmonary catarrhal symptoms, but severe attacks of spasmodic cough, day and night. Only temporary
relief obtained by Codein. etc Diatussin gtts. IV t.i.d. eliminated the spasmodic character of the cough
during the day and permitted undisturbed rest during the night.
Samples and Literature On Request
,o,,<S("*,
ERNST BISCHOFF CO., INC.
85 WEST BROADWAY, NEW YORK
Mentioning The American Physician Insures Prompt, Careful Service
The American Physician
[Phila.. Mar. 1«2
lafidkt.SilijlJi
ENDO-SODIUM IODIDE
ENDOMETHYLENAMIN
"~ " FEfi
ENDOQLOBIN
(CH..wii.Pe.«K..«u***i»,«)
Intravenous medication has
long since passed the experi-
mental stage. The favorable
attestations of thousands of
reliable physicians are unani-
mous in their endorsements of
this method of remedial treat-
At the hands of our chem-
ists, specialists in research, our
products are prepared with the
utmost care, skill and acumen.
Their purity challenges com-
parison.
Formulae of our specialties,
reprints of interesting articles
and price lists cheerfully fur-
nished to physicians on re-
quest.
lodi4+>. Qyaia&i. O*os*lt
"T»lis {ei/ewMjfrtpfrmtmB it
GUIOLEUM
(far lace/ IbetWy) .
GLVCO-ASEPTIC
You can buy with Confidence — See "Service Guarantee to Readers" i
Tkr American Physicisn.]
An Honest Market Place
.N
K
H
OF THESE BACTERINS FIRST
AND THINK OF THEM
WHEN ALL ELSE FAILS
these bacterins give results. When rightly used in combination with
other appropriate therapeutic measures, these bacterins are a definite aid.
Abbott bacterins frequently turn failure into success. Experience shows
that they are a deciding factor in many obscure and difficult cases.
1 . ACNE COMBINED BACTERIN
should be used in scute and chronic acne and seborrhea.
2. GONOCOCCUS COMBINED BACTERIN
effectire in urethritis, prostatitis, vesiculitis, cystitis, gleet, vulvovaginitis,
conjunctivitis, arthritis, endometritis, etc., of gonorrheal origin.
3. VAN COTT COMBINED BACTERIN
of value in obscure and mixed infections, tonsillitis, mastoiditis, phlegmon, sepsis
and obscure infections generally.
-». STREPTOCOCCUS RHEUMATICUS COMBINED
indicated in arthritis, acute and chronic, neuritis, myocitia, neuralgia, etc.
k hese Abbott bacterins of highest quality are supplied in ampules and, also, in the
» map roved and patented Abbott Bulk Container. Order at these prices direct or
'Sa rough your druggist.
Per box of six I -mil (l-Cc) ampules $1.13 net
5 mils (5-Cc) in bulk container 75 net
20 mils (20-Cc) in bulk container 2.63 pet
THE ABBOTT LABORATORIES
DEFT. 4M, 473B RAVENSWOOD AVENUE. CHICAGO
»1 F- lTth. St. 227 Central Bid,. 36* MIssIob St. SS4 L W. Hitlman Bid,.
New York S..tt).
Mentioning The American Physician Insures Prompt, Cartful Service
The American Physician
[Phiii. Msy. ISU
SANTYL
for the INTERNAL TREATMENT of
The Neutral Salicylic
Ester of Santalol
mm©w^%m
m from irritant actios
Dote: 1 capsules 1 or 4 times daily
Literature •ad nmf Ui frem
E. BILHUBER, lac, 45 John St, Ntnr Tort
"V/"|"7 A OnP/*\\jr^ ^m The purified active principles
I Cf\-3 X \J.lN Ed and VlTAMINES OF YBAST
GIVEN IN PLACE OF YEAST FOR MEDICINAL PURPOSES
Keeps well Pleasant to take Reliable
Literature and Sample on request
MERCK & CO. 45 Park Place New York
KgcK«j)1
What Is the Best "All 'Round" Alkali?
YEARS of clinical experience have demo nit rated the fact that McKesson fit
Robbint' Milk of Magnesia (magnesium hydroxide) i* by far the moat
dependable of all alkalies for therapeutic use*. McKeaaon At Robbint'
Milk of Masneaia ha* a higher neutralizing power than any non-eacharotic
It does not liberate carbon dioiide on con
doe-, sodium bicarbonate. Therefore. It does no
which frequently cause distress in certain g
especially those associated with dilatation.
de
ve7oP
acids— aa
ndltlona—
There is no better or more dependable neutr
for bottle- baby feeding than a teaapoonful or m
Robblns' Milk of Magnesia, added to the twenty
And It is mildly laiative aa well.
sllier of
are of M
-four hoi
.ow's milk
Kesson t.
r feeding.
Also, for neutralizing the hyperacidity of
have your patients rinse the mouth with a little M
Milk of Magnesia just before retiring at night.
he
oral secretions,
son & Robbine"
McK ec R Milk of Magnesia is better than all
rd
nary
nagnesias,
Specify McK & R, Doctor, and be sure of a dependable product.
Manufactured by
McKESSON & ROBBINS
INCORPORATED
Manufacturing CUmab
91 Fulton Street New York City
i buy with Confidence — See "Service Guarantee to Readers" on page 392
An Honest Market Place
Til
"1HE remarkable result* obtained by the use of Virol in
. Infant Feeding, for delicate children, and expectant and
nursing mothers, is shown by the fact that more than 2,600
Hospitals, Infant Clinics, and Maternity Centers are regu-
T»i# oery palatabU larly using this preparation.
«* eiati jan: soe, The marked improvement in growth and development
$im and t*M. brought about by the administration of Virol is due to:—
The presence of the vitamines in their active state.
The well-balanced nature of this food.
The ease with which it is assimilated in the most delicate
conditions of the intestinal tract
BIO-CHEMICAL INVESTIGATIONS
In view of the extent to which Virol is used in public health
work in Great Britain, the Bio-Chemical Laboratory of the
University of Cambridge recently conducted an exhaustive
investigation to determine whether the vitamines known to be
present in the raw materials from which Virol was manufac-
tured were present in their active state in the manufactured
Virol as sold to the public. The report, which fully proves
the presence of the vitamines in Virol, will be sent to any
medical man on application.
Sole Agents for United States
GEO. C. COOK & CO., Inc., 59 Bank Street, New York
Mentioning The American Physician Insures Prompt, Careful Service
An Honest Market Place
[Phila., May, 1922
STRENGTH FOR
THE ASTHENIC
Suprarenal insufficiency is one of the marked features of the asthenias.
The blood pressure in these individuals is almost always low and the cir-
culation poor. The activities of other glands of internal secretion are
always impaired. That is why pluriglandular therapy gives better results
than suprarenal substance given alone.
Hormotone
which is a combination of
thyroid ( 1/10 gr.), entire
pituitary (1/20 gr.), ovary
and testis, promotes oxidation,
increases blood pressure and
enhances metabolism by pro-
ducing suprarenal efficiency.
Dose: One or two tablets
three times daily before meals.
G. W. CARNRICK CO.
419 Canal Street
New York, U. S. A.
You can buy with Confidence — See "Service Guarantee to Readers" on page 392
We Must Lay Our Cards on the Table
In the Health Insurance Proposition
NEW YORK and Chicago advocates of health
insurance have been talking very frankly with
us, and they show considerable disappointment over
the status of affairs. They are willing to concede that
the so-called model law they formerly advocated was
defective and carried a political menace — one that
angered the physicians, who justly feared that the
politicians would control and make the status of the
educated physician intolerable. The model law is
a dead issue.
It is also conceded that conditions in England, the
Continent and in the United States are not at all
parallel and that any plans looking to the solution
of the problem of sickness incidence in this country
must be worked out on an American basis, not that
of England or Germany.
Yet, these people contend, we are not meeting the
sickness problem in any adequate way, and they now
look to the medical prof ession. to suggest some con-
crete plan acceptable to all concerned. Efforts have
been made to secure expression of view from phy-
sicians, but it is stated to us that physicians who are
approached for an opinion "go right up in the air,
become angry, and some swear roundly that they will
have nothing to do with the proposition in any form/1
Also, it appears, there is no group of physicians
authorized to meet the advocates of health insurance
in conference.
It h Omr Mm*
First of all let us survey conditions as they are.
Times are hard, taxes are high, business and profes-
sional overhead is burdensome. Community drives
for hospitals and charities are yielding disappointing
sums. Wealthy people feel the loss in income, and
this, added to high income taxes, make it improbable
that for some years to come the wealthy will heavily
underwrite our charities; they have all they can do
to maintain existing institutions and movements and
will not undertake new burdens except those impera-
tively necessary. Added to this is the outstanding
fact that state governments are compelled to pare
down instead of undertake new outlays. The rank
and file of people are in no position to contribute
largely to new enterprises; they are forced to thrift,
and while showing every disposition to do what they
can they will not look with favor on expensive ex-
periments. Therefore, it must be recognized at the
outset that the present is no time to suggest elaborate
plans looking to the expenditure of huge sums of
money.
Socialistic propaganda is on the wane except that
it is generally recognized that economic conditions
need adjustment, and that such readjustment should
be of a character to provide better housing, more
sanitary environment, a plentiful supply of nourish-
ing food and all conditions favoring sane living and
increased health. While not the sole province of
sanitarians to secure these things, they have a part
therein, but business and industry have larger parts.
This is coming to be recognized in many ways and the
opinion is forming that the sickness problem may be
better met by putting people in the way of living
well and helping themselves than by going on in the
old economic ruts and attempting to meet the evils
thereof by some sort of patent-medicine socialized
medicine supplied by the state. If we can show
business and industrial leaders that it pays in dollars
and cents to rearrange conditions and environments —
and they are being shown — a very substantial part
of the sickness problem will be met without increas-
ing taxes a cent, disrupting medical practice, or going
to the expense of administering a heavy work along
political or social lines.
The medical profession is a practical unit in the
view that public health work should be absolutely
divorced from politics in every shape or form,
workers being employed on none but an efficiency
basis from the United States Public Health Service
down to the local board of health, and that fancy
340
In the Health Insurance Proposition
[The American Physician.
stunts be eliminated. Were such a condition to
prevail in public healthy work, and it must prevail
ultimately, one dollar would do the work that it now
requires two or three dollars to do. Here is a very
positive and practical way to meet several phases
of the sickness problem.
Medical Practice
Both the public and the medical profession have
come to the place where it must be recognized that
private medical practice is a public concern, that it
must be regulated by law and by its own profes-
sional associations, and that it is just as important
a matter to the people to be protected jjf£m quackery
and incompetence in medicine as it is in other im-
portant matters, such as fire hazards, dangerous
plumbing, diseased meat supplies, impure drinking
water, reckless automobile driving or dangerous use
of explosives.
There is no getting away from the fact that a
tremendous incidence of disease is due to quackery,
cult foolishness, worthless patent medicines, and
ignorant and incompetent medical and surgical at-
tention. Wipe out these things and another large
section of the sickness problem will have been met.
Public Ignorance
Suppose we do have a politically managed form
of health insurance, or even a form of socialized
medicine free from politics, what assurance have
we that it would be intelligently used by the people f
We are not at all reassured by results in England
and Europe. How are we to keep the quacks and
incompetents out of it, and how shall we proceed
to line up the ignorant and mistaken elements in
society so that they would select only the best of
service and refuse the badf We know how our
present dispensaries are abused, how people go from
our offices to the quack around the corner, how
despite our best efforts our patients yield to every
nonsensical superstition and fail to follow our di-
rections, how they dose themselves recklessly with
everything advertised as a remedy, how they break
quarantine or refuse to be vaccinated, and how they
do everything they ought not to do and do mighty
few things we tell them to do. Wherein would any
form of health insurance mend this state of affairs?
No, gentlemen, it would not work. The state would
be supplying staple goods in plain packages at a
low price and the people would not appreciate it,
spending just as much money, or more, on all kinds
of medical foolishness and quackery as they do now,
and the result would be that the state would be
playing into the hands of the very elements responsi-
ble for the present high incidence of sickness and
spending a vast sum of money to do it. Rather, it
seems to us, education of the people should be
stressed, and they should be taught to pay their own
way medically and have sufficient discrimination to
avoid being cheated.
Oar Cards Are am the Table
We are sorry to disappoint the gentlemen who in-
sist on the medical profession elaborating a plan
of health insurance in place of that they formerly
tried to force on us. We don't believe that meeting
the sickness problem is an insurance proposition, or
a lodge affair, or one for the politicians, or lay or-
ganizations. We can see no real need for a special
organization, or a government bureau, or special
taxes, or supervising officialdom on salaries. Rather,
we take it, were the things done that we have indi-
cated in this article ought to be done, the sickness
problem will be met vastly more effectively than is
possible by any scheme of health insurance devised
by laymen or even by physicians. — T. S. B.
St. Louis and the A. M. A. Meeting
The arrangements of the St. Louis profession for the
meeting places for the session of the A. M. A., which
is to be held in their city May 22-26 next, are singularly
fortunate and convenient; never has the Association
been so well favored in this respect. The district in
which the meeting is to take, place is at the west edge
of the business section of the city, easily accessible from
all directions by street car or otherwise and not more
than fifteen minutes' street car ride from the most dis-
tant hotel. The grouping of the meeting places is so
compact that should one walk from the Registration
Building (Moolah Temple) to the farthest hall it can
be done in ten minutes or less; from section to section
is a matter of from one to ^iwt minutes. The conveni-
ence of the location and arrangements of the different
halls is more outstanding than in any other city in
which the Association has met, and a decided improve-
ment over the accommodations which were had at the
meeting in St. Louis, 1910. The registration office,
postoffice and commercial exhibit is to be in the Moolah
Temple on Lindell Boulevard, two blocks west of Grand
Avenue.
The St. Louis profession is preparing for an unusual
attendance; hotel reservations are coming in rapidly,
but it is purposed that even the late comer shall be
comfortably housed. The wise traveler, however, makes
his reservation as early as he finds it possible. Dr.
M. B. Clopton, 3525 Pine Street, St. Louis, is chairman
of the Committee on Sections and Section Work.
American Proctologic Society
Twenty-third annual meeting, St. Louis, Mo., May
22 and 23, 1922. Meeting place and headquarters, Hotel
Claridge.
Their preliminary program is very interesting and
they cordially invite the profession to attend the public
sessions.
Phite., May, 1922]
Syphilis and Alcohol in the Paralyses
341
Role of Syphilis and Alcohol
in the
Paralyses
OSLER, some time ago, said: "Of the killing
diseases, syphilis comes third or fourth." Ana-
lyzing the statistics of the Registrar-General for 1915,
out of 58,000 deaths from diseases of the nervous
system, 19,498 were due to syphilis, a large propor-
tion being various paralyses. And, inclusive of syph-
ilis-engendered cardiac and vascular diseases, still-
births, deaths of infants under one month and other
syphilitic conditions, he estimated the actual deaths
from syphilis as over 60,000, thus placing it at the
top, an easy first, among the infections. American
figures, which have been grouped by Vedder, in his
book, "Syphilis and Public Health," are equally im-
pressive, and they show that "syphilis is the greatest
cause of death of men in the large cities," as he
asserts. life insurance figures tend to prove the
same thing.
Discounting alarmist figures and propagandist
statements, deaths from alcohol and alcohol-engen-
dered pathology are admittedly very numerous, many
of the insanities and paralyses being due to alcohol.
Tcxf-fe** StetoMntf
Works on neurology divide and subdivide the paral-
yses, giving the causes on the basis of gross pathology
and neurone changes, but rarely going back of these
to the primary causes that induce the inflammatory
and pressure lesions productive of paralyses. Paral-
ysis agitans has a pathology not definitely demon-
strated; bulbar paralyses are attributed to inflamma-
tions, degenerations, vascular lesions, and the pres-
sure of tumors, some being syphilitic gummatae;
paralyses of the limbs have added to this pathology
lead poisoning, strain, dislocations and fractures,
dampness and cold, rheumatic deposits, nerve injury,
cord anesthesia, and pressure, as from crutches;
ischemic paralyses are attributed to pressure from
bandages and splints and suppurative conditions;
diver's paralysis (caisson disease) is attributed to
changes in air pressure; hysterical paralyses are
ascribed to lesions in the neurones or the cord;
Klumpke's paralysis is stated to be due to thickening
of the meninges. Then, too, infantile paralysis,
Landry's paralysis, diphtheritic paralysis, and some
others, are due to sepsis, infections, bacterial poisons
and specific diseases such as typhoid, influenza, etc.
General paralysis of the insane, tabes, etc., are
directly attributed, in a large proportion of cases, to
syphilis, and sometimes to alcohol.
It is, of course, to be remembered that trauma,
pressure, etc., are large factors in the induction of
paralysis, and that toxins of various types induce
many cases. Yet an analysis of the pathology in
many of the other types, and, as well, the frequency,
of a positive Wassermann reaction, make it apparent
that specific causes, such as syphilis and alcohol, lie
back of the disease in a large number of the paralyses
The following was clipped from the foreign news
section of the Journal of the American Medical As-
sociation for January 28, 1922 :
Tkt Sprtmi of Immmty in Hmmgmry
"A startling statement was recently made by Dr.
Koloman, a senior physician to the state asylum at
Lipotmezo. Dr. Koloman, who has made a careful
study of the life histories of the 12,000 patients ad-
mitted to the asylum during the last forty years, has
come to the conclusion that 53 per cent of the cases
of insanity among professional men were avoidable.
Every one of these patients, he tells us, died of paraly-
sis, 29 per cent, being physicians under 36 years of
age. As regards physicians over 36, the percentage
of deaths from paralysis amounted to 77, while among
lawyers who had passed the same age it rose to 89.
Out of fifty-three members of the latter profession,
ranging from 40 to 60 years of age, fifty-one suc-
cumbed to paralysis, and eleven actors admitted to the
asylum during the period in question all suffered from
the same disease. As regards the prevalence of paral-
ysis in other professions, the army was represented
by a fairly large proportion; 94 per cent, of military
officers over 26 years of age, and the church by 82
per cent, of Protestant and 42 per cent, of Catholic
clergymen. The lowest proportion seems to be found
among Jewish school teachers, there being only 6 per
cent, under and 40 per cent, over 26 years of age .in
the total number of cases. On the other hand, tha
proportion of paralysis among the total number of
mental diseases in Jewish merchants over 36 rises to
93 per cent., while in agricultural laborers it is only
25 per cent., and in railway and navigation men 71
per cent., therefore affording conclusive evidence that
it is moral conduct, not circumcision, that protects
the Jew from syphilis. The connection between
paralysis and immorality is clearly proved by the
data afforded by the histories of female paralytics, the
proportion of paralysis among women between the
ages of 16 and 30 being only 2 per cent., while in
prostitutes of the same age it rises to 30 per cent.,
and among women between the ages of 31 and 36,
8 per cent., as compared with the 60 per cent, among
their less fortunate sisters. It is surely a significant
342
Announcements
[The American Physician.
fact, moreover, that no one has yet seen a paralytic
nun. These figures, in Dr. Koloman's opinion, prove
that paralysis undoubtedly depends largely on the
previous presence of syphilis. There seems every
reason to believe, therefore, that only a man suffering
from the latter is likely to be smitten by the former,
and that he who is free from the one is likely to
escape the other. Alcoholism ranks next to syphilis
as an etiologic factor of paralysis, and unfortunately,
this cause is almost as frequent among the educated
as among the uneducated classes. This is proved
by the fact that only 9 per cent, of nonparalytice
among the physicians owe their mental disease to
alcohol, 41 per cent, of the judges, 21 per cent, of
the military officers and post officials, and 32 per cent,
of the railway employees have been reduced to their
present condition by a reckless indulgence in intoxi-
cants. On the other hand, not one of the thirty-three
Jewish school teachers suffered from alcoholic mental
disease, a fact which also proves that epilepsy is
relatively uncommon among Jews. These figures,
compiled from observations during forty years, con-
vey an important moral. It is Dr. Koloman's delib-
erate opinion that all these unfortunate persons could,
humanly speaking, have been saved from their dis-
ease if in early youth they had learned to resist
temptations to drunkenness and immorality. In this
respect Hungary compares very badly with such a
country as Sweden, for example. While only 1 per
cent, of the inmates of the Swedish state asylums
are paralytics, the Hungarian establishments contain
as many as 18 per cent, suffering from this disease,
and, moreover, many of the patients are physicians,
lawyers and other professional men who, instead of
being an object of expense to the state, ought to be
capable of working for twenty or thirty years for
their own and the public welfare."
These are startling, statements and they are en-
titled to careful consideration. It impresses us that
our whole conception of neurology is too anatomical
and histological, too much based on the neurone the-
ory, whereas progress lies in the direction of recogni-
tion of more obvious and primarily etiologic factors.
Now that public attention is being directed to the
evils of alcohol and venereal factors in the production
of disease, we may, if we profit from recent statistics
and set aside preconceptions, do a world of good in
limiting to the minimum the incidence of the paral-
yses.—
Coming In Next issue
If you have quickly and completely emptied a
chronically distended bladder, and in a few days signs
of urinary failure set in, do not be surprised at the
phenomenon and wonder what caused it Empty par-
tially.
Gastric and Intestinal Motility, by J. C. Boo del, M.D.
Motility, secretion, digestion, pain, ulceration, spasm
and obstruction in the alimentary canal are condi-
tions encountered by every physician in his daily
vocation. We thoroughly approve of the paper of
Dr. Boodel as the brief but clear descriptions on the
mentioned points will be of undoubted value to
every reader.
Preventive Gynecology, by H. S. Lott, M.D.
There is music in brooks, sermons in rocks and
poetry in gynecology. Still, in spite of the artistic
form of this paper, it is loaded with instruction,
utility and common sense.
The Proper Interpretation of Symptoms, by Alfred
Brown, M.D.
Symptoms are extrinsic expressions of intrinsic con-
ditions and are precious when properly understood.
However, when they run wild like a mob in alarm
and disorder, their interpretation becomes difficult
and their significance problematical. It is then that
the physician steps in and distinguishes between
the informative and valuable and the rambling and
confusing. These points are skillfully discussed and
vividly illustrated in Dr. Brown's helpful paper.
Familial Epistaxis, by H. I. Goldstein, M.D.
The disorder herein described is rare, obscure and
interesting and is presented by the author with char-
acteristic thoroughness. It should make unusually
profitable reading.
The Following Series will be continued:
A Case of Tuberculosis of the Foot, Twenty-seventh
Clinic, by A. Mackenzie Forbes, M.D.
In surgery the importance of judgment cannot be
overestimated. Some cases of tuberculosis of the
foot may be treated by expectant measures, in others
it is wise to amputate. The reasons for the decision
are carefully worked out and will prove interesting
and helpful.
Medical Diathermy, by Elnora Cuddeback Folkmar,
M.D.
This conservative article is a reliable guide to the
practitioner and gives exact technic that is safe and
effective.
Observation— Third Paper on "Footlights on the
Feet," by Charles Cross, M.D.
A brief but interesting paper on faulty shoes and
the trouble they cause.
The Following Clinical Editorials:
Take Care of the Spine Especially in These Days of
Traumatic So-called "Adjustments."
Chlorophyll and the Vitamines.
The following papers
are contributed exclu-
sively to this journal.
Republication is per-
mitted if credited as
follows: AMERICAN
PHYSICIAN, Phila-
delphia.
Original Articles
Saturn, Hi minn* km tapst mm Mtt mmum*
We are not respon-
sible for the views ex-
pressed by contribu-
tors; but every efort
is made to eliminate
errors by careful edit-
ing, thus helping the
reader.
Diagnosis of Blood Diseases
by the
General Practitioner
ON HIS DIAGNOSTIC ABILITY DEPEND THE REMAINING FEW YEARS OF THE PATIENTS LIFE
By D. A. Smith, B.S., M.D.,
1000 French Street, Wilmington, Del.
Nmd SBie a VahsM* Drngtrntic Index
Undoubtedly correct in stating that "the
general practitioner does not diagnose the
blood diseases as often as he should," it was
the author's happy thought to write this
timely and well-planned paper on all im-
portant blood dyscrasias and allied disorders,
covering them admirably, and leaving out, at
the same time, burdensome details and dry
technicalities, and presenting the subject in
an interesting and readable form. — Editors.
THE GENERAL PRACTITIONER does not
diagnose the blood diseases as often as he should.
The average doctor is a busy man, and the necessary
examination of the blood does take time. It is not
suggested that such an examination be made as a
routine measure, but only when the clinical picture
seems to call for it. An exhaustive study of the
blood, while desirable, is not essential, yet the exam-
ination of a properly prepared blood slide alone,
will sometimes add to the prestige of the doctor and
to the life of the patient.
The average doctor is more of a technician than he
will admit, for he has had several years of laboratory
work in college, university and hospital. The prep-
aration, then, of a blood slide presents few difficulties.
Unfortunately, not many physicians outside of those
directly connected with hospitals use the blood for
the valuable diagnostic index it undoubtedly is.
IUmI DitMscf
The blood is a tissue, as much so as bone and
muscle, and hence we should expect it to have dis-
eases peculiar to itself. However, modern research
teaches that there are no idiopathic blood diseases,
but that the blood, to an extraordinary degree, re-
flects conditions elsewhere. For this reason it is
seldom possible, and never advisable, to make a diag-
nosis of the so-called blood diseases from the blood
alone. The clinical symptoms are always the more
important, and the blood examination is merely con-
firmatory.
While it is scientifically true that the blood is never
primarily diseased, there are several disorders in
which the blood symptoms are very prominent, and
the true etiology very vague. Custom has given the
name "blood diseases" to these affections, and the
term will be used throughout this article as a matter
of convenience.
HemaMeUgU Cmaiimrmtmm m Heakk ami
The blood keeps a remarkably uniform morpho-
logical composition in health, and in many diseases.
In normal blood there are from 4,500,000 to 5,000,000
red cells (erythrocytes), 6000 to 10,000 white cells
(leucocytes) and 200,000 to 700,000 platelets to the
cubic centimeter. In certain diseases, however, the
number of the circulating erythrocytes is much de-
creased (the anemias), in other diseases the number
of the leucocytes is much increased (the leukemias).
All the leukemias develop a secondary or sympto-
matic anemia as the case progresses. The anemias,
on the contrary, seldom show an increase in the white
cells (leucocytoses), unless it is caused by the under-
lying disease.
In adult life, it is probable that all cells, both
erythrocytes and leucocytes, originate from large
mononuclear non-granular mother cells in the bone
marrow. In the anemias there is great destruction
of the erythrocytes (oligocythemia), and the bone
marrow seems unable to supply the demand for ma-
ture red cells. Hence, some of the immature nucleated
forms enter the circulation (microblasts, normoblasts
and megaloblasts).
The polymorphonuclear leucocytes are immediately
343
344
Diagnosis of Blood Diseases — Smith
[The American Physician.
derived from mononuclear basophilic, eosinophilic
and neutrophilic cells (containing bluish, reddish or
neutral granules). These cells, in their turn, have
for their common ancestor the mononuclear non-
granular mother cell. Most of the large and small
lymphocytes are formed in the bone marrow from
the same mononuclear cell. Some of these cells,
however, are undoubtedly formed in the thymus,
lymph nodes and general lymphoid tissue. The plate-
lets are formed either from the detached pseudopods
of the giant cells (megakaryocytes), or from the
extruded nuclei of the erythroblasts.
So much for the morphology of the blood. We use
only the variation in the number and character of
the circulating cells to make a diagnosis of blood
disease. The chemical tests (urea nitrogen, choles-
terin, creatinine, uric acid, eta) and the serum re-
actions (Wassermann, Widal, hemolytic, agglutina-
tion, etc.) are, as far as we are here concerned, not
necessary.
Obmcd Symptom
Sometimes the clinical symptoms of the blood dis-
eases bear such a striking resemblance to those of
other asthenic conditions, such as sepsis, tuberculosis
and nephritis, that particular care may be needed
for the differential diagnosis. The doctor will see
hundreds of the more common diseases, to one where
the blood condition seems the paramount factor.
Hence, if he is not on the alert, this one ease may
slip by him with results disastrous to the patient. To
complicate matters further, tuberculosis, nephritis or
any of the other more frequently met diseases may
coexist with the blood dyscrasias.
We will now consider the symptoms most often
found in the blood diseases. Of course, they are not
all present in any given case, or perhaps it is more
accurate to say they are not all emphasized to the
same degree. In one case the gastro-intestinal symp-
toms will be predominant (nausea, vomiting, stoma-
titis, constipation or diarrhoea). In another, the
nervous phenomena overshadow all else (headache,
vertigo, somnolence, neuralgia, various paresthesias,
psychic disturbances, etc.). In a third, the respira-
tory symptoms will hold the center of the stage
(rapidity of respiration, dyspnea, air hunger, chest
oppression, etc.). All cases invariably complain of
marked weakness, mental depression, palpitation of
the heart, anorexia and loss of weight. Every case
also develops pallor of the skin, edema of the hands,
feet and abdomen, and slight evening fever. We
shall refer to this paragraph several times in our
discussion of the individual diseases.
Prepmrmg md Exmmmmg the M—i Slide
A blood slide should be taken of any patient who
shows jaundice or facial pallor, and who complains
of the symptoms just enumerated. Use a sharp
lancet, and puncture either the lobe of the ear or the
finger tip. Make this puncture deep, so that it will
not have to be repeated. Any doctor who has had
experience with a nervous patient will understand
the advantage of this. Do not massage the part
selected for puncture, as this tends to change the
condition of the blood. Wipe off the first drop and
allow the succeeding drop to adhere to the face of a
clean slide. With the edge of a second slide make
as thin and even a spread as possible. After the
slide has been thoroughly dried in air, we are ready
for staining. Add eight drops of Wright's stain for
two minutes; then add eight drops of distilled water
and allow the mixture to stand for two minutes more.
Wash the slide in running water and dry in air.
For a complete blood examination, we should make
a red, white and differential count of the blood cells,
and we should also determine the percentage of
hemoglobin. Then by dividing the percentage of
hemoglobin by the percentage of red cells, we would
get the color-index, which varies characteristically in
the different anemias. All this, while not especially
difficult, takes more time than the average physician
can personally afford. By confining himself to the
blood picture, he can at least determine whether he
is dealing with a true blood dyscrasia. If he decides
this to be the case, he can send a specimen to a re-
liable commercial laboratory for a complete examina-
tion.
Tht Ammum
In the anemias we have a marked diminution in
the number of the circulating erythrocytes. There is
seldom a leukocytosis, unless caused by the under-
lying disease, and there is sometimes a leukopenia
(diminution of the white cells). Under the anemias
we will discuss pernicious anemia, chlorosis, sympto-
matic or secondary anemia, splenic anemia, Yon
Jaksch's anemia and malaria.
Pernicious anemia used to be called a primary or
idiopathic anemia, but we now know it to be sympto-
matic or secondary, even though the etiological factor
is in doubt. It generally appears in adult life, be-
tween the ages of twenty and forty, and is twice as
common in men as in women. The onset is very
insidious, and when the patient comes to the doctor
the disease is usually well advanced. The chief com-
plaint is extreme weakness, with palpitation and
dyspnea on the slightest exertion. The patient may
not have lost much weight, but he looks sick. Pallor
of the face and body is extreme, and as the case pro-
gresses the skin takes on a lemon tinge. The patient
may complain of any of the symptoms common to
the blood diseases. On physical examination, cardiac
murmurs (functional) may be heard, and a venom
hum can sometimes be demonstrated in the veins of
the neck (bruit de didble). The blood pressure is low
(less than 100 systolic).
Pbik..MaT, 1922]
DiigwMU of Blood Disease*— Smith
345
HmI t ictoat a f II nil ill Amtmw
In preparing the slide we will note the blood to be
abnormally pale and fluid. Microscopically the
erythrocytes are not uniform in size (anisocytosia),
and show bizarre shapes (poikilocytosis). The cella
do not take the stain evenly, so that some are deep
red, some very pale and some more or less bluish
in color (polychromatophilia). Many of the erythro-
cytes are nucleated (microblasts, normoblasts and
megalobtasts), and it is the presence of these nucleated
cells, eepeciallly the megalo blasts, that is character-
istic of the disease. More leukocytes may seem
present than in a field of normal blood, bat this is
only because the erythrocytes are so markedly reduced
(2,000,000 or less). The presence of megalobtasts
and other nucleated cells, the absence or reduction of
the blood platelets, the poikilocytosis, anesocytosis and
polychromatophilia, are the main diagnostic points
of the blood picture.
Fig. 1 shows a mieropbotograph of a typical case
of pernicious anemia. It may possess added interest
from the fact that it was made by the author during
some blood studies by means of an ordinary micro
scope, a photographer's camera and a great deal of
patience.
Fig. 1 pernicious Anemia.
1. Normoblast.
'i. Potjmorpnonnclear cell.
3. Ijirgi; lymphocyte.
t. Cell snowing- polycbromatoplillla.
5. Cell fragments.
6. Mesa lob last.
T. Poikilocytosis.
(Gnm 5ictatai W CirbJ
This disease is confined to girls at about the time
of puberty. It occurs more often in blonds than in
brunettes, and in subjects who have been under-
nourished and under-exercised. These facts consid-
erably narrow the diagnostic field.
Given, then, a young female, who complains of
the symptoms common to the blood diseases, we should
look for the special symptoms which point to chlo-
rosis. The patient may seem extremely plump and
well nourished, which fact is in marked contrast to
her great pallor. On the slightest exertion, she may
get very deceptive peach-bloom cheeks (chlorosis
rubra). She will evince a most extraordinary taste
for certain articles of food, such as pickles, highly
spiced dishes and even clay or chalk. Note that
edema of the feet and ankles is often present, and
we should not take this as evidence of a simple heart
or kidney condition until the blood has been exam-
ined. The heart, particularly, may be suspected, as
there is usually a systolic murmur present and a
loud venous hum in the veins of the neck (bruit de
diable).
MsW r IdW* M Ofarasu
When the blood slide is examined, nothing char-
acteristic will be noted. The same blood picture may
occur in any of the symptomatic anemias. The
erythrocytes are very pale (low hemoglobin content),
but of normal size (normocytes). There is little
poikilocytosis and a few, if any, nucleated cells.
Polychromatophilia is rare, and when found with
poikilocytosis indicates a severe type of the disease.
SjmHtmmie Ammm f/bcaasary Aseaae, Ac*, md Chrmut)
Acute symptomatic anemia is practically always
due to a severe hemorrhage. Sometimes it may be
caused by exceptionally severe bacterial infections,
such as typhoid fever, or puerperal -sisdas In all such
cases the etiological factor is evident and the blood
condition is secondary to it.
In chronic symptomatic anemia, the etiological
factor is also evident. This type of anemia accom-
panies all infectious diseases, as septicemia, syphilis,
diphtheria and tuberculosis. Parasitic infections,
such as malaria; inorganic poisons, such as lead, mer-
cury or arsenic; malignant disease, such as car-
cinoma; repeated hemorrhages from any part of the
body (gastric ulcer, menorrhagia, etc.), all cause a
concomitant anemia. The blood picture is not char-
acteristic and tails but little, hence, other tests must
be employed to clinch the diagnosis. The Widal
for typhoid, the Wassermann for syphilis, the Von
Pirquet for tuberculosis, the leukocyte count for
septicemia, etc.
SpUnit AmamiB (Splemmtflj)
Splenic anemia occurs most often in males during
later adult life. It is characterized by progressive
enlargement of the spleen without known cause. The
Diagnosis of Blood Diseases — Smith
spleen may enlarge enormously and sometimes ex-
tends into the pelvis (primary splenomegaly). Later
in the disease symptoms of portal cirrhosis of the
liver appear (ascites, jaundice, etc.), and the symp-
tom complex is then known as Banti's Disease.
Splenic anemia is not a blood disease in the sense
of the term used in this article. The blood picture
is not characteristic, and merely shows a simple
symptomatic anemia, leaning towards the chlorotic
type. The disease is mentioned here because the
name, splenic anemia, would seem to include it in
the blood dyscrasias.
V.. JlkttKi A— am (UmtU, Atmia)
Von Jaksch's anemia is probably the terminal stage
of a symptomatic anemia brought on by improper
food and poor hygienic conditions. Infectious dis-
eases, such as syphilis, or nutritional diseases, such
as rickets, also play an important etiological role.
As the name implies, it is a disease of infants and
children. The spleen is sometimes enormously en-
larged, and hence the disease bears some resemblance
to the splenic anemia of adults. It is only the more
serious forms that merit the name, Von Jaksch's
anemia. A slight enlargement of the spleen, with
a mild symptomatic anemia, is common in many
apparently well children. The blood slide shows
little more than the changes of secondary »"""'»
We may find a few myelocytes and megaloblasts,
which would indicate a far-advanced anemia. Fig.
2 shows a typical blood picture of a secondary
anemia. The blood was taken from a ease of Von
Jaksch's disease.
Pig.! Yon JaksclTi Anemia.
1. Erythrocyte allowing pale cell* of secondary a
2. Polymorphonuclear cell.
Malaria is not a true blood disease, although an
examination of the blood is of prime importance
for a proper diagnosis of the condition. The pres-
ence of the malarial organisms will then be dis-
covered and the type of the disease determined (quo-
tidian, tertian, quartan or estivo autumnal). In the
latter stages of acute malaria, and in all the chronic
forms, a severe secondary anemia develops. The
symptoms, which would suggest the making of a
blood slide, are too well known to need enumeration
here.
Tkt Umktmi- (Lnacylmtm*)-M^UU Uhu
There are two types of leukeinias, myeloid and
lymphatic. They are both rare diseases, characterized
by great activity of the leukoblastic tissues and a
vast increase in the circulating leukocytes. A
secondary anemia always develops more or less late
in these diseases. Two-thirds of the cases develop
in males during late middle-life.
In myeloid leukemia (myelogenous leucocythemia),
the patient may complain of any or some of the
symptoms common to the blood diseases, but he will
always complain of pain and discomfort in the region
of the spleen. On examination, the spleen will be
found much increased in size and very tender. The
liver is also enlarged and extends several finger-
breadths below the costal margin. These physical signs
are marked, because the patient seldom consults ■
doctor early in the disease. He knows he does not
feel well, but the symptoms are vague and indefinite.
What usually causes him to seek advice is pain in
the npper left quadrant of the abdomen, shortness
of breath, weakness or hemorrhage. Hemorrhage is
characteristic of the disease (80 per cent, of the cases],
and may occur from the nose, gums, stomach or
uterus. Hemorrhage may also occur into the skin
and suggest purpura hemorrhagia. They are some-
times very severe and may cause death. Fever 100-
102° F.) is always present. The dyspnoea is much
increased with the advent of anemia, and late in
the disease the other evidences of this condition will
become marked (edema, pallor, palpitation of the
heart). The superficial glands are rarely much en-
larged, while in lymphatic leukemia and Hodgkin'a
disease they may be huge. This fact is important
in the differentia! diagnosis.
MomI Pictmrt m Mjtiiii Lnktma
Microscopically, an enormous increase in the leuko-
cytes will be noted. The field is literally full of them.
Probably more polymorphonuclears than myelocytes
will be noted, but they are about evenly divided
This is the main diagnostic point in the blood picture
— the great number of myelocytes in the field. Few
lymphocytes, either large or small, will appear. The
Paila., May, 1922]
Diagnosis of Blood Disease* — Smith
34;
red cells are relatively few in number, and show the
ordinary changes of secondary anemia. Later in the
disease, normoblasts and megaloblasts may appear.
Fig. 3 shows a typical blood picture in myelogenous
leukemia.
SandB. Myelocytes with basophilic and roalnopblllc
i. Brrtbrocjlen.
Ckrtit IjraatatM lirnkmh (LjmpkMic U*ftjtkmit)
Chronic lymphatic leukemia is lees common than
the myeloid type. It occurs mostly in males iu late
adult life. As in all blood diseases, the onset is in-
sidious, with the attending malaise, weakness, dyspnea,
palpitation, anorexia, edema and loss of weight.
One of the main diagnostic points' is the enlargement
of the lymphatic glands. All the glands of the body
enlarge — the internal (mediastinal and abdominal)
as well as the external (cervical, axillary and in-
guinal). The glands are discrete and movable, and
are rarely tender. The patient usually consults the
physician because of extreme weakness and the pres-
ence of 'lumps" in various parts of the body. Some-
times he comes because of hemorrhage, the tendency
towards which is more marked than in the myeloid
type. Priapism may be severe and cause extreme
discomfort. Au irregular, moderate fever is always
present (under 102° F.). Anemia appears earlier
than in the myeloid variety, with its attendant symp-
toms (edema, palpitation, air hunger, tinnitus aurium,
vertigo, etc.).
Ml—i Kttatt a Chronic Ljmpkatic Ltmiemia
The blood picture is characteristic. There is a
tremendous increase in the number of leukocytes in
the microscopic field, and practically all are lympho-
cytes. Comparatively few polymorphonuclear cells
are present, and myelocytes and eosinophiles are
often absent. The erythrocytes are pale (low per-
centage of hemoglobin) and take the stain poorly
(polychromatophilia). Owing to the severe concomi-
tant anemia, normoblasts and megaloblasts are often
present.
Acmi* LymfUtU Ltdtaua
This disease is less common than the chronic
variety, and occurs mostly in women and chil-
dren— an important diagnostic point. The symp-
toms so closely resemble septicemia, typhoid fever,
sepsis or purpura bemorrhagia, that a correct diag-
nosis is seldom made. The onset may be insidious
or abrupt, with few prodromal symptoms. High
fever (103-104° F.) is always present, with profound
bodily weakness. Dyspnea, edema and pallor occur
as death approaches, probably because the secondary
anemia is just then entering its more severe stage.
The liver, spleen and all the lymphatic glands tend
to enlarge, but the course of the disease is often so
extremely rapid that death ensues before marked en-
largement occurs.
The diagnosis is confirmed principally by the blood
examination. The microscopic field is literally full
of lymphocytes (99 per emit, or more), mostly of the
large variety. Few polymorphonuclears, myelocytes
or eosinophiles are present. The symptomatic
anemia is usually severe (oligocythemia, nucleated
erythrocytes, poikilocytosis, etc). The case from
which the microphotograph in Fig. 4 was taken died
one day after admission to the hospital.
Fig. 4 Lymphatic Leukemia.
1. Larue and small lj-mptiucjtcs.
2. Polymorphonuclear cell.
3. Erythrocytes.
348
Footlights on the Feet — Cross
[The American Physician
fl <ttg*n . PilMM f" |' | ||fl|||ir J
Hodgkin's disease is not a blood disease. It is
mentioned here because the synonym, pseudoleukemia,
ia rather misleading, and because the symptoms do
resemble the leukemias. The characteristic feature
of this affection is the enlarged lymphatic glands.
These glands are discrete, freely movable and not
tender to the touch. Groups of nodes sometimes
reach enormous size, and pressure symptoms may
become prominent (cyanosis, edema, dyspnoea,
dysphasia, etc.). The cervical glands are generally
the first to enlarge, and the other glands change in
approximately the following order— axillary, inguinal,
thoracic and abdominal. It should be noted that
tubercular glands tend to fuse and break down, and
that in these cases there is usually a tuberculosis of
the lungs. However, we may have both diseases in
the same patient. The gland enlargement is not as
marked as in the leukemias, and the blood pictures
in the latter are distinctive.
8!~J Pictnrt m Hoigkaft Own*
Hodgkin's disease is extremely difficult to recog-
nize, and diagnosis is often impossible without re-
course to the excision and histological examination
of an enlarged gland. The blood picture has a nega-
tive value. There is usually no increase in the num-
ber of the leukocytes, which rules out the leukemias.
The erythrocytes merely show the changes common
to symptomatic anemia.
Footlights on the Feet
Anatomy
By Charles Cross, M.D.,
4623 California Street, San Francisco, Cnl.
Dr. Cross says the most needed service on
feet, in the doctor's office today, is a knowl-
edge of prophylaxis — the prevention of foot
ailments. This particularly applies to pre-
vention in children. A service which can be
rendered by office and home treatment, and
periodic observations. The practitioner qual-
ified and equipped to render this service is
much practice now neglected. —
This discussion of the anemias and the leukemias
is far from exhaustive. It was written solely to
remind the busy doctor that cases of this sort occur
in every practice, and to review a few points he
already knows. None of these diseases are common,
except, of course, the symptomatic anemias — but
they all come to the general practitioner first. On
his ability to properly diagnose the condition de-
pend the remaining few years of the patient's life.
So far as is known, pernicious anemia, the leukemias
and Hodgkin's disease, are invariably fatal. Even
with proper treatment all cases die within a five-
year period, and the fulminating cases (acute perni-
cious anemia, acute lymphatic leukemia) die within
a few weeks. If we can ever so slightly lengthen
the pitiful life-span of these unfortunates, we will
feel the extra time put on the diagnosis well spent.
SINCE THE PUBLICATION of several articles
on feet in Thk American Physician and other
medical journals,* numerous letters have reached em
asking for instructions about beginning the study of
this subject.
The number of medical graduates throughout the
country who have written and asked for this in-
formation has made individual letter writing a task
beyond my capacity. For that reason, reply will be
made to as many as possible in "Footlights on the
Feet."
The most called for service on feet, in the doctor*!
office today, is a knowledge of prophylaxis — the ore-
, "Announcing the Non-Surgical Orthopedic Specialty for
the Treatment of Ailing Feet. Rebuilding Broken Arches,
and Preventing Foot Ailments." California State Journal of
Medicine, November, 1919.
"Feet, and Rebnilding Broken Arches," Medical Record,
New York. March 27, 1920.
"Feet and Arches (Classification)," American Journal of
Surgery. New York. March. 1920.
"Foot Diagnostic Symbols." The American Pbyrlclan,
Philadelphia, January. 1921.
"Artificial Toes." American Journal of Surgery, New York1
September, 1821.
"Fool" -
'. Trouble beginning.
PhilL. May. 1922]
Footlighta on the Feet— Cross
Prevention of foot ailments m children is a service
which can be rendered by office and home treatment,
and periodic observations. The medical man quali-
fied and equipped to render that service is assured
of much practice which now goes neglected. It is
also an opportunity to render a much needed humane
service.
The non-surgical orthopedic specialty for the
treatment of ailing feet rebuilding broken arches,
and the prevention of foot ailments calls for in-
formation about feet which has not yet percolated
into medical text-books. For that reason, in begin-
ning the study of the feet, we start with first prin-
ciples, and get down to a real foundation of knowl-
edge of the human being and begin with anatomy.
The feet being as essential to the comfort and well-
being of humans as any other part of the body, it
appears about time to stop the habit common in
tome circles of the pot palling the kettle black. Ignor-
ance about feet and foot ailments is no reason for
■mailing the subject as being beneath assumed dig-
nity. Trying to clothe ignorance of a subject with
the rot of professional intolerance is quite out of
date when feet, in good condition, are so essential to
physical well-being.
There is much to know about feet which was not
taught in our college days, and is not taught today.
Therefore, this study of anatomy of the feet may
prove to real progressive colleagues a pleasing
pastime to review what was learned in the dissecting
room.
quired foundation upon which to begin his study of
the prevention of foot ailments, and the non-surgical
Fig. 3 Chllil. age 2% years. Retarded development.
orthopedic specialty for the treatment of ailing feet,
and rebuilding broken arches.
To FiW ik A-fmtd F«aaWiM
Today the world calls for scientific knowledge about
feet and the best place to find the anatomical founda-
tion is Gray's Anatomy, and Treves' Surgical Ap-
plied Anatomy. They are my text-books of choice.
350
Toxic Encephalitis— Likes and Knuckey
[The American Physician
In Gray's Anatomy — foot and leg — chapters on oeste-
ology, articulations, muscles and fascia, vascular sys-
tem and nervous system, and in Treves' Surgical Ap-
plied Anatomy, chapter on ankle and foot, are to be
studied. A re-reading of those chapters once a
month for a year may prove valuable in laying a
good foundation.
Following that, let us seek a knowledge of surface
anatomy, which is very important. This course of
lectures and instruction begins with anatomy of the
normal foot Emphasis is laid upon the value of the
old true and tried methods of acquiring scientific and
accurate information by inspection, palpation and
mensuration. To that is added information to be
gained from a study of photographs, blue-prints,
X-rays, arch craft, and many other interesting de-
tails. Also plaster casts are made with the feet in
action and give much accurate information.
Helpful im Stmdymg Smrfmct Ammtmmy
In studying surface anatomy colored crayons are
very helpful. With colored crayons, or actors' line
colors, the locations of important structures and
areas are graphically illustrated. This plan of study
greatly facilitates acquiring a knowledge of anatomy.
To graphically indicate underlying structures in the
study of anatomy, my preference is for Stein's Cos-
metic Line Colors. With four different colors, black,
No. 17, for structures; green, No. 19, for nerves;
vermilion, No. 14, for arteries, and blue, No. 10, for
veins, make an ample assortment for practical pur-
poses. These colors can be had for twenty-five cents
each from any drug store frequented by actor folks.
The colors can be readily removed with gasoline or
kerosene and leave the foot unsoiled. Actors usually
use cold creams to remove colors, but because of their
petroleum or vaseline base, no preparations with such
a base are recommended for use on the feet
Footlights on the Feet, No. 3, to appear later, will
take up other and interesting data about feet, lead-
ing up to examination, survey, diagnosis and treat-
ment.
Toxic Encephalitis
AN INTERESTING CASE REPORT GIVING HISTORY AND SYMPTOMATOLOGY, WITH SOME UNUSUAL FEATURES
By Drs. Lannixg E. Likes and C. T. Knuckey,
Lamar, Col.
DONALD D., age 12, well nourished, well de-
veloped and normal in all respects except that
his parents stated that he was always "highly nerv-
ous." For about ten days he had not been feeling
well, but continued attending school and delivering
papers on his route.
The only interesting feature at this time was that
while playing he was struck by a small rock in the
right parietal region, which raised quite a lump, but
caused no other symptoms.
On Saturday he went camping with the Boy
Scouts. On Tuesday evening following he refused
supper, but ate watermelon which he vomited thirty
hours later. Wednesday evening he complained of
pain in his bowels, vomiting a few times about mid-
night The colicky pains were becoming quite severe.
The parents gave calomel, castor-oil and enemas with
good results, but with no relief.
The child getting no better, but apparently becom-
ing unconscious, the parents became alarmed and Dr.
Likes was called in about 7.30 A. M., Thursday, Sep-
tember 9. The patient was then in comatose condi-
tion, temperature, axillary 97* F., pulse 70. Lungs
and heart negative. No adenopathy. Lower ab-
domen painful, evidenced by agonized expression and
constantly putting hands to abdomen and crying out.
Rigidity of abdomen, relaxed at times, but becoming
rigid on attempting palpation. Pupils normal to
light and accommodation, and remained so until the
end. No Babinski. Plantar reflexes present Both
knee jerks present, exaggerated in left. Tossing both
arms. Slight spasticity in arms, legs, neck and jaw.
No retraction of head at this time.
Fimimg* in Cm witefi—
Dr. Knuckey saw him at 9.30 in consultation, and
the findings were practically unchanged. Bowels and
bladder emptying involuntarily. Bowel movement
quite offensive, grayish-yellow in color. Urine nega-
tive— 1028 sp. g., acid, no albumen or sugar. Micro-
scopically negative.
No tympanites at any time. Not much change in
condition during the following twenty-four hours,
except deepening of coma and increase in spasticity,
especially in left arm and leg. Left arm kept mov-
ing almost constantly. Seemed to have lost volun-
tary control of right arm and leg. Head drawn to
left side and neck rigid. Jaws set and necessary to
pry mouth open to give medication and fluid which
he swallowed fairly well. No elevation of tempera-
ture or acceleration of pulse. Bowel movement ex-
tremely offensive, consisting of yellowish mucous,
Bladder emptying frequently in small amounts.
By afternoon temperature was 99.2° F. axillary,
and pulse 96. Coma deepening and slight increase
in spasticity, general appearance not good, the faciei
Phils., May, 1922]
Medical Diathermy— Folkmar
351
showing a slight pinched expression.
frfe* Fmlmg UpiHy
From then on the child failed rapidly. At midnight"
there was a slight attack of respiratory paralysis,
artificial respiration necessary to resuscitate him.
Temperature 100% axillary. Pulse 120. Slight
cyanosis. Slight ptosis of left eye, and right eye
closed. By 10 A. M. Saturday, September 11, there
was almost total inability to swallow.
Mucous rales in throat, marked cyanosis, com-
plete paralysis of right arm and leg, but all showing
spasticity on passive motion, still more marked on
left side. Patient continued to fail and death took
place at 2 A. M., September 12, practically three
days from beginning of acute symptoms.
fit If <
faterct W the Cm*
The unusual features of this case were the acute-
ness, the early cortical involvement which preceded
any elevation in temperature or pulse by 30 hours,
the early progressive coma, the mild objective ab-
dominal symptoms which consisted merely of rigidity
in the lower abdomen which seemed to be only present
when brought on by palpation. Unfortunately it was
impossible to secure a post-mortem, so pathological
findings cannot be given. Probably toxins from the
intestinal tract were the cause or perhaps lowered
resistance and thus helped to develop the encephalitis.
The question arises, "was the blow on the head
sufficient to cause a locus minor resistentiae" so the
toxins found a favorable field to attack.
Medical Diathermy
GIVING ESSENTIAL EQUIPMENT. FUNDAMENTAL PRINCIPLES. TECHNIQUE. AND THERAPEUTIC INDICATIONS
By Elnora Cuddeback Folkmar,
M.Ph., D.S.S., M.D.,
1730 Eye Street, N.W., Washington, D. C.
Ntcegmry Hem WtOmd Tmx m Bedy Fmtm
Medical diathermy is not a panacea for
all diseases. Yet its indications are many,
and it is a most excellent adjuvant to other
therapeutic measures. In many cases it is
the indicated therapeutic agent par excel-
lence. For diathermy is heat, and heat is
necessary to Ufe, to health, to function, to
repair in injury, and to the restorative proc-
esses when disease is present. And dia-
thermy furnishes the needed heat where it is
wanted and when it is wanted without taxing
the heat-regulating forces.
This first installment goes thoroughly into
definition, essential equipment, fundamental
principles, technic and therapeutic indica-
tions. We hope you will get as much of a
stimulus as we did from reading Dr. Folk-
mar's excellent paper. — Editors.
DIATHERMY is a term introduced by Nagel-
schmidt in 1907 for the heating through and
through of the body, or a part of the body, by the
passage through it of a high-frequency current. In
deference to the French physiologist, who first dis-
covered that the passage of a high-frequency cur-
rent through the body produced no other effect than
warmth, the current used in diathermy is often called
the d'Arsonval current. The diathermy current may
be employed either as a medical or surgical meant
of treatment.
Meiicd m Thuwfnik DmAtrmy, the subject of this
paper, is the use of the flow of a high-frequency cur-
rent through the body as a therapeutic means for the
production of only a moderate rise in temperature
without any destructive effect. This is what Gey-
ser calls physiological diathermy. Smrgted Dmthermy
employs an active or smaller electrode, so small in
comparison with the larger electrode as to deliver an
intense current which is destructive to tissues.
Medical diathermy may be either general or local.
General diathermy is often called autocondensation,
and local diathermy was tailed direct diathermy by
d'Arsonval.
Gmmd Dimhermy is the increasing of the general
body temperature from .5 to 2.5 degrees Fahrenheit
above normal by the passage of a high-frequency
current.
Ltd Dimhtrmy is the raising of the temperature of a
special area of the body to any degree desired within
physiological limits by the passage of a high-fre-
quency current. This may vary, according to Doyen*
from one to thirty degrees, since he finds that living-
cells can withstand a rise of thirty degrees without
damage. In practice, a rise to ten degrees is found
to be therapeutically efficient.
PhyskUgicd E0tcU W
The warmth of diathermy differs from that pro-
duced by any other artificial method. It is produced
within the tissues, within the interior of the body.
When the diathermy treatment is applied as a gen-
eral treatment or as a prolonged local treatment of
352
Medical Diathermy — Folkmar
[The American Physician
a- considerable area, every cell in the body partici-
pates in the warming. Dr. de Kraft notes that
centers of heat are formed in countless numbers of
cells and that this heat is slowly dissipated, especially
in the more resistant structures, such as bone. The
deeper the seat of the warmed cells, the slower is
the loss of the stored-up heat. The less vascular
the structures heated, the more gradual is the loss
of warmth. The sympathetic system is stimulated.
This is evidenced by increase in oxidation and elimin-
ation, by increase in glandular secretions, by increase
in phagocytosis, by increase in physical and mental
vigor.
Therapeutics of Nature
When Nature attempts to restore an injured part,
or to eject an invading body of germs, she produces
increased heat — inflammation, fever. This is done
by the expenditure of energy. Sometimes Nature's
work is overdone and we have resulting adhesions,
fibrosis, scars. Sometimes Nature is unequal to the
task set before her. She fails in her restorative and
repulsive processes and we have the death of myriads
of wandering cells, leucocytes (pus and necrosis of
tissue) and overwhelming toxemia. Diathermy pro-
duces heat necessary to normal function, to the res-
toration of altered functions to normal, to the repair
of damaged tissues, to the more successful repulse
and destruction of an invading enemy, without any
expenditure of energy on the part of the heat-regu-
lating forces of the body.*
Essential Equipment
The requisites for diathermy are a good diathermy
apparatus, a condenser couch or chair, electrodes of
various sizes, shapes, and materials, conducting cords,
clips for attaching cords to electrodes and materials
for holding electrodes for local diathermy in place.
The limits of this paper exclude any lengthy dis-
cussion of the diathermy machine. Suffice it to say
that for general diathermy those machines which
give a relatively higher voltage, that produce a cur-
rent more nearly of the type of the original d'Ar-
sonval current, seem to give the best results. This
is also true when skin heating is desired by means
of the condenser electrode. These machines have
a frequency of 500,000 to 1,000,000 oscillations a
second. For local or direct diathermy those ma-
chines which have relatively a very low voltage and
relatively a very high amperage, an amperage up to
three amperes with 3,000,000 oscillations a second give
the best results. A machine which gives a proper
current for X-rays is not necessarily a good machine
for diathermy.
Most diathermy models on the market deliver a
* Rechon observed great change in the consumption of
oxygen and the elimination of CO2 before and after dia-
thermy. Before the treatment the oxygen consumed in 10
minutes was 2.96 litres. After 80 minutes treatment it fell
to 2.14 litres. Before treatment the CO2 elimination was
2.64 litres. After 30 minutes' treatment it fell to 1.96 litres.
current sufficiently satisfactory for medical diathermy
when supplied by the street alternating current of
110 volts. These can be attached to the lighting
current of a house. For machines to be used on the
direct current a motor generator is employed to gen-
erate an alternating current to supply the diathermy
machine. In this process considerable voltage is
lost unless a special step-up transformer is employed
and the efficiency of the machine is reduced between
the motor generator and the machine. For fire
safety special wiring should be installed when a motor
generator is used.
The spark gap is the most sensitive and important
part of a high-frequency machine. It must be kept
clean.
Thm Cooienser Comch or Chair
Experiments of de Kraft, Titus and others have
shown that for the d'Arsonval current as produced
from a static machine or from a high-voltage coil
machine a thick dialectrio should be employed for
the condenser couch. The dielectric is the inanl^ting
material used between the metal plate of the couch
and the patient. Their experiments also show that
for machines of relatively low voltage and high
amperage, a thin dialectric, such as is used by Mc-
intosh for their autocondensation pad and by Wap-
pler and Campbell in the construction of condenser
chairs, gives the best results.
The Handling of the Patient
If the condenser couch (thick cushion) is used,
the patient lies on the dialectric and holds in his
hands a metal or non-vacuum glass electrode. If the
condenser chair is used, the patient sits in the chair
and places his hands in contact with the metal plates
or knobs on the arms of the chair, and in case of
the deKraft chair also places his bare feet on a
foot-rest which is covered with metal. In any case,
one terminal of the* diathermy machine is connected
to the condenser couch or pad, or to the back of the
chair, and the other terminal of the diathermy ma-
chine is connected to the arms of the chair, or to
the foot-rest or to both arms and foot-rest.
The patient, for general diathermy treatments,
should be dressed in loose clothing. A bathrobe is
ideal. There must be no constricting bands to inter-
fere with circulation.
It is a good plan to take the blood pressure, the
pulse, and the temperature before every general
diathermy treatment. In any event this must be
done before the first treatment. In certain cases
temperature and blood pressure should be taken
again after treatment.
Before attaching conducting cords to the terminals
of the diathermy machine make sure that the spark
gap is closed, and that the current supply to the
machine is turned off.
Strength of Current Used
The strength of current generated by a diathermy
machine is measured by a hot-wire amperemeter. The
Phil*., May, 1922]
Medical Diathermy— Folkmar
353
scale of the latter indicates a maximum of 1.2 to 3
amperes according to the make of the machine. Re-
liance, however, should not be placed alone on the
reading of the hot-wire amperemeter when giving
treatments.
Scale's Pint Lmm
If the part of the body through which the d'Arson-
val current passes has a low resistance, the ampere-
meter will indicate a strong current while the body
is only slightly warmed. This is in accordance with
the first law of Joule : "The amount of heat generated
in any circuit is proportional to the resistance, pro-
Tided the current strength is constant." If, however,
the part of the body traversed by the current has a
high resistance, only a small amount of current will
flow, yet the part will be much heated because the
greater part of the electrical energy is converted into
heat in overcoming resistance. What the ampere-
meter really indicates is the strength of current pass-
ing through its resistance wire. The current passing
through a part of the body thrown into a d'Arsonval
circuit 'will be the same as that which passes over the
hot wire, but the amount of heat generated in the
tissues traversed will depend on the resistance of the
tissues to the circuit, the area of the electrodes, the
time the current passes, and the strength of the
eurrent.
JmU't S*c—i Lmm
Joule's second law here holds good: "The amount
of heat developed in any circuit is proportional to
the square of the current passing, provided the re-
sistance is constant." This means that the increase
in heat varies directly in proportion to the square of
the eurrent strength. If the current strength is
doubled the temperature will be increased fourfold,
if trebled the increase in temperature would be nine-
fold. This explains why a patient who feels only a
comfortable sensation of warmth may complain of
burning if the current strength is only slightly in-
creased.
The amount of heat produced in a given area bears
a direct relation to the size of the electrodes. The
size of the electrodes governs the density of the cur-
rent when a certain unit of current is passing. If
we employ in local diathermy a pair of electrodes
of the same size, say, four by five inches, or 20
square inches to each electrode, and then increase
the size of the electrodes to six by ten inches, the
current density will be reduced to one-third what it
was before, the current in the second instance being
distributed over 60 instead of 20 square inches. When
we change the size of the electrodes we change not
only the current density but the area of the mass of
the intervening tissue to be heated.
Generally speaking, when electrodes are of equal
size, the greatest degree of heat is generated midway
between the electrodes. When the electrodes are of
unequal size, the greatest degree of heat generated
will be relatively near the smaller electrode. A safe
rule when giving diathermy treatments is never to
give over 100 milliamperes to the square inch of sur-
face of the smaller electrode. This caution is to be
especially observed in treating areas of anesthesia,
areas of paralysis, and when treating mental defec-
tives. In all other cases the comfort of the patient is
the best guide.
JmU'i Third Lmm
In any diathermy treatment the intensity of the
heat produced is in proportion to the time the current
passes. This is in keeping with Joule's third law.
But this proportion has some variations in the use
of diathermy medically, owing to the circulation of
the blood. At the beginning of a diathermy treat-
ment the circulation of the blood tends to prevent the
overheating of the tissues, but the longer the applica-
tion, the less the cooling effect of the blood, and the
relatively greater increase in the amount of heat
developed from the passage of any given current
strength. For this reason the current strength should
be gradually diminished during the second half of
the time allotted for a treatment.
Another thing that must be taken into account is
the stimulation of reflexes by strong currents. Ex-
periments of Furstenberg and Schemel demonstrate
the advisability of the use of milder currents over
longer periods of time to reach the deeper structures.
They found that a higher temperature could be
developed in the interior of . the stomach with 300
milliamperes of current than with 2000 milliamperes.
Dr. de Kraft explains this apparent paradox by
pointing out that when strong currents are used the
reflexes are stimulated to such an extent that all func-
tions that regulate the heat of the body are activated.
The weaker current offers no stimulation to the re-
flexes; it steals by the reflexes.
Pmtk W FUm •/ Cairo*
The power of the living body to conduct high-
frequency currents is due to the presence of ions in
the circulating and tissue fluids. The drier tissues
like bone and cartilage are much more resistant to
the flow of the current than are the soft tissues of the
muscles and viscera. Many experiments have been
performed to ascertain the degree to which the tem-
perature of different portions of the body can be
raised by medical diathermy currents. It is not
known to a certainty just what is the path taken by
high-frequency currents in the body. De Kraft be-
lieves that in general diathermy the path of the cur-
rent flow is along the large blood vessels. For the
patient lying on the condenser couch the wrist is the
narrowest part of the circuit. It receives the greatest
density of current, offers the highest resistance, and
attains the maximum degree of temperature. If the
de Kraft chair is used the ankles, like the wrists, offer
great resistance and attain a similar mftTimnm degree
of temperature. Cumberbatch calls attention to the
354
Medical Diathermy — Folkmar
[The American Physician
fact that the flexor surfaces are heated more than the
extensor. This is thought to be due to the high re-
sistance of the cartilage and bone of the extensor
parts. The major portion of the current, following
the line of least resistance travels through the soft
flexor tissues rich in blood and lymph vessels.
If the limb is flexed the difference in heating be-
tween the flexor and extensor surfaces is still more
marked. The effect of shortening the distance tra-
versed by the current by flexion of a joint can be
readily demonstrated by placing an electrode in the
palm of the hand and flexing the wrist. The anterior
region of the wrist will be heated some degrees higher
than the posterior. Next, place the electrode on the
back of the hand and dorsiflex the wrist as much as
possible. In this position the shorter path is along
the more resistant tissues, and it will be seen that
there is now very little difference in warmth between
the anterior and posterior surfaces of the wrist.
Electrodes for Local Diathermy
The most satisfactory material for electrodes is a
thin sheet of lead. This can be cut and moulded to
fit any area to be treated. The size of the electrodes
used will depend on the area to be treated and the
depth beneath the skin that the greatest warmth is
desired. When the electrodes are of unequal size the
larger electrode is referred to as the indifferent elec-
trode and the smaller one as the active electrode.
The author attaches a small strip of lead foil to
the center of each electrode by means of a strip of
adhesive tape. This gives a convenient means for
attaching the conducting cords.
Plmcmg the Electrodes
Care should be taken in placing the electrodes to
see: (I) That they are so placed that the current
will flow through the area to be treated. Electrodes
should always be placed on opposite sides of the
region to be treated, and never both electrodes on the
same side. In the latter case the current would pass
from the edge of one electrode to the edge of the other
and there would result only a warming of the skin.
The current should pass from the surface of one elec-
trode through the region to be treated to the surface
of the other electrode. If greater warmth is desired
nearer one surface than the other, the active electrode
should be placed on that surface.
(2) That the electrodes are so placed that the dis-
tance between their edges is greater than the distance
between the centers of their surfaces, otherwise the
major flow of current will be from edge to edge and
little from center to center of the electrodes. This is
especially important in treating joints, where one elec-
trode is placed on the anterior and the other on the
posterior surface of the joint. Or the electrodes are
placed on either side of the joint, or one electrode is
placed above the joint anteriorly and the other below
posteriorly. In selecting electrodes of a size to give the
greatest heat in the center of a joint it may result that
some parts of the joint are uncovered. If so, the
position of the electrodes may be so placed for the
next treatment that the current flow will be at right
angles to that of the first application. This is termed
the cross-fire method. It is particularly useful in
treating pelvio troubles.
As more heat is produced along the flexor aspect
of a flexed joint, less heat will reach the interior of
a knee when the patient is seated in a chair with knee
bent, than when recumbent with the leg extended. To
heat wrist, fingers, or toes, one electrode should be
placed on the dorsal and the other on the palmar or
plantar surface.
Sometimes one electrode can be placed on or very
near the part to be heated. In such a case the active
electrode, the small electrode, should be placed near
the part to be treated, and the larger or indifferent
electrode so placed that the path of the flow of
current traverses the part to be warmed. For
example, in treating a cervicitis or adhesions about
the cervix, apply the active electrode (a metal vaginal
electrode) in the vagina and the indifferent electrode
on the abdomen just above the pelvic bone.
Holding Electrodes in Plmce
In the application of large electrodes to anterior
and posterior surface of the body, the patient should
lie on pillows. The weight of the body will hold the
lower electrode in place, the upper electrode may be
held in place by sand bags, small blankets, or both.
Or the patient may hold the upper electrode, covered
with a folded bath towel, in place with the hands.
Electrodes about joints may be held in place by
bandages. The smaller the electrodes the more care-
fully must they be secured in place, otherwise there
will be a spark gap between the electrode and the
skin and burning will result.
All electrodes should be well moistened with liquid
soap before being applied to the skin.
Comdmctimg Cords
Conducting cords should be well insulated. They
should not be too heavy or very long (not over fa*
feet) as their weight tends to pull the electrodes away
from the skin. They should be firmly attached by
proper clips to the electrodes. Otherwise there may
be a sudden separation from the electrode with, an
unnecessary shock and a burn. The cords must like-
wise be firmly fixed to the outlet terminals of the
d'Arsonval apparatus.
Regmh&ion of Current
When all is ready and the spark gap closed, the
current is turned on to the machine and the spark
gap is very gradually opened. Ask the patient re-
peatedly if any pricking is felt. If so, stop, turn off
current and readjust the electrodes. If not, gradually
increase the current flow to the milliamperage desired.
Allow from one to five minutes between each increase
in flow. If a high amperage is thrown on rapidly
the skin soon becomes very hot, and bnt little of the
i
Phila.. May, 1922]
Dibromin — Roberto
355
current flow will reach the deeper tissues. If increase
in number of milliamperes of heat is slowly made the
deeper tissues will be heated while the skin is only
slightly warmed.
Dmrmtiem mi Prtmmtmey W Tremtmemt
Dosage in diathermy is a thing that can be learned
only by experience. In treating small areas with local
diathermy, the number of milliamperes of current
should never exceed 100 milliamperes to the square
inch of the active electrode. In most cases the com-
fort of the patient is the best guide. The duration
of a treatment will depend on the condition to be
treated and on the patient Treatments vary in dura-
tion from five minutes to an hour. Frequency of
treatment also depends on the condition to be treated
and the ability of the patient to come for treatments.
In most cases daily treatments are advisable at first,
then thrice weekly, and later twice, or even once
weekly. «
Hernia* W Smperidml Tome*
When it is desired to limit the heating to the skin
or most superficial tissues, a non-vacuum, a bakelite,
or a glass condenser electrode may be used for the
active electrode. The gases of ozone and nitrogen
formed in the region of the sparks from these con-
denser electrodes are germicidal in their action on the
superficial layers of the skin. The diathermy current
does not pass through the material of which the con-
denser electrode is made, but charges are induced in
the part with which the electrode is in contact.
Imdicmtmtm It Medial Dimtktrmj
Medical diathermy is not a panacea for all diseases.
Yet its indications are many. It is a most excellent
adjuvant to many other therapeutic measures. And
in many cases it is the indicated therapeutic agent
par excellence. For diathermy is heat, and heat only,
and beat is necessary to life, to health, to function.
Heat is necessary to repair in injury, to the restora-
tive processes when disease is present. And diathermy
furnishes the needed heat where it is wanted, and
when it is wanted, without taxing the heat-regulating
forces.
Dimtimmy m DUemses W fftc Circdmtmry Sy$tem
Diathermy has a profound effect on the circulation.
General diathermy tends to reduce hypertension and
to raise hypotension to normal tension. Local dia-
thermy causes a local dilatation of the blood vessels
of the part treated. Blood from the surrounding
healthy tissues rushes into the dilated vessels. This
influx of healthy blood replaces the stagnant poison-
ous blood, and increases cell metabolism and germ
resistance.
(To be concluded in next issue)
Dibromin
An Ideal Moist Dressing
By David Yandell Roberts, M.D., F.A.C.S.,
Surgeon-in-Chief, L. C. & L. & Louisville Division
of the L. & N. R. R. Francis Bldg., Louisville, Ky.
A Mm AmtUtptic mad
The author has used dibromin in more
than eighty cases of surgical infection in the
past year, with uniformly good results. It
is an active germicide, at least equal to the
chlorine compounds, and has met all the re-
quirements of a surgical bactericide because
of its ease of preparation, its efficacy, and
the absence of irritation, odor and color.
Particularly has it proved ideal in those
cases requiring irrigation and where a contin-
uous moist dressing was desired. — Editors.
IN THE TREATMENT of infected traumatic
wounds one of the perplexing questions that so
frequently confronts the surgeon, and especially
those doing railway or industrial surgery, is the se-
lection of an effective germicidal agent but at the
same time devoid of irritation, is easily prepared and
applied, and which will not stain the tissues or linens,
etc.
Various agents have been used by the profession
from time to time, most of which have had their
advantages, but at the same time certain disadvan-
tages. The chlorine preparations, such as the Dakin,
Carrel-Dak in solutions, and Chloramine T, are ef-
fective germicidal agents, but have certain objections.
Special skill and technique is required to properly
prepare them, and to be effective they must be freshly
prepared and contain between .45 and .50 per cent,
free chlorine. Should they set free higher percent-
ages of chlorine than this they are highly irritating,
and should the amount of chlorine be below this they
are ineffective and fall short in abating and overcom-
ing the infection.
The saline solution has its place, but in the more
virulent forms of infection, such as those produced
by the colon bacillus, gas bacillus, and others, a more
potent and reliable germicide is required, as in many
instances the life or limb of the patient may depend
on a prompt control of a local infection.
A Htm Amtbeptic mad Germuddt
In the last year I have used a new agent, called
dibromin, which is not only an active germicide, at
• Read at the meeting of the Attending Staff of Sts. Mary
and Elizabeth Hospital, February 3, 1922.
356
Dibromin — Roberts
[The American Physician
least equal to the chlorine compounds, but has met
all the requirements of a surgical bactericide, by
reason of ease and preparation and the absence of
irritation, odor and color. Particularly has it proved
itself ideal in those cases requiring irrigation and
where a continuous moist dressing was desired.
Dibromin, chemically known as "dibrom-malonyl
ureide," is an oxidizing agent containing 56% avail-
able bromine in chemical combination and from which
the bromine is readily set free. Unlike the other
oxidizing agents, the chlorines, the peroxides, etc.,
which attack normal cell tissue with as great activity
as they do micro-organisms, dibromin has a peculiar
affinity for the delicate structure of bacteria, but has
practically no action upon the normal living cell
tissue, which no doubt accounts to no small extent
for its non-irritability.
Dibromin, according to the Hygienic Laboratory
method of assay, has a phenol coefficiency of 105 as
against 55 of Chloramine T, determined by the same
method, or almost double the germ-killing power of
the chlorine derivative.
The ease with which solutions of dibromin may
be prepared for use is a big factor in its favor, as
the chemical is put up in 6-grain capsules, with
which any strength solution desired may be easily
prepared and ready for use in a short time, as the
salt is readily soluble in either warm or cold water.
Dibromin may be used in varying strength solutions.
In my experience the best results have been obtained
with the 1: 5000 solution (1 capsule, or 6 grains, to
V2 gallon of water), which has not only proved its
germicidal worth, but in this dilution has been abso-
lutely free of any irritation either to the surface
irrigated or the surrounding skin where the moist
dressing was maintained.
Cm* lUpwU
The following case reports may be of interest:
Case No. 1. — Mr. T. M., age 70, married, and cab-
inetmaker by trade, presented himself with a ragged
and torn wound, extending over the index finger and
thumb of the right hand, the result of a ripsaw injury.
Aside from the pain and profuse bleeding there was
a loss of motion, the result of extensive laceration of
both thumb and index finger. Upon examination a
compound, comminuted fracture of the middle
phalanx of the index finger was found. The treat-
ment consisted of cleansing the wound, reduction of
fracture, suturing of the wound and a sterile dressing
applied. Gangrene developed in finger, necessitating
amputation at the first joint. An infection of the
whole hand followed the amputation. Wet dressings
with dibromin were now commenced, using a solu-
tion of 1 : 5000, and applied twice daily for one week,
and then once daily for two weeks, at which time
the wound was sterile, the patient making a rapid
and satisfactory recovery. The dibromin undoubt-
edly shortened the course and duration of the infec-
tion. No irritation whatsoever.
Case No, 2. — Mr. W. W., aged 35, single, boiler-
maker. Came to my office complaining of severe
pain in thumb of left hand. Upon examination
found thumb greatly enlarged with fluctuation over
the last phalanx, redness, much tenderness, with loss
of motion. No history of injury could be obtained.
Diagnosis: Tenoarthritis of thumb. The treatment
consisted of a free incision over the medial line of
the palmar surface of the thumb, and the wound
dressed twice daily for one week with gauze satu-
rated with a solution of dibromin 1 : 5000. The wound
was then dressed once a day for a week, at which
time the wound was free from pus, aseptic and gran-
ulating rapidly. Patient made a hasty and uninter-
rupted recovery, and no complaint of irritation.
The two illustrative cases are included in this re-
port merely to show the unmistakable influence of
dibromin solution in controlling local infections. The
good results in these two cases are indicative of the
effects obtained in more than eighty cases of surgical
infection, which presented a variety of conditions and
which I have treated with dibromin solutions during
the past twelve months.
Blood Cholesterol and Cancer
In summing up his atricle, "The Blood Cholesterol,
Its Importance and the Value of Its Determination in
Cancer Research/' in the Canadian Medical Association
Journal, Georgine Luden, M.D., Ph.D., first assistant in
cancer research, Mayo Foundation, says:
1. Cholesterol is an important chemical constituent of
the blood.
2. There is evidence that the blood cholesterol plays
an important part by promoting cell proliferation and
by combating bacterial invasion.
3. The test for cholesterol in the blood is not a diag-
nostic test, but it furnishes valuable information con-
cerning the efficiency of cholesterol metabolism.
4. The activation of cholesterol metabolism after
radium treatment demonstrated by the blood cholesterol
determinations, and the parallel improvement of
patients suffering from malignancy indicate that there
is an intimate connection between disturbances of cho-
lesterol metabolism and malignant disease.
5. Cholesterol metabolism can also be improved by
dietary measures, suggesting that beneficial effects may
be expected from dietary measures tending to reduce
the cholesterol intake with the food, combined with
radium therapy.
6. Since the life of the cells depends upon their blood
supply, the chemical composition of the blood must be
equally important; radium treatment changes the chem-
ical composition of the blood, as is shown by blood-
cholesterol determinations.
7. Spontaneous cures have been observed in well-
authenticated, inoperable, "hopeless" cases of cancer:
this proves that the body can wage a winning fight
against malignant disease; as therapeutic measures had
proved ineffective in these cases, some internal read-
justment must account for the cures. Chemical investi-
gations will solve the cancer problem by revealing the
nature of this internal readjustment.
Phil*., Maj, 1922]
The Greedy Colon— Gillette
357
The Greedy Colon
Radical Treatment of Auto-Intoxication by Colonectomy
By Norris W. GiLLEiTi, A.B., M.D.,
Surgeon to Robinwood Hospital, Toledo, Ohio
If your patient were constipated would
you excise his colon? There are good sur-
geons, with good reasons, thai do. Bead Dr.
Gillette's paper and see whether you would
do it or not. — Editors.
ABNORMAL absorption of normal intestinal eon-
tents with resultant auto-intoxication and gen-
eral constitutional effects is so common that it falls
within the daily work of every practitioner of either
medicine or surgery.
Almost all individuals, particularly those living a
sedentary existence, suffer at times from faulty ex-
cretion. With most people the complaint is tempo-
rary and easily relieved by common cathartics, but
with many the inability of the intestines to properly
excrete is a chronic and serious complaint leading to
migraine, rise in temperature and pulse, lack of
energy, mental and physical fatigue, flatus, hemor-
rhoids, prolapsed rectum, and, I am sure, in severe
cases to an uncomfortable life and a more or less
shortened existence. The absorption of the bacterial
products, of phenol, indol and skatol in small amounts
over a long period of time is none the less lethal
because slow in its action.
EtmUgicd Factors
While the effects are obvious the causes are many
times not appreciated. In general, I believe, they
may be classified as follows:
1. Failure to obey the call of defecation.
2. Intoxication from drugs or some local infection.
3. Neurosis.
4. Lack of proper exercise.
5. Obstruction, adhesions, and abdominal tumors.
6. Weakness of intestinal reflex or musculature.
7. Weakness of abdominal or pelvic musculature.
8. Ptosis of abdominal viscera.
9. Excessive absorption of liquids leaving hard and
bulky feces.
10. Excessive digestion of food in the colon.
The constipation resulting from these causes can
in most cases be corrected by habit, the judicial use
of cathartics, treatment of constitutional disease, ex-
ercise, or abdominal supports.
The Greedy Cehm
The excessive digestion of food in the colon, how-
ever, has not been amenable to ordinary treatment,
and it is this type of case that I wish to speak about
in particular. Arthur F. Hurst, of Guy's Hospital,
London, has properly given to this class the name
of "greedy colon," for the reason that the cecum
accepts the normal contents from the ileum, and
starts the absorption that takes place throughout the
colon, leaving only a small bulk to be excreted. The
loss is not entirely due to absorption of fluids, though,
of course, this accounts for a part. There is an
actual diminishing in amount of fat, cellulose, and
nitrogen.* This absorption of starch cells and muscle
fibers takes place in all types of constipated stools,
but is particularly practiced in the greedy colon.
In constipation due to any other cause there is a
slowing up in the rate of speed of the passage of
feces through the colon, so that there is more ample
opportunity and time for the absorption, but in the
case of the greedy colon there is no diminished rate
of movement, but a very great loss of bulk in a
short time. This increased absorption produces the
effect of a severe and chronic constipation.
The Imiectm* U$e W Ceilmrtic*
The use of cathartics to increase an already active
colon only tends to demand an ever increasing and
more drastic use of them, so that in the end no
real benefit can be expected. Such an aid to defeca-
tion as agar-agar, while it does not delay absorption,
may be given with some benefit because it allows
enough bulk to reach the rectum to stimulate the
reflexes of defecation and causes an early passage,
instead of waiting for enough fecal matter to ac-
cumulate to stimulate them. This cathartic only
hinders the absorption for such a time as the feces
would lie in the rectum, but is of no value through-
out the major part of the colon where most of the
damage is done.
The best method, I believe, to permanently relieve
this condition is to eliminate the colon entirely by
colonectomy, but it can be done satisfactorily in many
cases by the short circuiting method of "Arbuthnot
Lane" of amputating the terminal ileum from the
colon, closing the opening into the cecum, and trans-
planting the ileum by an end to side anastomosis of
the small intestine into the sigmoid flexure. After
this operation toxic absorption from the colon is
usually corrected.
Sir Arbuthnot Lane advocates the elimination of
the colon by colonectomy for all cases of chronic and
obstinate constipation with evident auto-intoxication
in which short circuiting is of no avail, and I believe
with great deal of justification, for without doubt
this operation relieves from suffering and often from
• (Deutsche Archives from Klinlsehe Medicine — 1904.)
358
The Greedy Colon— Gillette
[The American Physician
chronic invalidism and lengthens the life of the
patient.
The following is a case in point by reason of the
excellent result obtained.
The C*$€
Mr. F. S., age 26, single, occupation, elevator boy.
No family history of hereditary or infectious diseases.
Father died of Bright's disease Mother living and
well. Three brothers and two sisters living and well.
One sister died of influenza.
Past history:
Measles at age of 8. Tuberculosis of left int. malle-
olus in 1910, which was operated on in Germany.
This drained for three years before it healed, but
has not opened since. Had polyps of nose in 1920,
which Dr. Thomas Hubbard removed successfully.
Has never been troubled with sore throat, tonsillitis,
or cough. Has been examined repeatedly for pul-
monary T. B. C. because of T. B. C. bone, but none
has ever been diagnosed. Has been markedly con-
stipated for years, and only the most severe and
drastic cathartics would keep his bowels open. He
felt markedly toxic due to the fact that his bowels
did not act. Denies venereal disease.
Present complaint:
For past two weeks bowels have been unusually
sluggish. Has taken many cathartics and enemas
that have done him little good. When passed, the
feces were very putrefactive and in small hard masses.
Physical examination:
Temp., 98°; pulse, 80; B. P. S., 118, D. 80; resp.,
18 and regular; weight, 120, three months previous,
127; height, 5 ft. 3 in. Appearance, poorly nour-
ished. Skin has unhealthy pallor.
Eyes myopic. React to light and accommodation.
Throat negative. Nose somewhat blocked on both
sides by thickening of mucosa. Teeth, fair condition.
Hearing normal.
Neck, no enlargement of glands or thyroid. Chest,
hyper-resonance on rt. chest only. Otherwise negative.
No rales or dullness. Heart, no enlargement or
murmurs. Abdomen, soft and full. Movement of
gas under fingers of colon. No pain over abdomen
qr tenderness. No distention. Genito-urinary sys-
tem negative. No venereal history. No enlargement
of glands. Hernial rings not enlarged. Neuromus-
cular reflexes negative. Bones, left int. malleolus
shows scar of operation and deformity of bone.
Ankylosis of ankle partial. Bones and joints other-
wise negative.
Laboratory findings by Dr. A. H. Schade:
W. B. C, 5,400; R. B. C, 5,208,000.
Haemoglobin, 95%. Wassermann negative. Urine,
negative to albumen, sugar, bile and blood. Indican
present. Microscopical amorphous urates, calcium-
oxalates, few pus cells and large amounts of mucous.
Few bacteria present.
X-ray report of Dr. A. J. Hartman:
Habitus, hyposthenis.
Esophagus, patent.
Stomach, hypotonic tone, normal size, free mobil-
ity, active peristalsis, no tender points or filling de-
fects, normal position, fish-hook shape, normal posi-
tion, no inoisura, four-hour emptying time, no six-
hour residue.
Pylorus, normal position and patent.
Duodenum, normal size, regular contour, active
peristalsis, no tender points, patent, incomplete evac-
uation.
Jejunum and ileum, normal with no delay. Ap-
pendix not seen.
Colon, cecum large and mobile, 24-hour small
mass seen. Trace in transverse colon descending very
small bulk.
The Operative mi Poet-Opermtivc Progress
On operation, done under ether, no pathology
was found. The appendix was removed as a matter
of routine. The terminal ileum was amputated from
the colon and inserted into the first portion of the
sigmoid flexure by an end to side anastomosis and
the abdomen closed. The patient made an unevent-
ful recovery.
The patient was given cathartics on the fourth
day of eight drams of ol. ricini and the bowels moved
well. At the end of three weeks the patient left the
hospital with the bowels moving well and the gen-
eral health gradually improving.
I have seen this patient at regular intervals since
his discharge from the hospital and he has improved
steadily in health and strength. His weight has
increased and he is no longer constipated, his bowels
moving regularly without cathartics. The toxic effects
of absorption are entirely absent.
Cemchsiotu tmd
This is a case in which constant cathartics were
of no avail and in no other way, I believe, than a
short circuiting operation or a colonectomy could a
happy result have been obtained.
1. Greedy colon is a condition of increased absorp-
tion in the colon of normal intestinal contents.
2. Cathartics are of little avail in remedying the
condition, because the bulk is not present to pass
along.
3. Short circuiting operation is, or if necessary a
colonectomy, the best method of giving permanent re-
lief in many of these cases.
Do not lay too much stress on albumen in a pros-
tatic's urine. A large part of it is due to pus
which becomes decreased through proper treatment of
the bladder. The question of albuminuria should bt
of minor importance in determining the advisability
of a prostatectomy.
PhiU., Majr, 19221
The Therapeutic Value of the lee Bag — Colton
359
The Therapeutic Value of the Ice Bag
iM
Acute Inflammatory Conditions
BRINGS OUT NEW POINTS AND WIDENS FIELD OF USE OF THIS OLD STANDBY
By Albert J. Colton, M.D.,
27 Jewett Parkway, Buffalo, N. Y.
Physician to the Sisters' Hospital, and Consulting
Physician to St. Mary's Maternity and
Infant Hospital.
Am Old Am Mm
The use of cold in attempted reduction of
elevated temperature is as old as man. The
feverish animal instinctively plunges into
cold water to obtain relief just as the fever-
ish human applies the wet kerchief to relieve
headache. Still Dr. Colton brings out new
and interesting points on the utility of this
excellent remedy. You will agree with us
that it is a paper worth while reading — and
you will be surprised at the extent of the use
to which you can put this good, old-fashioned
ice bag. — Editors.
IT IS SCARCELY expected to arouse very much
enthusiasm over such a cold topic as an ice bag,
but if your results have been as favorable as mine
yon may warm up to the occasion.
As a therapeutic measure cold in some form has
been used from time immemorial and about on a
parity with the hot poultice; although probably less
frequently on account of the lay mind being prej-
udiced against the use of cold for fear of a "chill."
Its uses were confined largely to the relief of pain
and the reduction of high temperatures.
It is seldom that I have found much of any real
virtue in the hot poultice except in certain conditions
for the relief of pain or hastening suppuration; but
many times have I had most excellent results in the
proper use of the ice bag.
The Scientik'e Reason
Since seeing such good results in many cases and
in a few the terminations of which seemed almost
marvelous, I have tried to figure out the scientific
reason for it. After a little reflection it becomes as
simple and logical as the art of bread-making or food
and fruit preserving by the housewife. She would
not be guilty of mixing yeast in her dough and then
placing it in the refrigerator to rise. Neither would
she put milk or cream in the kitchen back of the stove
if she wished to keep it sweet. No, she would place
the dough after being mixed with the yeast in a warm
place, (not too warm) and leave it until it had become
light and porous, and the milk or cream she would
place in the ice box. Should you ask her why she
placed the dough in a warm place or the milk and
cream in the refrigerator, she would probably tell you
so that the dough would rise and the milk would keep
sweet and not get sour.
A housewife skilled in domestic science would give
you a more scientific reply. She would say that yeast
which was mixed with the dough contained lite or
living organisms and in order that it may grow and
multiply, heat and moisture are required and in thus
growing, gases are given off which make the dough
light and porous.
Furthermore she would tell you if the heat were
too great the organisms would be destroyed and thus
by either means defeating the ultimate purpose of
the yeast ; the milk she would tell you contained germs
which had gained entrance either through accidental
or atmospheric contamination, and that the growth of
these germs in the milk produced an acid (lactic acid)
and caused it to sour and curdle, but if kept in an
ice box dt a temperature of 40 degrees F. or less the
growth of the organism would be inhibited and no
acid would develop, and the milk would thus remain
sweet.
If you wished to indefinitely preserve the milk the
germs in it should be destroyed by heating and the
milk then placed in a sterile container hermetically
sealed.
The foregoing illustration serves as a perfect anal-
ogy for the care and treatment of local inflammatory
conditions. The same natural laws are present in
the growth of yeast, souring of the milk or putre-
faction of food as exists in acute inflammatory condi-
tions.
Inflammation and Micf-organ'umu
Pathologists tell us that where there is inflammation
there are bacteria. Inflammation, therefore, is due to
the growth of some pathogenic bacteria in the human
tissues. These pathogenic organisms grow best and
most rapidly at body temperature or about 100 de-
grees F. ; therefore, when the temperature of the
tissue in which the organisms exist is reduced the
growth of that organism is held in abeyance accord-
ingly.
* Read before the Aesculapian Club of Buffalo, November 17,
1921.
360
The Therapeutic Value of the Ice Bag — Colton
[The American Physician
By holding the organism in abeyance (i. e., by the
use of the ice bag) the body is not overwhelmed by
toxins, produced by the germs, and nature is given
an opportunity to create her antibodies, and thus
immunise the patient against the poisons thrown off
by the micro-organisms.
The pathogenic organisms that have entered the
tissues cannot be destroyed by heat as in preserving
milk or fruits without destruction of tissue; but by
the local application of the ice bag, the growth of the
bacteria may be controlled until nature can come to
the rescue with her antitoxins.
Nature is very kind to us and attempts to cure all
acute inflammatory conditions, and usually does, if
she is not defeated by the rapidity with which the
poisons are produced by the invading organism.
Why, in one case a streptococcus, staphlococcus,
diphtheria or colon bacillus, etc., may be so very
virulent and another so extremely mild I shall not
attempt to explain, but will leave for the bacteriol-
ogist or pathologist to tell you; but that they may be
held in check by the proper use of the ice bag, I am
thoroughly convinced.
Tke Proper Us* *4 tkt let-Bag m AppemiicUb
When I say the proper use of the ice bag I say it
advisedly. There is no doubt but what the improper
use of the ice bag could cause much discomfort and
possible damage.
If called to see a small child in which I had diag-
nosed appendicitis, arthritis, cellulitis or any acute
local inflammation, I would not leave the patient by
simply saying to the mother or nurse to apply the
ice bag. If it were appendicitis I would map out
with a pen or pencil on the skin overlying the in-
flamed area where I wished the ice bag kept.
If it were a small child and a large ice bag I would
take a piece of asbestos paper and cut an opening in
it the shape and size of the inflamed area which I
wished covered by the ice bag. In the absence of
asbestos paper I would use ' several thicknesses of
newspaper in the same way and have the ice bag
kept continuously over that area either by tying it
with a piece of tape or having it held in place by
hand if necessary.
If this precaution be taken, no injury is caused by
the long continuous use of the ice bag, and the child
will not be restless and uneasy; but on the contrary,
in a few minutes it will be perfectly quiet on account
of the ease and comfort given. One should try to
have the ice bag cover an area slightly in advance of
the inflamed part and there will be no complaint as
to the feeling of the cold.
I am certain that I have aborted many cases of
appendicitis in this way, in connection with the use
of a heavy para Sine oil and a lactic acid milk made
with the Bulgarian lactic acid and acidophilus bacil-
lus given internally.
The surgeon may claim that appendicitis will
return. It may, but I have had cases that have gone
from five to twenty years without recurrence, and
when it does, the patient is in better condition to
withstand an operation than if the treatment had not
been carried out. I mean by this statement that the
patient's resistance has been built up by having
secured a higher leucocyte count and having given
nature time to build up immunizing bodies, thereby
making the patient less susceptible to those complica-
tions incident to the operation, such as cellulitis,
phlebitis, peritonitis and general infections.
With the early use of the ice bag there would be no
necessity of rushing a patient to the hospital in the
night for an immediate operation, for fear of a rup-
tured appendix, except in severe fulminating eases,
which would surely not be as numerous under this
form of treatment if at all.
No, the organism would be held under control with
a possibility — yes a probability — that the local inflam-
mation would entirely subside; if not entirely sub-
sided, it would at least be held in abeyance so that the
local inflammatory condition would have an oppor-
tunity of being walled off and give nature a chance
of getting its immunizing bodies at work and thus
giving the patient greater resistance and less suscep-
tibility to spreading infections which are incident to
operations in an infected field.
Besides, there is the nervous shock to the patient
and relatives by rushing him or her to the hospital
without due time and deliberation. I believe if the
ice bag were used early there would be no more need
of an immediate operation for appendicitis than there
would be for operating on acute cholecystitis or sal-
pingitis.
Cholecystectomy and salpingectomy is occasionally
done during the first acute attack, but in my opinion
when it is done it is at a great risk to the patient and
discredit to the surgeon.
I know that these conditions frequently undergo
complete resolution when properly treated and if they
do not the bacteria becomes less virulent and the pa-
tient is in a better and safer condition to undergo an
operation later by the immunizing action created by
the slow development of the organisms.
When possible assist nature in building up her
antibodies bv the use of small doses of vaccines made
from the offending organisms.
In treating patients with vaccines the desired end
is often defeated by use of too large an initial dose.
Begin with a very small dose, say five to ten million,
and gradually increase, if no reaction occurs, to sev-
eral billion and in this way completely inmunize the
patient against the offending organism.
Tk* Ict-Bmg mi Vaccimet m EpUii'mHU mmi Arthrku
Acute epididimitis is another condition in which the
ice bag can be used with wonderful results, especially
when followed by the use of gonorrheal vaccines.
By this treatment one not only hastens the cure of
Fhfl*, M*y, 1922]
The Therapeutic Value of the Ice Bag— Colton
361
the ease but lessens the danger of gonorrheal arthritis
developing, and I believe that a gonorrheal oph-
thalmia in a patient thus treated would be unheard
of, and gonorrheal ophthalmia is not to be ignored.
Although it may not occur of tener than in one-tenth of
1% of the eases of gonorrhea, nevertheless when it
does occur it is a real tragedy.
Acute arthritis due either to a focal or local in-
fection is greatly benefited by the use of the ice bag,
and it should always be used after breaking up adhe-
sions in a recent infection of a joint. In articular
rheumatism where it has been the custom to apply
heat to the affected joints for the relief of pain, the
ice bag will give much greater and more permanent
relief.
iee-Bmg in End+cmrikU, lekm Pumm !■■■ mi Typmid Peter
This treatment applies as well to an acute endocar-
ditis but probably with not quite the same efficiency,
as the heart cannot be surrounded by an ice bag as
can a joint ; therefore, the inhibitory action or growth
of the germ is not as pronounced; nevertheless bene-
fit will follow, especially if patient is suffering great
pain accompanied by dyspnoea and high temperature.
In lobar pneumonia and typhoid fever the ice bag
has a dual effect when placed over the seat of the
disease. It not only has a tendency to reduce tem-
perature but has an inhibiting action on the offend-
ing organism, and is thus again giving nature time
to come to her own rescue.
In typhoid fever where the ice bag is used early
the patient will be less susceptible to intestinal
hemorrhages and tympany which should always be
anticipated and dreaded.
The let-Bag in EryriptUn mi Htmwtmiit
In erysipelas and other streptococcic infections of
the skin and cellular tissue the ice bag will give
marked beneficial results. By covering the surface
with gauze which has been dipped in a boric acid
solution with 30% alcohol the value of the cold is
enhanced.
Edward H. Ochsner, of Chicago, in his monograph
entitled "A Specific for every Pathogenic Organism,"
says that boric acid in solution with 25 to 50% alco-
hol is a specific for all strains of streptococcus,
staphylococcus albus and citreus and diplococcus of
Weischilbaum.
I have used many of Ochsner's specifics in various
infections and have had very happy results, espe-
cially when combined with the ice bag.
Acute external protruding hemorrhoids is another
condition in which wonderful relief is given by the
use of the ice bag in connection with the local appli-
cation of liquor plumbi acetas.
The Ice-Bmg m Memmmmry Abeeeuee, CmrkmmcUs, Meningitis mi
Ottos M dim
But my most startling results have been in aborting
mammary abscesses of nursing mothers, and I know
of nothing more pathetic than a young mother with
a deep mammary abscess.
The infant must be taken from the affected breast
and if the mother shows much sepsis removed en-
tirely from both breasts: then trouble begins. The
breasts become engorged, and instead of having one,
may have multiple abscesses.
The infant is placed on a bottle, and in so doing,
unless one skilled in infant feeding is called in, may
mean the loss of the infant, and all for the want of
doing the right thing at the right time.
The picture is quite different where the discovery
is made early and the ice bag applied. The symp-
toms of beginning infection of breast are quite char-
acteristic: the mother who has been progressing
nicely for several days after delivery except possibly
of sore nipples, complains of feeling chilly, and asks
for more clothing, or she may have a genuine rigor
followed by a temperature of anywhere from 100° to
140° F., and a pulse from 100 to 140. She may or
may not complain of pain in her breast, but if the
breast be examined a tender and inflamed gland will
be found in the breast.
If then the ice bag be applied and a saline ca-
thartic given and diet restricted, in 24 to 48 hours the
trouble has gone and an abscess aborted. These re-
sults I have seen so many times that I have come to
look upon the ice bag as a specific in mastitis of
nursing mothers.
I recently controlled a crop of carbuncles in a
few days by the use of the ice bag, autogenous
vaccines, boric acid and alcohol locally.
In acute infectious diseases involving the brain
and spinal cord the good results are not so apparent
for the reason that the disease is more diffuse and
the organisms are so insulated by the skull bones and
vertebra? that the cold cannot penetrate; nevertheless
it is the most common remedy in meningitis and
cerebrospinal meningitis that is brought into action.
In otitis media and mastoiditis, like meningitis,
the good effects of the ice bag are not so positive,
although it is recommended by some authorities. It
is well to remember the law of heat and cold, i. e.,
heat rises and cold descends, therefore, placing an-
ice bag above the inflamed area is decidedly more
efficient than placing it below.
1. Where there is inflammation, there are patho-
genic germs.
2. The growth of pathogenic germs are retarded
by the action of cold.
3. Nature attempts always to produce her own
cure, in inflammation, by immunizing the patient,
if not overwhelmed by the invading organisms.
4. The immunizing process works more slowly than
the poisoning, hence retard their growth with the ice
bag and give nature a chance to cure the patient.
362
Morbidity in Obstetrics — Nour
[The American Physician.
Morbidity in Obstetrics
To the Editor:
The August number of The American Physician
contained a very interesting and useful article on
"Morbidity and Mortality in Obstetrics," in which
the author. Dr. Inglis, adopts Dr. T weedy 's Standard
•of Normality and oites very valuable remarks for
tthe reduction of morbidity.
Morbidity in obstetrics means any deviation from
the normal condition of a woman, after her delivery.
This may not always be due to faults of the ac-
coucheur, but to certain intrinsic or organic causes
in the lying-in woman, as is illustrated by the fol-
lowing two cases.
Case 1. Mrs. M., a multipara, was delivered by
a midwife, June, 1914. I was called to see her
on the twelfth day after delivery and found that
the woman was sick since delivery, having had a
•chill and slight fever, and the third day lochial dis-
charge became scanty and gradually disappeared. In
a few days patient continued to have a form of re-
mittent fever with slight chills and sweats — tempera-
ture 38° to 40° C.
The midwife ordered vaginal douches of corrosive
sublimate. I considered this a possible cause of
the puerperal septicaemia. The vaginal examina-
tion did not reveal any special cause for the fever;
I made up my mind to treat the case symptomatically.
The vaginal douches were stopped, as there was
no apparent reason to indicate their use. Consti-
pation was relieved by tablespoonful doses of cas-
tor oil daily, and the following prescription was
ordered :
I£ Quinine bisulphite, grams 3.00, divide into 8
capsules.
Sig. one capsule to be taken every four hours.
The next morning a small quantity of yellow fluid
-was thrown out by the uterus and temperature
dropped to normal. A tonic was administered. Pa-
tient recovered.
Case. 2. My wife, multipara, last confinement
May 27, 1921. She was unusually indisposed dur-
ing her pregnancy. The liver was sluggish and
conjunctiva slightly icteroid. The condition of her
heart alarmed me greatly. She would have attacks
of dyspnoea, tachycardia and palpitation, so that
I was greatly concerned about her safety. My
colleagues offered their services and one offered a
free room in the hospital, but the patient preferred
the same old room of her home. Confinement time
came on and, to my great delight, I found the con-
dition of her heart improved with the advent of
pain, so that at the time of the most intense pain
the heart became steady, slower and regular and
beat stronger.
The antiseptic precautions were, by force of cir-
cumstances, somewhat faulty, delivery was unevent-
ful; the after birth came out twenty minutes after
delivery, placenta and membranes complete. The
uterus was a little larger than usual in previous
deliveries and, fearing hemorrhage, 1 gave her 2
cc. of ergot hypodermically. The next morning
two large pieces of placental tissue were expelled
by the uterus. Where did this tissue come from!
Were they the result of a second pregnancy which
was possibly arrested by absorption of foetus? I
do not know. Temperature was 37.2° C. The third
morning a tablespoonful of castor oil was given, but
temperature went up to 37.5° C, and 38° C. I
could not detect anything abnormal, and thought that
the temperature might be due to absorption from
gastrointestinal tract; hence, tablespoonful doses of
castor oil were given every morning. But tempera-
ture went up to 38.2° C. Thereupon I insisted on
milk diet, and the first glass of milk taken gave
her such gastric pains that it was promptly vomited,
with much bile. Soon I ordered a second glass of
milk and gastric pains returned, milk curdled and
vomited together with bile. The administration of
milk was repeated seven times and was rejected each
time, but 1 could notice an apparent change for
the better in the expression of the face every time
after vomiting. The eighth glass stayed on her
stomach and half an hour after that temperature
dropped to 37.5° C. Next morning temperature be-
came normal and kept normal.
The morbidity in these two cases was, in my opin-
ion, not due to faulty attendance or to infection
from improper antiseptic precautions, but was ap-
parently due to septic conditions in the system
brought about perhaps by pregnancy, and affecting
organs remote from the generative tract
The first case 1 now think was due to intestinal
intoxication and malarial poisoning and the second
case was probably due to condition of the liver
and the slight icterus. So it behooves us to take
into consideration the whole system of the lying-in
woman while treating puerperal conditions and not
to concentrate our minds only upon microbic in-
fections in the generative tract at time of delivery.
George E. Noub, M.D.
Beyrouth, Syria.
Acid Fruit in Typhoid
To the Editor:
Twelve years ago I had a patient so low with ty-
phoid fever, all he could say was, "Grape juice, grape
juice." I ordered a pint, such as they dispense at
soda fountains, and gave him all he wanted. He
went to sleep and woke up much improved. Con-
valesced rapidly. 1 give buttermilk from start to
finish — no sweet milk. 1 have only cream churned,
no water in milk. If the cream is too cold to
Phil*., May, 1922]
Oar Pedigreed Stock — Evans
363
churn well, set the churn in a vessel of hot water.
If the butter does not gather or collect, I have it
strained to get butter out. Have regular hours to
give milk, grape juice, orange and lemon juice. If
this is published, I hope it will benefit someone.
C. H. Mitchell, M.D.
Box 2, Lulu, Okla.
Our Pedigreed Stock
By Roland C. Evans, A.M., M.D.,
Sheffield, Alabama
RATHER a peculiar title for a paper to be pub-
lished in a medical journal, but nevertheless
fitting and appropriate.
Just a few days ago, while reading some reports
from the United States Department of Agriculture,
the thought struck me rather forcibly that not only
our government, but, I am sorry to say, we seem to
be devoting more time and attention to the breed-
ing of various animals, and to the propagation of
various fruits and vegetables than we are to the
breeding and raising of our own children.
The race horse is pampered and cared for with
a great deal more attention than the great majority
of children. The brood sow is shown more consid-
eration than the mothers of some of the next gen-
eration, who will be called upon to make our laws
and administer our business and professional affairs.
Even the guinea pigs, rabbits and other small ani-
mals used for experimental purposes in our path-
ological and research laboratories are selected with
more care and watched over with more solicitude
than is the average child.
Selective breeding, and the culling of undesirable
offspring, are considered routine business in the
animal and vegetable kingdoms. Registered cattle,
hogs, dogs, chickens, and other animals and birds
may be found on almost any farm.
But what can be said of the human family? What
steps are being taken to insure the future health
and improvement of the race ?
A start has been made through the study of eu-
genics, but what a poor and feeble start it has been.
Some of our states require that a man who contem-
plates marriage shall pass a physical examination
and be pronounced free from all communicable dis-
ease by a reputable physician before he can procure
the coveted license, How many of these examina-
tions really amount to anything, and even if they
did, why should such procedure apply to the man
only and not also to the woman f
If this law could be made national, and applied
equally to both parties concerned, and also be fixed
so that the examining physician would have a proper
conception of his duty in the matter, it would have
a good and restraining effect. But what will be done
with the question of prostitution and the children
born out of wedlock f
Everything cannot be accomplished at once. We
cannot allow the diseased or deformed infant to
die. It must not be made to suffer for the sins of
one or both parents. But what are we to dot
Some will say it is a subject to be approached
through educative means. That is going to take
a long time and extend over several generations.
And even then it is going to be difficult to reach
a great many of the uneducated and the careless.
It is almost a daily occurrence for the average
medical practitioner to come in contact with some
child, or even a grown person, who is carrying in
some form or other the stigmata which could have
been prevented by proper marriage laws, properly
enforced.
As I said before, there would be some that the
law would not reach, but this number would gradu-
ally decrease.
Preventive medicine is one of the greatest bless-
ings we have, but we must make it more far-reach-
ing and make it not only prevent disease, but make
it reach so far that the persons liable to convey these
diseases, both of mind and body, to their offspring,
shall be prevented from producing and bearing off-
spring at all.
You ask me how is this to be donef Let me
answer frankly and truthfully, I do not know. All
great reforms are gradual. "Rome was not built
in a day."
Perhaps as we think over such problems and bring
them home to ourselves, a way will be revealed, and
it will not be long before pedigree will mean some-
thing worth while in the human family as it already
does in some of the lower forms.
Our Medical Schools Over-manned
To the Editor:
I have read your journal for years. I also read
a good many others. I seldom express opinions, but
I am so much in sympathy with your article "Our
Medical Schools Over-manned" that I must say so.
Keep it up! and probably the trustees of some
schools will take notice. The intrenched faculties,
of course, will not reform themselves, and as there
are probably many outsiders trying to get in, the
remainder being indifferent, the profession as a whole
cannot be expected to help improve the situation, so
it's up to you editors and the trustees.
The same tendency exists in many hospitals, too
many men on the staff; a small, efficient, responsible
staff would be infinitely better.
Leon Thurston, M.D.,
Suite 604-5-6 Empire Bldg., Pittsburgh, Pa.
364
Polyneuritis of Infections Origin — Williams
[The American Physician.
Polyneuritis of Infectious Origin
Aatfe/s Ahttfd
Discussion of the pathologenesis of neuritis daring
infection, with special reference to disorders of the
hepatic function. Distinction from radiculitis treat-
ment.
Polyneuritis during infection is not common. It
has been assumed that the specific toxin is here its
cause. Because polyneuritis occurs from poisoning
by minerals, and in chronic alcoholism, a common
factor may be responsible in most kinds except that
of diphtheria, in which the .frequency of local
paralysis points to a specificity.
Clinically, hepatic disturbance in polyneuritis is
shown by the presence in the urine of altered pig-
ment and indican and urobilin. Post-mortem cloudy
swelling of the liver is found.
Whatever the pathogen may be, the central nerv-
ous system, too, is affected in the Koraskoff syn-
drome. In some cases there is increased tension of
cerebro-spinal fluid with hyperalbuminosis (and
sometimes slight lymphocytosis) of several weeks'
duration.
Cases of polyneuritis are briefly reported during
diphtheria, tonsillitis, typhoid fever, chronic gon-
orrhoea and influenza, all of which recovered. The
Symi
Definition.
Etiology:
Toxin.
Chemical poisons: Alcohol or metals.
especially arsenic or lead.
Diffuse bacterial poisons aside from
local exudation, especially diphthe-
ria and influenza.
Metabolic poisons: lithemla, arthri-
tism.
Endocrine imbalance.
Focal infection.
Tuberculosis.
Syphilis.
Neoplasm.
Physical agencies: Cold, trauma, etc.
Concomitant of arthritis.
Pathology :
Onset:
Symptoms :
Pain.
Tenderness.
Conductivity.
Hypesthesia.
Sensory dissociation.
Motor weakness.
Atrophy.
Deformity.
Reflexes.
Trophic changes.
Extent.
Diagnosis:
Differential Diagnosis:
Prognosis:
Treatment :
Metritis
Irritation of peripheral nerves.
The usual cause.
Frequent.
Occasional.
Occasional.
Possible.
Occasional.
Scarcely.
Doubtful.
Occasional.
Occasional.
Of the neighborhood.
Usually degenerative from toxicosis, or
by strangulation by neurodocitis.*
Often abrupt.
Except in plumbism or pure motor neu-
ritis.
Characteristic, especially of deep tissues.
Impaired.
Except in early stages, irregularly pro-
gressive.
Not usual; sometimes pseu do tabetic, but
never truly of tabetic type.
Usual.
Severe and of long duration except in
mild cases.
Contracture and stretching of tendons
and ligaments.
Impaired except at first.
Early and evident.
According to distribution of nerve af-
fected. In polyneuritis more marked
peripherally.
Increased deep tenderness with or with-
out hypsesthesia. Syndrome conforms
to distribution of peripheral nerves.
From trauma, osteitis, arthritis, myo-
sitis, meningitis, poliomyelitis, en-
cephalitis, myelitis.
Highly favorable upon removal of cause.
Elimination of the pathogen; metabolic
regulations; physical agencies to stim-
ulate local nutrition.
Radicwliti*
Irritation of spinal root.
Doubtful.
Doubtful.
Ctoubtful.
Doubtful.
Doubtful.
Doubtful.
Frequent.
Commonest cause.
To be suspected.
Especially trauma.
In the spine.
Often inflammatory; by strangulation,
by inflammatory or neoplastic com-
pression.
Insidious.
Usual when posterior root is Implicated.
Absent or minimal.
Impaired.
Except in early stages, Irregularly pro-
gressive.
Occasionally of syringomyelic type in
tuberculous radiculitis; of tabetic type
in syphilitic radiculitis.
When anterior root is affected, best
marked in tuberculous radiculitis.
Less evident except in tuberculous ra-
diculitis.
Contracture and stretching of tendon
and ligaments less marked.
Impaired.
Scarcely.
In the segmental distribution of the
roots affected.
Hypaesthesia both cutaneous and deep.
Syndrome conforms to distribution of
roots.
From the same.
Unfavorable In proportion to destruction
of sensory fibres favorable as re-
gards motor fibres except when dense
cicatrices have occurred.
Removal of the pathogen; rest of the
regions affected.
• A term to denote inflammation of the fibrous sheath or
the fascia lata for the n. femorocutaneous or the aqueduct
Experimentally, pyridin causes swelling of nerve
tissue by hydration. It is a product of faulty hepatic
metabolism. Some of the products of cholin, a de-
rivative of lecthin, are highly toxic in nerve tissue.
One of these in particular, neurin, can be experi-
mentally produced in eggs or brains in an included
intestine.
bony canal through which a peripheral nerve passes; e. f.,
of Fallopius for the n. facialis.
differential diagnosis is tabulated against radiculitis
because of the omission of the latter syndrome in
American text-books.
The author's treatment emphasizes the metabolic
factor and includes a model dietary and absence of
narcotics. — Tom A. Williams, M.B.CJL, in Medical
Record, December 31, 192L
While surgery, the specialties, hospitals, People ate to be served, the primary im- ordinate* in constructive co-operation with
institutional medicine, public health work, portance of the function of the General the essential service of the Family Physician*
industrial medicine, etc., have their definite Practitioner must be recognised. Other dnri- This is an integral purpose of The American
functions, if the best health interests of the sions of medical service must be properly co- Physician.
To Much Complexity
Making Ducks and Drakes of our Civilization, Business and Medical Practice
LIFE IS BECOMING one patented complexity
j after another, and it "gets" us at every torn.
One ean't smoke a cigar "in good form" now without
a lot of complexity. Out of a fancy case or humidor
one takes his favorite brand, puts the case back or
closes the humidor, opens his coat to fish for his fancy
cutter on his watch chain, finds it and nips off the
end of his "smoke," buttons up his coat again after
hunting for the amber holder in his vest pocket,
strips off a fancy and useless band, breaking the
wrapper in doing so, adjusts the cigar in holder and
has trouble to make it fit, takes it out and works the
end around in his mouth a bit, puts it back in the
holder, forgets where his patented lighter is and
opens his coat again to find it, finally lights up,
eloses the lighter and restores to his pocket, buttons
up the coat — and then agrees with Walt Mason, who
mourns that modern cigars are made of herbs and
grass. Result : ten minutes' fussing with twenty dol-
lars' worth of contraptions and a bum smoke at the
end.
Yes, this illustration is trivial, and all of our triv-
ialities have become standardized and dolled up. One
can't change his shirt without prying a lot of
dinguses out of the soiled one and then breaking his
finger nails quarrying them into the freshly laun-
dered one and getting his fool collar and tie adjusted.
All day it's the same thing, and the next day some
more contraptions to buy to keep up with "what
gentlemen are supposed to do."
Harking Back m
In July, 1914, we were standing before a cathe-
dral chatting with a friend, a scholarly and thought-
ful priest. In the course of conversation he re-
marked about the wonderful progress of the world and
predicted a long period of peace and prosperity,
basing it on the "strenuous life" theories of Theodore
Roosevelt keeping people busy and out of mischief.
"Yes," we replied, "that is all right in theory and
for super-men, but the average human body and brain
has not changed essentially since Adam bought a suit
of clothes; and, take it from a doctor, the world is
due for one grand crash most any day and for the
simple reason that human flesh and brain can't stand
the pressure of modern life." And now, long after
the war, which failed utterly in teaching humanity
the real causes of the catastrophe and that a continu-
ance of these same causes will make another crash
inevitable, we want to "tell the world" that, unless
we so adjust life and business to the natural limita-
tions of normal flesh and brain, the next crash will
come within a few years and will disrupt our pres-
ent economic and social conditions. The trouble with
economics today is this: it has become pigenomics,
while sociology has become soak-'em-ology.
Sou Up On Business Friends
We have been trying to find a business friend who
will admit to making money and having his business
on a settled and stable basis, and such men are
hard to find. One closed out because he can make
more renting his building than he can by conduct-
ing a business in it. Another sold out his stock of
luxury stuff because he got prices for it that, he
predicts, is greater than the retail sales value will
be a year from now, and the syndicate buying it
will scatter it and unload at present prices within
a month. Four stated that overhead is so great
that they fear being forced to the wall. A banker
fears that the clamor of France and England will
cause Congress to write off that war debt they owe
us on a political dicker, making government and
industrial bonds shrink so as to unload the whole
obligation on the people, with disaster to them and
to the banking business. He is unloading his paper
while the unloading is good. Perhaps he is merely
frightened. Another wants to sell out because his
taxes are high, and he says bitter things about the
politicians. Two complain that foreigners have
365
366
Too Much Complexity in Business and Medical Practice
[Phila., May, 1922
opened up near to them, jazzed up their stores with
cheap glitter and equally cheap goods, and they can't
compete with these foreigners. Three over-extended
business and facilities during flush times and now
are in difficulties. Several claim to be merely break-
ing even. Some little stores pay seventy-five dollars
or so a month rental, and they carry stocks in these
expensive rooms that would not inventory at one
thousand dollars. One says he can't compete with
the advertisers', he knows, for he says he "threw
away sixty dollars in advertising." And so it goes.
Now most of these business people are in trouble
because they have not learned there is a buyers'
strike against the war-time flush in prices, unneces-
sary merchandise, fancy fixtures with poor goods
displayed, and lying advertising. They keep on stock-
ing up with clap-trap and jigamarees, expecting to
sell it now, not understanding that the jobbers are
unloading on them. They borrow money to put in
a fancy store front, with shoddy goods on their
counters. Many of the small establishments are
mostly fixtures to sell goods, with very few goods to
sell, and one can't tell them that their establishments
are utterly unnecessary in their communities without
a reply that is unprintable. Salesmen and efficiency
propagandists hammer into the merchants a line of
talk about the complex needs of the people, how
luxuries are now necessities, what the good times
just around the corner will do for the merchant who
carries fixtures and bric-a-brac, and what they will
do to the dealer who handles staples on plain shelves.
What nonsense! It is perfectly amazing to see the
amount of unnecessary bookkeeping and printed
forms used in small business establishments and the
complex way they have of doing simple things.
Seme Who See the Light
Yet there are exceptions. These merchants have
neat fixtures in proper amount, advertise regularly
but conservatively, keep stocked with what the people
need and want, make quick turnovers, keep down
unnecessary overhead, mark goods and prices hon-
estly and are doing business intelligently. They are
not making much money, and say so, but they will
be in business after the flashy stores are closed out,
and they will be making good profits soon as busi-
ness adjusts itself to the changed and much less
complex conditions ahead.
The Jazzing of the Medical Profesnen
The medical profession has gotten into the same
fix as did the railroads. There must be palatial union
depots and equally sumptuous hospitals. Special
trains must be all Pullman, travel at high speed
and give a service that costs so much the freight
traffic must be loaded up to carry passenger losses;
and the specialists and high-speed technicians in
medicine must get the cream of the traffic at the
expense of the locals who carry the real burden of
meeting disease in small town and country. The
government must take over the railroads, and when
the bureaucrats got control they made a pretty mess
of it; and now the cry is to take over the medical
profession and make political ducks and drakes of a
self-sustaining service that wants to run its own af-
fairs. Our books are jazzed ; our journals are in the
way of being jazzed ; we must run a business with a
lot of fixtures that are for show, "front" that is a
bluff, carry a tremendous overhead with a one-man
business or quit in favor of the group clinics; we
must be socialized and allow our hospitals and dis-
pensaries to be so over-run by women social workers
with feminism gone so rampant that the physicians
have no room to turn around between the girls pound-
ing typewriters; we must play second fiddle to the
foundations who fill up our working quarters with
fixtures and a lot of complexities that play jazz; we
must be regulated and surveyed by officialism with
new toys, the wheels of which we must make go
'round by our own hard work; our medical schools
must make everything except general practitioners;
when we open a boil we must go through as many
unnecessary maneuvers as the chap who lighted a
cigar in the first paragraph of this article, and when
we remove soiled bandages and put on clean ones it
is as fancy a job as changing stylish shirts as out-
lined in the second paragraph. Worst of all, we must
by our own hard work, technical ability, diagnostic
discrimination, horse sense and service-giving un-
selfishness, sit on the lid to keep it from being
blown off by lay hot air, or the whole works wrecked
by socialistic monkey wrenches being thrown into
the machinery going at jazz speed to amuse the
horde of fools who think doctors don't know how to
practice without a brass band playing a speedy dance
tune.
The Patients' Strike
Even as there is a buyers' strike in retail mer-
chandising, so there is a patients' strike impending
unless we change some of. the complexity-making
tendencies in medicine. If modern discovery and
research were placed on a constructive basis by the
war or the post-war period, the world could afford
being jazzed a little; but these scientific and tech-
nical advances were used simply to place wholesale
murder on an efficiency basis. If the wonderful ad-
vances in modern medicine were in the way of being
actually applied to the advantage of the whole peo-
ple, we could indulge needless complexity and afford
to be jazzed a bit; but these desirable results are
not in evidence.
We are not alarmists, pessimists or sore-heads; nor
are we blind. Far be it from us to favor returning
to rampant individualism or narrow empiricism in
medicine. Happily the day for that sort of thing
has passed. But we confess that we are a bit sore
over the fact that, soon as medicine was in the way
of being an exact science and a workable art that the
tim American phr»cUn] The American Physician 367
Constipation in Young Girls and Women—
especially those who spend much time indoors engaged in sedentary pursuits — is
almost invariably attended by a retention of waste and toxic substances. Sooner
or later these mike their way from the bowel into the general system and give rise
to a host of autotoxic ills.
Correction of this condition is imperative, and the safest, simplest and most effect-
ive remedy for the purpose is
INTEROL
Direction* s
To relieve the constipa-
tion of young firU and
women, fire two to four
teaspoonfuls of INTEROL
morning and night, in-
creasing or decreasing the
quantity as conditions re-
quire. As the bowels yield
to the action of INTEROL
gradually cut down the
dose to the least amount
that — taken at bedtime —
will assure a daily evac-
uation.
a pure mineral oil of the proper density and viscosity to assure
satisfactory lubrication of the intestinal canal, and thus relieve
and correct bowel inactivity without the usual disagreeable
effects of cathartics as commonly employed.
Besides lubricating the canal, INTEROL renders the feces
soft and plastic, thereby promoting their easy passage and
evacuation with gratifying freedom from discomfort and dis-
tress.
It would indeed be difficult to suggest any more serviceable
and agreeable medium for the correction of constipation, with
its attending autotoxemic conditions, than INTEROL.
Sample and Interol Brochure on requesl
AHied Drag and Chemical Corporation
2413 Third A**., Not York City
Manufacturer* of
ORASEPTINE— Internal and External Antiseptic, Wash, Spray and Douche.
ADACCO SALT— Effervescent Saline Laxative and Uric Acid Solvent
VELOGEN— "The Doctor's Handmaid and Household Emollient."
To Regulate Cardiac Rhythm
Disturbances of cardiac action, manifested by Tachycardia and met
with in Exophthalmic Goitre, Tobacco Heart and in Cardiac Neurosis
respond readily to the action of
ANASARCIN TABLETS
because of their inhibitory action upon the cardiac nervous system,
resulting in the slowing and regulation of the heart's action. In
addition Anasarcin Tablets contain diuretic agents which act defi-
nitely and reliably upon the kidneys to increase the output of both
urinary solids and fluids.
Also indicated in dropsy, post-scarlatinal nephritis, albuminuria of
pregnancy, chronic Bright's disease, and in cardiac valvular lesions
resulting in loss of compensation, circulatory stasis and effusion of
fluid into the tissues.
Sample and literature to physicians on request,
THE ANASARCIN CHEMICAL CO. Winchester, Tenn.
Mentioning The American Physician Insures Prompt, Careful Service
368
Medical Fellowships
[Phil.., May, 1922
whole people would support and the large interests
of the world find necessary to a smooth running of
civilization, the jazz artists in business and politics
must seize on the opportunity to advance selfish in-
terest by endeavoring to control medicine and sanita-
tion, caring little for the interests of the profession
that has made all of this possible and caring even
less for the real interests of the people who ought
to profit by it all.
Nor are we blind to the fact that there are selfish
interests in the medical profession itself, whose ex-
cesses, quackery, self-seeking and narrow-mindedness
are responsible, in part, for the present conditions
handicapping medicine and sanitation. Many mis-
taken sociologists who want to transform medical
practice are entirely sincere, seeing only the dark
side of practice under the old plan; and the profes-
sion will make a mistake unless we let in the light
ourselves, showing that while there are dark corners
full of putrefaction in the cellar of the medical struc-
ture, the great superstructure is clean, scientifically
planned, useful, and promising to become a great
temple of healing. Gentlemen, let us make it such,
cleaning out the dark cellar; but let us also beware
that, in furnishing the temple of healing, we do not
admit a lot of junk, bric-a-brac, complex playthings
and useless fixtures. — T. 8. B.
Medical Fellowships
The National Research Council announces the estab-
lishment of Fellowships in Medicine created for the pur-
pose of increasing the supply of thoroughly qualified
teachers in medicine in both clinical and laboratory
subjects and in both curative and preventive aspects.
The fellowships are supported by appropriations of the
Rockefeller Foundation and the General Education
Board amounting in total to one hundred thousand
dollars ($100,000) a year for a period of five years.
Those receiving awards will be known as Fellows of
Medicine of the National Research Council.
To qualify for appointment as a fellow, a candidate
must have the degree of Doctor of Medicine or Doctoj*
of Philosophy from an approved university, or prepara-
tion equivalent to that represented by one of these de-
grees. Only citizens of the United States and Canada
will ordinarily be appointed, although the fellowship
board is authorized to set aside this provision in excep-
tional cases. The fellowships will be open to both
sexes.
Since the principal purpose of establishing these fel-
lowships is to increase the number of competent teachers
in the field of medicine, each incumbent will be required
to gain experience in teaching. As creative work is
regarded as essential to the best teaching, emphasis
will also be placed upon research.
Fellows will be at liberty to choose the institutions
or universities in which they will work, as well as the
men under whose direction they will carry on their
researches, subject to the approval of the fellowship
board.
Appointments are to be made for a period of twelve
months, beginning at any time in the year, with an
allowance of six weeks for vacation. The time may
be extended, however, if in the judgment of the board
the work which the fellow has done justifies it. The
stipends are not definitely fixed in amount, but they
are intended to enable the individual to live comfortably
while carrying on his special work as a fellow.
Board to Administer the Medical Fellowships
The National Research Council has appointed a spe-
cial board of eminent medical men to administer the
National Fellowships in Medicine which the Research
Council is able to offer through special gifts to it by
the Rockefeller Foundation and General Education
Board amounting to $100,000 a year for five years.
The members of the board are: Victor C. Vaughan,
formerly Dean, Medical School, University of Michigan,
now Chairman, Division of Medical Sciences, National
Research Council, ex-officio chairman; David L. Edsall,
Professor of Medicine and Dean of the Medical School,
Harvard University; Joseph Erlanger, Professor of
Physiology, School of Medicine, Washington Univer-
sity, St. Louis; G. Carl Huber, Professor of Anatomy
and Director of Anatomic Laboratories, University of
Michigan; E. O. Jordan, Professor of Bacteriology,
University of Chicago; Dean Lewis, Professor of Sur-
gery, Rush Medical School, Chicago; W. G. McCallum,
Professor of Pathology and Bacteriology, Johns Hop-
kins University; Lafayette Mendel, Professor of Physi-
ological Chemistry, Yale University ; and W. W. Palmer,
Professor of Medicine, Columbia University, School of
Medicine.
The fellowships are open only to students who have
already obtained the degree of M.D. or Ph.D., or have
equivalent qualifications. Fellows will be appointed for
one year with the privilege of applying for reappoint-
ment Applications or requests for special information
should be made to the Division of Medical Sciences,
National Research Council, 1701 Massachusetts Avenue,
Washington, D. C.
Hookworm Remedy Found in Carbon Tetrachloride
Following the discovery by the United States Depart-
ment of Agriculture that the chemical, carbon tetra-
chloride, is effective against hookworms in animals,
numerous trials in various parts of the world have given
strong indication that it is the long-sought remedy for
this parasite in human beings. This important advance
adds another discovery to the list of those that Depart-
ment scientists have contributed to human medicine, one
of the most important of which is the fact that certain
diseases may be transmitted from one animal to another
by such external parasites as ticks and insects. If it
comes up to expectations, and all tests made so far have
been highly encouraging, this drug will be a boon to
millions of people in many parts of the world.
The Department has demonstrated beyond doubt that
this chemical is a remedy for hookworm and related
bloodsucking worms in animals, and its use for this pur-
pose was first called to the attention of the medical
profession in the Journal of the American Medical Asso-
ciation for November 19, 1921, by Dr. Maurice C. Hall,
who made the investigations.
According to a recent article in a London medical
journal, natives in the Fiji Islands have been given this
treatment for hookworm with satisfactory results.
Ninety-eight per cent, of the parasites were removed
with one dose of the carbon tetrachloride and no bad
effects were noticed. The absence of harmful effects
on the patients, in the tests so far, is very encouraging,
as the danger attendant on the employment of the drugs
most used at present constitutes a serious handicap to
the work of hookworm eradication. The new treatment
is, also, extremely cheap, the chemical being one that is
commonly used for cleaning clothing.
At the present time the Department's discovery is
being tried out as a drug for removing hookworms from
(continued one leaf over.)
The American Physician] An HofWSt Mar\d PlaCC 369
Doctor: Did you ever stop to
realize the significance of
this fact about Grape-Nuts?
Probably no other food in the
world is so thoroughly baked.
Cereal food that can be swallowed as a pasty bolus is not in
a condition suitable for the action of the digestive juices.
Long exposure to carefully regulated heat not only splits the
starch granules and brings about a proper physical condition for
digestion, but partially dextrinizes the carbohydrates, giving added
flavor to the finished product.
Grape-Nuts — the correctly digested cereal food — made from
whole wheat flour and malted barley, is subjected to approxi-
mately 20 hours* baking under the most careful regulation of
temperature.
Probably no other food in the world is so adequately pre-
pared for "simplified" digestion. Grape-Nuts is so prepared as
to insure natural and thorough mastication. It is never swal-
lowed wholes- as are so many "pappy" cereal foods.
Grape-Nuts contains calcium, potassium, magnesium, iron,
phosphorus, and other mineral elements that go to build sound
tooth, bone and nerve structure.
For these reasons Grape-Nuts is indicated in digestive and
deficiency disorders, and wherever re-mineralization of the tissues
is desired.
Served with cream or milk, Grape-Nuts is a complete food
and delicious to the taste.
Samples of Grape-Nuts, with full information, for personal or
clinical trial will be sent on request to any physician who has
not received them.
Postum Cereal Company, Inc.
Battle Creek, Michigan, U. S. A.
Mentioning The American Physician Insures Prompt, Careful Service
Book Reviews
[Phil*., May, 1921
Cancer Work Budget for 1922
While the budget for 1921 called for $15,000, the
Society actually raised and spent approximately $28,000,
the increase being largely due to the demands conse-
quent upon the National Cancer Week. The increased
demand for information and the desirability of assist-
ing the field organization by creating a field department
so impressed the representatives of the Society that a
budget of $60,000 for the year 1922 was voted.
The Lasker Memorial
One of the most encouraging financial matters re-
ported upon at the annual meeting and one which led
the directors to believe that the Society was becoming
more widely known and its value more fully recognized,
was the gift of $50,000 by the family of Mrs. M.
Lasker, of New York City, to the memory of her son,
Harry M. Lasker, who died of cancer in March,
1921. The income from this fund, which is the first
endowment the Society has received, will be applied to
the production and distribution of educational material.
"Book IteTtiews
A. great deal of information can be teenred from
palpation of the prostate, but nothing worth while
unless one is thoroughly well informed as to the aue,
contour and density of the normal gland. Try a few
normal ones.
You need cot hesitate to tell those of jour pa-
tients contemplating prostatectomy that the opera-
tion does not always produce impotence. To the con-
trary, the sexual function is unchanged or even
improved in the majority of cases.
The Glands Regulating Personality
By Louis Berman, M.D., of Columbia University, pub-
lished by the MacMillan Company, New York. Price,
$3.50.
The views concerning the physiology of organs and
tissues as well as of the entire organism could not be
considered rigorously accurate and thoroughly scientific
without a consideration of the relationship of the duct-
less glands. It has been shown repeatedly that the influ-
ence of the internal secretions of these glands is of no
negligible importance.
The present work of Dr. Berman throws a new light
on the problem. He attempts to go one step further
than previous investigators. Not onlv mood, disposition
and attitude are dependent on the internal secretions,
but the character, feelings and behavior, otherwise
speaking, the entire human personality is dependent on
the character of the glandular functions.
After a detailed consideration of each individual gland
the author discusses their inter -relationship, their influ-
ence on the psychic activities, on the entire personality,
on the formation of types of personality, finally, on
human evolution.
The book is an excellent contribution to the subject
and the author acquitted himself in a creditable manner
in his arduous task. The work is scientific and deserves
recognition. — Alfred Gordon, M.D.
(Book Reviews continued o
What Makes the Hogan High Frequency Superior?
The improved Spark Gap illustrated is
responsible for the great satisfaction experi-
enced by users of the apparatus. This con-
sists of a series of discs of a highly refractory
metal mounted upon insulating material of great heat-resisting qualities with a
sliding rod running through the central apertures regulating the length of spark.
The Hogan High Frequency Apparatus
offer* triple service, affording Oudin, Te*U and d'Anonval cur-
rent* suitable for vacuum electrode effect*, diathermy, auto-
condcniation, fulguration, electro -coagulation, etc. U*ed by
leading operator*.
Ask for complete literature.
Mfan
■rd by
Mcintosh Electrical Corporation
Successors lo Mcintosh Battery & Opt Co.
Established 1879
Eutwn Office ud Service Station
406 Lexlnston A**., New York /. Vi "
/the Hog!
Main Office and Factory: Mcintosh bid*-,
223-233 N. California Ave, CbicafO, III. / NaQ,c
/ Address.
/ e»ted in high
/frequency. Ki„d-
/ly send n.e liter*.
You can buy with Confidence— See "Service Guarantee to Readers" on page 392
The American Phy&ician
keixoggSbran
appeals to the tastes
of patients became it
is so delicious
Physicians find that patients really enjoy
Kellogg'a Bran, cooked and krumbled, because
it has an appetizing, nut-like flavor that wins
instant favor. Kellogg's Bran is entirely
unlike the common bran that becomes very
irksome to eat, yet Kellogg's contains all
those wonderful food and regulatory elements.
Kellogg's Bran, as you know, adds to the
indigestible residue in the bowel tract, its bulk
serving to distend the intestine, thereby induc-
ing better peristaltic action. If Bran is eaten
regularly each day — at least two tablespoon-
fuls; in chronic, old-age or bedridden cases,
eaten with each meal — it can be prescribed
with confident expectations of results.
We are anxious that you should know the
excellence of Kellogg's Bran from a personal
as well as a professional viewpoint. We ask
that you eat it for a couple of weeks as a cereal
or on your favorite cereal ; or have it made up
into any one of countless appetizing bakery
batches. All grocers sell Kellogg's Bran.
Kindly vend u a request card and we will
promptly mail yon a large package of Kellogg's
Bran, cooked and krnmbled, without the (light,
eat obligation on your part. PLEASE HAIL
THE CARD TODAY!
3KSES55
An Aoalrsl* of
Killotg", BRAN
evoked mad krumbUd
Adds (rom It! null.
MINERAL SALTS %.A
tile original BRAN -coo/ceti and krumbled
Mentioning The American Physician Insures Prompt, Careful Service
Book Reviews
I* tkt Start in It* •
>ss, M.D., CM., Douglas Fellow in
[1 University, and Research Associate,
ospital, Montreal; with an introduction
)erte), McGill University. Cloth, large
Tiber, very elaborately illustrated with
Hoeber, New York City, publisher.
monograph is based on elaborate and
.rch covering anatomy, the supply of
ie valvular structures, and full constd-
je-period changes in the blood supply
their pathogenetic relations. Conclu-
d that should prove of real clinical
jh the work is not one devoting espe-
clinical cardiology. The plates are
work, as is also their reproduction for
This original piece of research is a
or and should make a strong appeal to
iterested in the subject
Eltct r—OiKftmat am1 Thttmptmtra
nd de Laroquette, M.D., Chief of the
o-radiology. North Africa at Algiers,
vision. Translated from the French by
icetham. With a foreword by Robert
ith, 180 pages, fully illustrated. Pub-
Hoeber, 67-69 East Fifty-ninth Street,
:e, $4.50.
European writers on electro -therapeutics are character-
ized in their work by accuracy and scientific complete-
ness. This admirable atlas is an illustration of this
fact, for the author has presented the most valuable text
on this subject that has come to our attention. The
English and American readers are under obligation to
Miss Cheetham for her admirable translation, wbo un-
fortunately died before the work saw print The work
is of great value to the practitioner who aims to do
creditable work in this line.
Dotma ef sit Slam
By Richard I,. Sutton, M.D., Professor of Diseases of
the Skin, University of Kansas School of Medicine.
Fourth edition revised and enlarged. Cloth, 1132 pages,
969 illustrations and 11 plates in color. The C V.
Mosby Company, 508 North Grand Avenue, St Louis,
Mo. Price, $9.50.
The first edition of this work was well received.
Written by an experienced dermatologist who has opin-
ions and expresses them, the book was refreshing and
was not a mere compilation from other treatises. Tbt
present fourth edition is in no sense disappointing. The
text is complete without being verbose and the whole
subject is covered within the compass of one volume,
while the illustrations, to the credit of both author and
publisher, are admirable, making it unnecessary for the
practitioner who purchases this valuable work to refer
from the text to an atlas of skin diseases. This book
(Book Reviews continued one leaf 'over.)
Bronchitis
especially the bronchitis associated with pulmonary tuber-
culosis, is benefited by creosote therapy.
CALCREOSE (calcium creosotate) is a mixture containing
in loose chemical combination, approximately equal weights
of creosote and lime.
CALCREOSE differs from creosote in that it does not have
any untoward effect on the stomach; hence patients do not
object to its administration.
Price: — Powder, lb., $3.00. (Prepared by adding I lb. to I gallon of
water.) Tablet*: 4 gi-.. 1000, (3.00; 500, $1.60; 100, 40c.
Samplta (tablat*) und literatim fm.
THE MALTBIE CHEMICAL CO. New.*, N.J.
You can buy with Confidence — See "Service Guarantee to Readers" on page 392
The American Physician]
The American Physician
373
SAVE 30% ON
Intravenous Specialties
This firm, pioneer of yesterday and leader in the field today,
now offers many intravenous specialties to the physician at a
saving of 30c on the dollar.
These products, made in our large laboratories from the
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We have always set the standard of quality — now we are
establishing a price that is of further advantage to the physician.
Write for our latest price lists today.
GEORGE A. BREON CO.
Coca Cola Bldf. Dept 102 Kama* City, Mo.
The Management of an Infant's Diet
Constipation
Protein indigestion or the failure to take care of the
casein of cow's milk may result in delayed bowel movements.
When constipation in infancy is due to casein curds
it is readily overcome by employing some means of pre-
venting the firm coagulation of the casein.
Mellins Food
acts upon the casein of milk in such a manner that the
coagulated casein is presented in a most favorable condi-
tion for the action of the digestive fluids; therefore, Mellin's
Food is especially indicated in constipation due to faulty
protein digestion, and results will at once be apparent if
Mellin's Food is used in sufficient amount to thoroughly
attenuate the milk casein.
Mellin's Food Company, Boston, Mass,
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
[ Phil*., M.T. 1«Z>
is complete both in text and illustration and serves well
the purposes of the general practitioner as well as of the
specialist.
A Therapeutic Aid in Difficult Cafes
Many physicians have not been satisfied with thera-
peutic results in their cases of whooping cough ; and also
it has been difficult to give relief in asthma and bron-
chitis. In this regard it is interesting to note the results
some clinicians have been getting with Diatussin. A
Detroit physician says : "Diatussin positively relieves,
and comes as near a specific as I would wish in whoop-
ing cough."
You will find it, as have others, a most efficacious
therapeutic aid in the treatment of asthma, bronchitis
and whooping cough, for children and adults.
Ernst Bischoff Co., Inc., 85 West Broadway, New
York, will send you a sufficient trial quantity of this
excellent product, so that you can prove its efficiency
yourself, also interesting literature giving case histories.
Write them today for samples and literature.
The Host Widely Employed Antiseptic
For cleansing infected wounds, or dressing fresh
cuts or abrasions, there is no antiseptic more serviceable
and efficient than peroxide of hydrogen.
But it is necessary to be sure that the peroxide of
hydrogen employed is pure, of uniform character, and
of well-defined germicidal potency. It is the possession
of these properties to an exceptional degree that has
made Dioxogen the most widely used peroxide of
hydrogen. No other antiseptic is so prompt in its con-
trol of suppuration, so gratifying in its promotion of
tissue repair, or so satisfactory from every other stand -
A bottle of Dioxogen in his office or in his surgical
grip gives the busy practitioner the gratifying assur-
ance that he is prepared to meet any condition or emer-
gency calling for antiseptic treatment.
Bran Furnishes Needed Mineral Salts
An analysis of bran quickly proves its value to the
physician. The natural regulatory value of Kellogg's
Bran, cooked and krumbled, in the treatment of con-
stipation has long been recognized by physicians. As
you know, it is prescribed even in chronic cases with
The delicious flavor and edibleness of Kellogg's as
compared with common bran, makes it a delight for
the patient to eat. Thus the proper quantity can be
very readily taken.
But only lately have physicians become informed on
the food value of bran, as shown by chemical analysis.
Kellogg's Bran contains a greater quantity of calcium,
of iron, of phosphates, than many preparations that
feature those elements ! Bran gives more than 8 per
cent, mineral salts — and, as you know, iron and salts
from foods are more completely assimilated than iron
and salts derived through chemical processes. Bran
will give your patient, as well as regulatory action,
brain and nerve cell and energy producing food.
A full-size package of Kellogg's Bran, cooked and
krumbled. will be sent to American Physician readers
on request. Address: Kellogg Toasted Corn Flake
Company, Battle Creek, Mich.
(Helpful Points continued one leaf over.)
You can buy with Confidence — See "Service Guarantee to Readers" on page 392
The American Physician.]
An Honest Market Place
375
Surprised Her Doctor with
Wonderful Improvement
We offer to every physician and practitioner, ample opporttmity to prove to
himself and hit patient, the superiority of the Philo Bart Spinal Appliance
IT is because the Philo Burt Spinal Appliance is built upon sound, cor-
rect and advanced scientific, physiological principles that it is such a
great success in the hands of conscientious physicians. Here is a
strong proof from a doctor who. despite his knowledge of the many
remarkable benefits obtained by use of our appliance, was astonished at
the results attained in a fitting he made himself.
'About one year ago I secured one round shoulders were gone, her back
of your appliances for Connie B. I
had not seen her for six months
when she came into my office last
Saturday. I was very much sur-
prised at her improvement. The
was very much straighter, and her
health so very much better. I
thank you for your help and interest
in the case. I am perfectly satisfied
with your methods and appliances.
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Each Order ia Accepted Subject to a 30 Day Trial
It has been our privilege to
co-operate with thousands of
physicians, surgeons, ortho-
Farsnlts Ahaolut. V**c stpecimlijt* and practi-
countries. We will gladly refer any physician to
some of his contemporaries. We are anxious to co-
operate with any local physician who has had a
case under observation and will send him our
PHILO BURT MANUFACTURING CO., 115-17 Odd Fallow* TeenpU, JAMESTOWN, N. Y.
Physician's Portfolio without charge and explain
to him our plan of co-operation. We win make an
appliance for any case and send it on 30 days' trial.
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if either the doctor or patient is dissatisfied. We
have followed this plan for more than 20 years
and have treated successfully over 45,000 cases of
spinal curvature, diseases and weaknesses. We will
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ACTIVE CATHARTICS OR PURGATIVES THAT PRODUCE A WATERY
STOOL DO NOT GIVE GOOD RESULTS IN
Habitual Constipation
as the digestive secretions are carried off and a period of constipation follows
until the secretions again accumulate and the natural process of digestion and
assimilation is resumed.
A mild tonic laxative gives the best result and you can obtain this with Cascara
Comp. Tablets (KiHgore's), as they stimulate the secretions, give an easy natural
movement without griping and do not become ineffective by continued use.
Dose: One or two tablets at night
Liberal Sample and Formula Sent to Physicians on Request
CHARLES KILLGORE
Manufacturing Chemist Established 1874
55 WEST THIRD ST., COR. WEST BROADWAY NEW YORK
Mentioning The American Physician Insures Prompt, Careful Service
376
Helpful Points
[Phtla., May, 1922
From Nature's Own Pharmacy
Nature has provided a tasteful, healthful laxative that
should find proper place in every physician's Materia
Medica. Made into prune juice, Sunsweet Prunes offer
a fine, fruity laxative-drink, that may be dispensed to
young and old alike.
Even aside from their traditional laxative value, clin-
ical tests have proved the body-regulating qualities of
prunes. For example: prunes are rich in benzoic acid
— the natural fruit benzoic acid. This benzoic acid is
eliminated as hippuric acid — the acid that is normal to
the urine and always ought to be there. Where the
urine is alkaline, prunes possess actual medicinal value
in restoring the normal acidity. This applies to both
children and adults — and more especially to the aged
who are so prone to alkalinity of the urine.
As one eminent clinician puts it: "Prunes should
be used freely and can do only good." To American
Physician readers who are interested in the dietetic
and medicinal value of prunes, the brochure "For the
good that's in them" and new Sunsweet Recipe Packet
containing recipes tested for their nutritive and palate-
pleasing qualities — will be sent gladly on request. Ad-
dress: California Prune and Apricot Growers, Inc.,
580 Market Street, San Jose, Calif.
The Remedy for Hemorrhages
Many physicians have found Styptysate the effective
remedy for hemorrhages. It is of particular advantage
in menorrhagia and metrorrhagia, and has also been
found to be of great value in vesical hemorrhages and
hemorrhages from mucous membranes in general.
Results in many cases have been surprising; there are
no secondary ill-effects upon circulation or respiration;
Styptysate is therefore a safe remedy. Turn to page 327
and see special introductory offer.
Authoritative Book on Request
A new authoritative book on yeast is now offered to
American Physician readers on request It is written
by a physician for physicians, and discusses the manu-
facture, physiology, chemistry and therapy of yeast with
a symposium on vitamins. The growing interest in
yeast as a therapeutic agent has made it essential that
physicians should have at their disposal some book of
reference which will summarize in an authoritative way
the present known facts about yeast.
A copy will be sent to you free, address: The
Fleischmann Company, Dept. S4, 701 Washington
Street, New York.
Write for This Informative Report
In view of the extent to which Virol is used in public
health work in Great Britain, the bio-chemical labora-
tory of the University of Cambridge recently conducted
an exhaustive investigation to determine whether the
vitamines known to be present in the raw materials from
which Virol was manufactured were present in their
active state in the manufactured Virol as sold to the
public. The report, which fully proves the presence, of
the vitamines in Virol, will be sent to American
Physician readers on request, address: Geo. C. Cook
& Co., Inc., 59 Bank Street, New York.
Effective in Whooping Cough
If you knew the excellent results physicians are get-
ting from the use of Creo^Tussin in whooping cough
you would not be without it. Good results are evident
the first night. If you are not familiar with this excel-
lent product, just turn to page 381 and send in the
coupon for sample and literature.
(continued one leaf over.)
pmuiiiiiiwwiiwmniHiP
I CHLORYLEN
M A New Treatment for Trigeminal Neuralgia
1 Chlorylen is used with marked success in the treatment of tri-facial neuralgia.
B It has a specific action on the sensitive Trigeminus, gives immediate relief and the
3 pain disappears after a few treatments.
j Chlorylen is applied by inhalation. 20 to 30 drops are placed on cotton or
H the handkerchief and inhaled through the nostrils, until the odor disappears. It
J is a volatile liquid with a pleasing odor and is obtainable in bottles of 25 grams each.
NEUTRALON
A substitute for the Bismuth salts,
Sodium Bicarbonate, Silver Nitrate,
etc., in the treatment of Hyperchlor-
hydria, Hypersecretion, Ulcus Ven-
triculi, etc. A white, tasteless, odorless
powder; supplied in packages of 100
grams each. The dose is one teaspoon-
ful in a glass of water before food.
VALAM1N
A sedative and soporific for use in
the treatment of Neurasthenia, In-
somnia, Hysteria, Palpitation of the
Heart, etc. It is a Valerian and Amy-
lene combination, is easily absorbed
and acts promptly. Valamin is mar-
keted in packages containing 25 cap-
sules of 4 grains each. The dose is
one or two capsules after meals. In
nervous insomnia, two to four capsules
should be taken before retiring.
For further information and literature address:
KIRBACH, Inc., General Agents, 227-229 Fulton St.,
NEW YORK
fi^MiuiiniiniiiiiiniiiiwiiiiM
iiiiiiiiifiifiifiiHitiiiiiifiiiiiitiiiiiffliiiiiifitflraiiii
You can buy with Confidence — See "Service Guarantee to Readers" on page 392
The American Physician.)
An Honest Market Place $77
FIDELITY TO AN IDEAL
has won
PROFESSIONAL COMMENDATION
for
MANSFIELD AGAR AGAR WAFERS
A DRUGLESS LAXATIVE FOOD
Originally produced at the suggestion of physicians, these wafers have
been manufactured for ten years with a persistent endeavor to merit the
confidence and approval of the medical profession. That we have succeeded
is demonstrated by continued and increasing sales, unstimulated by any
advertising during the last four years.
We believe that the hygroscopic properties of agar and the vitalizing
qualities of the entire wheat grain, combined, have resulted in a product of
proven value in the treatment of constipation due to intestinal atony. As
evidence of this belief, we gladly offer any physician a package of the wafers.
THE MANSFIELD LABORATORIES, Inc.
18 CHANDLER STREET BOSTON, MASS.
To Reduce and Control Hypertension
The clinical significance of increased blood pressure is always that of a
danger signal. It should be interpreted carefully and treated efficiently.
Pul voids Natrium Compound
(High Tension Dr. M. C. Thrush)
is a scientific, safe, reliable combination of proven agents. It produces
prompt action and its effects are prolonged. It does not disturb digestion
or renal function.
Composition
Potassium nitrate, sodium nitrite, sodium bicarbonate, nitroglycerin and
Crataegus oxyacantha (tonic for heart muscle and to prevent shock). Special
(green colored) sugar coating, to dissolve in intestinal tract, and avoid
gastric disturbance.
Booklet on High Blood Pressure: How to take, interpret and treat it sent free on request.
If you dispense ask for price list of Pulvoids, Wafoids, Vita- Yeast, Organic Products, etc
Special Offer to Physicians and Hospitals Only
200 Pulvoids for $1.00. One time only.
1,000 Pulvoids for $5.00. On 60 days' trial; money back if not satisfied.
Either mailed free when cash accompanies order or if sent C. O. D. mailing and collection charges added.
THE DRUG PRODUCTS CO., Inc., ISO Meadow St, Long Island City, N. Y.
Mentioning The American Physician Insures Prompt, Careful Service
378
Helpful Points
[Phila.. May. 1922
PIUUWIIIIIIIIHJIIWIIIIIIIIIIIIW
| The New Violet Ray Tube |
s Is a new and important advance in the =
= heat and light therapy, and will add to =
M your professional prestige and income. It ||
= produces a pure Violet Ray entirely free §§
= from other rays. =
It is giving excellent results in the
treatment of Pain, Goiter, Lumbago,
Sciatica, Neuritis, Ulcers, Tumors of the
Breast, Prostatic troubles, and in all Gland
and Skin troubles.
Over 1400 treatments given in the past
5 years without a single failure to effect
a cure. It is a RAY or Light that can be
used with absolute safety to both physician
and patient.
No expensive equipment is necessary, as
it can be attached to any socket or holder
that has a cone-shaped reflector, such as
an ordinary reading lamp with a flexible
= arm.
The price is only $10. Descriptive lit- M
erature on application. Truly, Doctor, in =
this New Light you have a wonder worker §§
in the curing of diseases. =
THE NEW VIOLET TUBE CO. |
Fred'ksburg,Va. Dr.W. J. Chewning, Pres. s
llllliMU
A Htm Mtrcmrki
We have long needed a satisfactory mercurial for
hypodermic administration; and of all hypodermic
methods, the intravenous is obviously the best Ars-
phenamine is thus administered ; but arsphenamine with-
out mercury will usually fail to eliminate the spirochete
of syphilis.
Mercurosal (Parke, Davis & Co.) is a new mercurial,
one that is said to have the blandest possible effect upon
the vein when administered intravenously, but a power-
ful effect upon the spirochete. It is the counterpart of
arsphenamine, the two together constituting effective
medication in syphilis.
Parke, Davis & Co. have a new piece of literature on
Mercurosal — excerpts from recently published clinical
papers. Send them a card asking for "Mercurosal as
an Antiluetic,, __
The Result of Research and Clinical Test
Nujol is especially suitable for all forms of intestinal
constipation. It is scientifically adapted by both vis-
cosity and specific gravity to the physiology of the
human intestines.
It is the achievement of an organization of fifty years'
experience in the making of similar products. In de-
termining a viscosity best adapted to general require-
ments, the makers of Nujol tried consistencies ranging
from a water-like fluid to a jelly. The viscosity of
Nujol was fixed upon after exhaustive clinical test and
research and is in accord with the highest medical
opinion.
Sample and authoritative literature dealing with tfie
general and special uses of Nujol will be sent gratis.
Turn to page 383 and send in the coupon.
(Helpful Points continued one leaf over.)
ANUSOL
(.Trade-Mark)
Hemorrhoidal
SUPPOSITORIES
'Hesitate to Operate
Until They've Had
Their Chance"
To be sure, there will always be Hemorrhoid cases that yield to the
knife only.
But their number is not by any means as great as is generally assumed.
At any rate, it is a fact that the verdict "Operation" is pronounced
much too readily and lightly in a great proportion of Hemorrhoid
cases.
Whenever possible, suspend sentence until Anusol Suppositories have
been given their chance.
Ample Trial Quantity and Literature from
SCHERING & GLATZ, INC, 150 Maiden Lane, New York
You can buy with Confidence — See "Service Guarantee to Readers" on page 392
The American Pliyjicinn. ]
An Honest Market Place
"Massage alcohols" usually leave a heavy, unpleas-
ant odor, due to the denaturant used.
"ALKOLAVE S&D"— the quality rubbing alcohol
— leaves a refreshingly pleasant odor; it is denatured
differently; by special process.
Use it clear or diluted; but only of course on
unbroken skin surfaces — never on mucosa and
never internally.
"AlkoldVe S&D" Sharp & Dohme
id 4 ox. and pta. Chamiata tinea '60
EVERY DAY doctors are advising a rest, a trip to a sanitarium, a visit to
a specialist, an operation — anything to get rid of their old, stubborn cases of
Prostatic Disease and Impotence
lfaybe juu are doing, or are about to do thia very thing. You ire loiing pouibilitiei of dollars and prcatin,
to in netting of tht lasitfaction of having man « hard fight.
Too many of Ibeae caaea are passed up by food doctort, only to fall into the banda of untcrupulona men who
offer nothing but promiac* and frequently five leae.
YOU CAN GET RESULTS
in many af thcac wa. If yon -ill try SVPPOS. PROSTANS thoroughly in one or two caaei you will tardy
eonTince yoortelf and will thereafter knf tht bmintu you-'v dm" iwniiap oiwy.
There ii nothing aecret about S%ffoi. Pretitn* — formula wito each box.
If after a fair clinical teat you feel that the reaulta do not more than meet all your expectation), we hereby
**"% Lt_ IJoetor, that your immediate order meant a clear saving of *4 to you. It icerna a duty to
inn— tomorrow.
Fin out the coupon now. Sincerely,
REGENT DRUG COMPANY. .
Thit Coupon Mfomt Smtttit and Monty Saved as W,l\. Fill It Out. Send Teday
RECENT DRUG COMPANY, ■""" B"*™ •' *
5152 Woodward Awe., Detroit, Mich.
1 endows $5.00, tend me aw boxea of Name —
Suppoa. Proatana (worth J9.00) alao
the above book and "Succeaaf ul Proatn- ...
tic Therapy"— free. Address ■ „ ,
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
[PhiU., M»y,l»22
Pluto Water
Relief in Chronic Cases
Many physicians have found from experience that
the Ultima No. 1 Sinustat will relieve pain in sciatica.
neuritis, rheumatism, lumbago, neuralgia and like con-
ditions by producing a sedation of the nerves. Also
that mild applications to the gastro- intestinal tract stim-
ulate normal functions.
The Ultima No. 1 Sinustat is a general utility appli-
ance, for which the active physician will find many
uses. As well as for administering the sinusoidal cur-
rent, in the above conditions and for exciting spinal
reflexes (Abrams) it can be used as a current controller
to regulate the voltage of any small lamp for diagnostic
purposes, such as cystoscope, urethroscope, etc.
A very favorable opportunity is given American
Physician readers to try this apparatus thirty days
without charge. If satisfactory it is to be paid for in
monthly payments of $5.00— if you are not satisfied re-
turn it at the end of thirty days with no charge what-
ever. A valuable chart and booklet on "Sinusoidalogy"
will be sent to you free. Turn to page 385 and send in
the coupon.
has been successfully employed
and endorsed by the Medical
Profession as a uric acid sol-
vent and eliminating agent in
renal disorders; prompt, safe
and efficient and well retained
by the most delicate stomach.
Many practitioners direct con-
valescent patients to the spring
for rest and complete treat-
Frtneh lick Springs Hsttl C..
Fimth Lick, lad.
h Early Lilt
Regularity in bowel movements contributes much to-
ward normal, healthful progress of your small patient
And a knowledge of the number and character of the
stools during each twenty-four hours is an important
part of the general management of early life and assists
much in properly adjusting the diet.
Suggestions for the regulation of infants' stools by
slight changes in the make-up of the diet and particu-
larly in relation to constipated movements, are given *u
the book, "Formulas for Infant Feeding," and in a
pamphlet devoted especially to this subject, both of
which will be sent to Amekica^v Physician readers on
request. Address, Mellin's Food Company, Boston.
(continued one leaf over.)
Nervous Conditions
are invariably aggravated by the irritation that essentially
accrues from the repeated impacts of leather heels on hard,
unyielding floors and surfaces. Happily it is easy to obvi-
ate this continual pounding, with its cumulative depressing
effects on the nervous system, by wearing
O'Sullivan's Heels
So pronounced are the resulting benefits, that the use of
O'Sullivan's Heels has become with many physicians a
fundamental detail in the care of the nervous patient. The
relief of jarring not only adds much to the patient's com-
fort and well-being, but the marked relaxation of nerve-ten-
sion that follows often proves an important factor in assur-
ing a prompt and satisfactory recovery. O'Sullivan's Heels
are a boon to the neurasthenic patient.
CSULLIVAN RUBBER CO., Inc., New York
You can buy with Confidence — See "Service Guarantee to Readers" on page 392
The American Physician.]
An Honest Market Place
381
A rational
measure in the treatment
of INFLUENZA is t6 en-
courage the invariably de-
pleted adrenals by using
ADRENO-SPERMIN CO.
(Harrowr)
One, q. L d; in acute con-
ditions 2, t. i. d. is proved
to be rational because it is
effective. It opposes the
asthenia, hypotension and
peplessness that is so com-
mon.
Have You Made Your Reservation
for a copy of the new third edition of Hat-rower's
"Practical Organotherapy?"
The present edition contains most of the old fea-
tures and many new ones — fifty new chapters;
larger page; larger type; better in every way.
This New Book is Ready for Immediate Delivery
Send your order for a copy at once— enclose a dollar bill;
and if this big, new, cloth bound, 416-page book does not "suit
you to a T' " your money will be promptly returned on request.
The regular price of this book should be $4.50, but a dollar
represents the entire cost to you and the book will be sent on
approval if you prefer.
The Harrower Laboratory
Box 68, Glcndak, Calif.
I
Creo-Tussin in Whooping Cough
IF YOU ONLY KNEW the excellent results physicians are getting from
the use of Creo-Tussin in whooping cough you would not be without it for,
as one physician stated, "good results are evident the first night."
Physicians who are unfamiliar with tjreo-Tussin are
requested to write us for sample and literature. Please
use attached coupon.
The Maltbie
Company, Newark, New Jersey
Creo-Tussin
is a palatable solution of creosote,
gelsemium, passiflora, yerba santa,
menthol and aromatic*. Conveniently
put up in 2 oz. bottles with blank la-
bels for directions, each bottle in
plain carton.
Price— Dozen 2 oz. $4.00, Pint, $2.40 ■
•-- - - —-Cut Here and Mail Today,
THE MALTBIE CHEMICAL CO., Newark, N. J.
Please mall aample Creo-Tnaain ta
_ -Jf.D.
A. P. 4-22
Mentioning The American Physician Insures Prompt, Careful Serznce
J
Helpful Points
(PhiU.. May, l)U
A Doctor Writes-
Worcester. Mass,
February 24. 1922.
Nestle's Food Company.
Dear Sirs:
There is a tremendous amount
of illness amongst children,
especially malnutrition. The
parents are out of work, they
are shy on money, they eat cheap
food — and the Mothers' milk
lacks nutriment. Babies are
starving, though they take the
breast each two hours, as the
milk contains no fats.
I have put many babies on
Nestle's and in almost all cases
have done well — one three months
old baby increasing from 5 lbs.
to 12-1/2 lbs. in three months.
Yours very cordially,
NESTLE'S
MILK
FOOD
Pure Cow's Milk, properly modified, ex-
plains the general successful professional
use of Nestle's Milk Food. A liberal supply
of samples on request.
Nestle's Food Company
Nolle Building 111 Market Street
Hew York S*n Francisco
An Aid to Greater Success
Your patients' confidence in your ability is inspired to
a great extent by your own sense of absolute accuracy
oi knowledge ot anatomy.
The Pilz Anatomical Manikin has helped many an
ambitious physician toward more accurate diagnosis and
therapy and the merited confidence of his patients.
Install in your office the Pilz Anatomical Manikin,
life size, reproduced in folding layers, life-like colors,
complete in every detail, at $15 for male and sexless,
$16 for female— or the Dr. Minder's Manikin, 20 by 8
inches, male, $2.50; female, $3.00— and you will find it
a real aid to greater success in practice.
Order, now, or send for free booklets, address:
American Thermo-Ware Company. 16B Warren Street,
New York.
An Improved Blaud'a Pill
Blaud's pills of ferrous carbonate have probably been
more widely used :n medicine than any other form oi
iron. But it was found that in many of the pills on the
market the iron salts have been converted from (be
ferrous to the ferric state and therefore failed to pro-
duce the results characteristic of the ferrous carbonate.
This trouble has been entirely eliminated by the Wil-
liam S. Merrell Company in Blaudules, which are soft,
gelatin capsules, each containing 5 grains of Blaud's
mass in an oily medium. This mass is promptly as-
similated and the iron is retained in the ferrous state
until it is actually absorbed into the system. These
Blaudules are put up in boxes of 40 and are carried in
stock or will be obtained by all leading pharmacists. A
free sample will be sent to Amekican Pbvsicw
readers. Address: The William S. Merrell Company,
Cincinnati.
(Helpful Points continued one leaf over.)
^SjlOTCOS
%Nine Months
I When Its Yours
' $2.50 Monthly Brines I!
tinted BksJ
It WW for ItMlf .
'Leather Cascnj BookletFree
Ten Days' Trial -Money Back
*sdl"d"*"- ,—*^rT"J — ""I QUI 1.1 ■!■■ .iilmtlJKj
•d »ou wMnS jantew » ™» SiVroJoiri,™ ull cS>S«!
SwmJi ^"JL^" "■"«"• «■*■»- »■"■*£ *Mg
You can buy with Confidence — See "Service Guarantee to Readers" on page 3
_J
The American Fbyaician.l
An Honest Market Place
NECESSARYIN DIVERTICULITIS
A specialist of international reputation, after defining Diverticulitis a* tbe
formation of (mall pouchei along the wall* of the colon due to prolonged
constipated condition!, points out that these pouchei, becoming filled with
fecal matter, quickly cauae inflammation which leads to ulcen of the bowel,
■hjCMM or adhesion* — even the growth of tumor masses and obstructions.
A very serious condition, which, he says, is to be remedied only by care-
ful t\oo-tomti paring diet and the administration of liquid petrolatum.
NUJOL is the ideal liquid petro- tencies ranging from a water-like
latum for the correction of fluid to a jelly. The viscosity of
intestinal disorders. Its purity, Nujol was fixed upon after exhaus-
quality, and general suitability to rive clinical test and research and
conditions of intestinal stasis is is in accord with the highest medi-
attested by leaders in the medical cal opinion.
profession. Sample and authoritative litera-
In determining a viscosity best ture dealing with the general and
adapted to general requirements, special uses of Nujol will be sent
the makers of Nujol tried consis- gratis. See coupon below.
NtUSJ
A Lubricant; not a Laxative
Normal Colon Multiple DiitrlKnla
Nujol Laboratories Standard Oil Co. (New Jen
Room TAB, 44 Beaver Street. New York
PleaM and booklet! marked :
0 **ib General Practice"
D "A Surgical AaatMul"
Name_
Mentioning The American Physician Injures Prompt, Careful Service
384
Helpful Points
[Phila., May, 1922
t
u
i«
A Stand-By in
Uterine Troubles
VIBURNO
(BEACH)
The best evidence of this is the
repeat orders received from physi-
cians and druggists.
Nervine-Tonic and Anticongest-
ive, with calmative and corrective
action on the bladder. Employed
with much satisfaction in ovarian
congestion and congestive dysmenor-
rhea; weak pregnancy and deficient
lactation; menopause and its phe-
nomena, including hallucinations, hot
flushes, etc.; nervous and menstrual
derangements after "flu,** and the
troubles of adolescent girls. Sterility
often responds after 2 or 3 bottles if
no lesion exists.
Physician Wanted
From one of the medical houses of New York comes
the following:
Wanted — Physician, preferably with some literary
experience, for editorial and general duties in the office
of a manufacturing chemist. State age, education, ex-
perience, salary expected. Excellent position for quali-
fied physician. C. F. L., Box 34, Station V, New York,
N. Y.
UnliW similar products, VIBURNO
is palatable ami pleasant to take.
Dose: 2 teasp. (undiluted) ti.<L
before meals.
Put up in 11 ox. bottles
Sample and Formula on Request
THE VIBURNO COMPANY
116 Maiden Lane, New York
An Acceptable and Effective Combination
Bronchitis, especially that associated with pulmonary
tuberculosis, is benefited by creosote therapy. And
physicians are finding that Calcreose offers creosote in
a particularly acceptable and effective form. Calcreose
(calcium creosote) is a mixture containing in loose
chemical combination, approximately equal weights oi
creosote and lime. Calcreose does not have any un-
toward effect on the stomach, as does creosote, and
hence is acceptable to the patient and effective.
Samples and literature will be sent to American
Physician readers on request, address: The Maltbie
Chemical Company, Newark, N. J.
Helps in Your Practice
The new Com fort- V Supporter is very satis f acton*
in cases of enteroptosis, gasteroptosis, floating kidney
and post -operative conditions. It relieves dragging on
the solar plexis. The price is $4.50 and up, and the
supporter is washable, durable and economical. Order
now or write for literature, address: Huston Brov.
Atlas American Building, Chicago. The obstetrician
will find that their Obstetrical "Shoe Horn" will elim-
inate hours of suffering and danger — price, $5.00— fur-
ther information on request.
(Helpful Points continued one leaf over.)
TESTOGAN
THELYGAN a
For Men For Women
Formula of Dr. Iwan Block
After seven years9 clinical experience these products stand as proven
INDICATED IN SEXUAL IMPOTENCE AND INSUFFICIENCY
OF THE SEXUAL HORMONES
They contain SEXUAL HORMONES, L c the hormones of
the reproductive glands and of the glands of internal secretion.
Special Indications for Testogan:
Sexual infantilism and eunuchoidism in the
■ale. Impotence and sexual weakness.
Climacterium virile. Neurasthenia, hypo-
chondria.
Special Indications for Tkelygau:
Infantile sterility. Underdeveloped mam-
mae, etc. Frigidity. Sexual disturbances m
obesity and other metabolic disorders. Cli-
macteric symptoms, amenorrhea, neurasthe-
nia, hypochondria, dysmenorrhea.
fmniAU fa TABLETS for {stand ■*, taJ fa AMPOULES, for fatraffatel hMa
Prk«K T*U«to,4Sfaah«x,$2.St;fta»M|«.2tfaah«x.$I.St.
EXTENSIVE LITERATURE ON REQUEST.
CAVENDISH CHEMICAL CORPORATION
Sole Agents.
2t5 Pearl Stare*
Established 190$
You can buy with Confidence — See "Service Guarantee to Readers" on page 392
'the American Fnyiician.]
The American Physician
A CQ A I Acyl-Methylene-Diaehcylie
rtP^rtl . Acid ui i quo tin liable rem-
■^ «dy for RHEUMATISM.
Price, 75 cent* per ox.
DETUC A I T1>* Cinchoninic Acid
|)J_J'jj/\JJ and Benzyleater Com-
pound of AFSAL. Many
prefer thi* new lynthetit. Price, $1.00
per oz.
PDCACCU Benzylidene-Dibenzyl-
LKL/wLr **eihr' "wl»u»r
Dii odo-Diguaia col
Contain* 25% of iodine in an unirritaling
and auimiiable form. Valuable altera-
tive and anti*eptic, especially uaeful in
influenza and pneumonia and chronic
bronchili.. Price, $1.00 per oz.
IODOMER^wf^
and 29% iodine in
organic combination. Chemically react*
on the spirochete! of lyphilii end also
uaed in place of the many inorganic com-
pound* of iodine and mercury.
Price, $1.00 per oz.
PYRAZOPHEN ftfgJXSSSr
Methylene Diaallcyllc D, cinchoninic Acid.
DR. S. LEWIS SUMMERS
Producer of Synthetic Chtmical Compound*
Fort Washington, Penna.
EXCEEDINGLY HELPFUL
The New Comlurt-U (Supporter)
»n"U^iTnrra"ivV''c3'^^.B*'Rdkierdr«KVn7 on 11
■olar plexus. Price, (4.5U up. Washable, Durabl.
The Obatotrical "Shoe Horn"
Anatomically Correct aa Rafaid*
Sir. and Shape '
(award the bin
worth ita weight in gold. The head of
■he foctut may be readily deflected to
». ward the canal. El.mi.ia.cs hour* o
a suffering and dancer to mothers. Price IS
-NEVERSSUP'j
each. Send ua -I'.SO and »
it once prepaid. Neversslip i
HUSTON BROTHERS, Atla* American Building
CHICAGO
Cemplftt Lintl of Phyiician/ SufUitt
Jr
%,
A Compound Conliinma; Ihe Bile S
Glycocholile. Sodiujn Taurocholale with Can
Sagrada and Phenolphthalien
TAUROCOL COMPOUND TABLETS
re ot the Uvcr and Bile TiKI
THE PAUL PLESSNER CO.
DOCTOR! Do Yon Want
Results
tin
I Chronic
(Cases
Ne. 1 SINUSTAT iievc
Rheumatism, Lumbago. Neuralgia,
inducing a sedation of the nerve*.
tact stimulate norma! function*.
Try Thi* Thirty Diri Fieel Jus
U.P.
, CbicagD.
free trial without one cent in ' Centfunesi
sdvance. If It fail), retur ' ' '
FREEI A Valuable' Chart , / trial the Nc
- - ■ - - - -- . / Slnuatat- If
n 30 day*'
tax.
/
i i-a. • m ' I ' juj.uu in au day*; $8.00
Ulbma Phyncal / in so day*; M.oo la s
Appli-.Co./.is?- ^rtfSJU .
1S8 W. Lake , will return it at the end ef SO
CHICAGO, / (Signed)
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
Gynecologically
Marrel Whirling Spray
MARVEL COMPANY
XI W. 48th Si™. t N»w York
pounding, with its cumulative depressing effects on the
nervous system, by wearing O'Sullivan's Heels.
The relief of jarring adds much to the patient's com-
fort and well-being and effects a marked relaxation of
GIVES GRATIFYING RESULTS
The rein method of treating disease appeals strongly
to the progressive, busy clinician confronted with diverse
practical bedside conditions and striving earnestly to
meet them in a rational and scientific manner and with
a fair degree of certainty and rapidity.
Many physicians are finding Sodium Iodide and Guai-
acol (Endocreodin) for the pain, cough and dyspnea
of bronchitis, broncho-pneumonia and bronchitic asthma.
Sodium Iodide liquifies mucus secretion, reduces the
viscosity of the blood, increases leukocytosis and stimu-
lates glandular activity. Guaiacol is a mild anesthetic
and expectorant. The technic is simple and many phy-
sicians are finding the results worth while.
For catalogue giving complete formula" of intravenous
specialties, reprints of interesting articles, and price list
address: Intravenous Products Co., of America, Inc.,
121 Madison Avenue, New York.
Nature's Own Method
The best antiseptic for preserving the integrity
of any mucous membrane is its own normal secre-
tion. And a particularly good corrective of mucous
membrane irritation, inflammation, congestion, hyper-
(Helpful Points continued one leaf ever.)
To ALLEVIATE PAIN, to PROMOTE DIURESIS
and to PROTECT the membrane of the urethra, especi»U»
THE POSTERIOR PORTION— the* are the important
object! of the treatment of acute cases of Gonorrhea,
The entire urinary tract should be influenced by means
of proper internal medication. Local injections alone will
not be sufficient.
This is the rationale' of GONOSAN.
RIEDEL & CO., Inc.
104-114 South Fourth St. Brookhra, N. Y.
IABETIC FLOUR
Starch-free. Produces Bread,
Muffins. Pastry that makes the
distressing features
TEs
Grow
Lessand
Listen prepared casein Diabetic Flour — self rising. A month's supply of 30 boxes $4.65
LISTER BROS. Inc., 405 Lexington Ayenne, New York City
You can buy with Confidence — See "Service Guarantee to Rraders"
The American Physician
History of Denial Anaesthetics, No. 2
1846— LETHEON
DENTISTRY w*. agony before 1846.
On September 30th of that year
Willi.™ T. G. Morton, D.D.S., ad-
ministered what be termed "Letheon" to
a patient and extracted a tooth painleuly.
"Letheon" wii nothing but sulphuric
ether disguised with aromatic oila. It was
crude but of tremendous importance, for
it revolutionized dental practice.
Dentistry owe* much to this long-for-
gotten anaesthetic
Painlew dentistry is the dentistry of to-
day, and of the future-. No longer do
patients need to suffer. Dentists are
servos for this New £
Nerve Blocking,
easy to master tnia method with the aid of
Dr. Wait* * course of instruction* with 30
photograph* — FREE with Dr. Waite 's com-
plete $ I 2.00 Nerve Blocking Outfit.
Antiseptic Local
Anaesthetic
■nth cocaine 1% or with procaine I'fe
(Procaine t* the word adopted by the U. S.
Government tor the word Novocain)
IN BOTTLES IN AMPULES
Is*. Sea. lW«;2V*«(iaui be*)
R*e*> ferns* Ace (10 in bo.)
■-
liple box of Ampule*
FREE.
Pleaae state
wha
-— •-»
TOW u.iug
Specialties for
Tonsillitis
Benzomint
INTERNAL REMEDY
Compound of Sodium
Benzoate with Alka-
loids of Colisaya
A TIME-TESTED, highly
therapeutic formula which
has proved a veritable
wonder worker in many thou-
sand* of case* of Tonsillitis.
Benzomint ha* pronounced anti-
septic and antipyretic properties.
It soothes instantly the intense
pain from swollen, inflamed
glands, and quickly counteracts
both local and systemic infection.
Glycodin
(GARGLE)
AN efficacious astringent
and antiseptic gargle of
great value in the treat-
ment of Tonsillitis.
1 HROAT SPECIALTIES
LABORATORIES
(MILBURN PHARMACAL CO., INC)
BALDWIN. L. 1. NEW YORK
HcKmsob * Robblni
WhoUula Distributer*
N*w York Citr
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
[fhib , Uir. its
Amenorrhoea
Dysmenorrhoea
and other disturbances of the
menstrual function call for the
tme active principle of Parsley:
APIOLINE
(Chapoteaut)
It Secures Results
by acting directly upon the uterine
nerve endings and producing ovarian
hyperemia, but without disturbing
gastric or renal functions.
Avoid impure or unreliable aubatitute*.
Prescribe original Dials of 24 capsules.
Laboratory of
Dr. Ph. Chapetie, New York-Paris
Phynciimt lamplc anJ literature on request to
E. Fougera AY Co., Inc., American Agent.
» Beakman Straet, New York
Canada! l.yman* Limited, Montnal
secretion or atony is Alkalol. Because Alkalol is
physiologically constituted, not only to feed ex-
hausted or depleted cells with needed salts, but
also to restore circulatory and tissue tone, normal-
ize secretory action, Alkalol is soothing and heal-
ing. As a nasal douche or spray, as a gargle and
mouth wash, Alkalol is an efficient prophylactic
agent. In the eye, ear, bladder, urethra, vagina,
on the skin, or given internally, Alkalol is prompt
to bring about the success of Nature's efforts to
prevent or overcome disorder or disturbance.
Sample and literature will be sent gladly to
American Physician readers on request Address:
The Alkalol Company, Taunton, Mass.
MORPHINE
uhoaHtcWatrToadl. Nop™.,..
aaawaaod be toa who daw*. Endow fUmp tot ._ _
DR. QUAYLE'S SANITARIUM
MADISON. OHIO BOX S
New and Effective Violet Ray Tube
After testing out his new Violet Ray Tube for five
years in daily use, giving over one thousand four
hundred treatments without a failure, Dr. Chewning
has been persuaded by his colleagues to make this ■
available for the profession.
Physicians who have seen the new Violet Ray Tube
in use are enthusiastic about it — so much so that
Dr. Chewning has gradually taken up the task of
supplying physicians with it. With many satisfied
owners, the Doctor states he has yet to receive any
"kick."
See the advertisement on page .. The price is
only $10 and can be attached to any socket or holder
that has a cone-shaped reflector, such as an ordinary-
reading lamp with a flexible arm, so no expensive
equipment is needed. Address: The New Violet Tube
Co.. Dr. W. J. Chewning, Fredericksburg, Va.
Woodlawn
Maternity Home
K itiictly private and ethical Hook Retreat
OWBGO, Tloi
DR. GRIBBLE'S SANITARIUM
Formerly at Lebanon, Tenn., for
DRUG, ALCOHOL and TOBACCO ADDICTIONS
EetabliBhed IS year..
A quiet, home-like Institution. Only refined caw* accepted. Over 5000 cam
rested. For reference* addreae
DR. POWER CRIBBLE, 1519 McGavock Street, Naahrille, Tama.
You can buy with Confidence — See "Service Guarantee to Readers" on page 392
The American Physician.1 An HoTlCSt Moffat PlaC€ 389
Ask the User of ALKALOL
why it produces results superior to those obtainable from the
ordinary so-called antiseptic solution and several reasons why
will appear.
BECAUSE:
AJJCAJLOL tones up instead of relaxing tissue, due to its correct
alkalinity and proper salinity.
AJJCAJjOL does not produce hypersecretion or catarrh of mucous
membranes, due to the fact that it is hypotonic.
ALKALOL overcomes congestion and quickly restores mucous mem-
branes to normal tone, due to the fact that it feeds the
cells with needed salts.
ALKALOL i* soothing and healing, on account of its power to over-
come inflammation.
ALKALOL i* ideal and efficient in the eye, ear, nose, throat, urethra,
vagina, rectum, bladder, on the skin or internally.
Send for sample and literature — and become convinced.
The Alkalol Company Taunton, Mass.
RHINOL
in All Affections of the Nose and Throat
RHINOL CO.. INC., March 15th, 1922.
1416 Broadway,
New York City. Attention Dr. A. H. Werner, Prea.
My dear Doctor:
I believe I have an interesting- report on the administration of Rhinol in a case of acute sinusitis, and
since I myself was the patient, I had the best opportunity of studying its effects in the most direct way.
During a heavy snowstorm on January 17, 1922, I contracted a severe "cold," and as doctors will do.
neglected it and attended to my duties for a week more, when an inflammation of both frontal sinuses and
both antrums forced me to give up. From my own experience I know now that this is one of the most
painful diseases in existence. A friend Rhinologist was consulted, and of course, he did what he could,
but I continued to suffer tortures of hell.
About a week later, through Dr. Graf, of New York, I heard of Rhinol, and ordered an outfit.
Well, Doctor, if Rhinol did nothing else but relieve a condition like mine, it would be one of the most
valuable additions to Materia Medica. But I am certain it cured me. Gradually the heavy pus diminished,
and I at last ceased to suffer.
About a week after a radiograph taken by Dr. Teperson showed the left antrum still involved. Friend
Rhinologist advised operation and rinsing, but I was determined to keep on with Rhinol, since its application
had established free drainage and I was improving every day. About two weeks after there was no more
pus, and subjectively I felt perfectly well, and at the date of this writing continue to feel well. Another
radiograph will be taken soon, and I am positive it will reveal normal conditions.
I now employ Rhinol in ray office and carry it with me on my daily visits, using it in every case of
Measles, Scarlet Fever, Tonsillitis, Rhinitis — and it has always given immediate relief, shortened the duration
of illness, and probably prevented in several cases the usual severe complications.
I am grateful to Dr. Graf for having called my attention to Rhinol and congratulate you for having a
remedy which ranks most high among the pharmaceutical preparations at our command.
I cannot help feeling that if the medical profession would show something of the spirit attributed by
Caesar to the inhabitants of Gaul — no varum re rum cupidi — it would be better for them, as well as for their
patients. Very sincerely,
Signed, G. Theodoi Fischsu, M.D.,
383 Clinton Street,
Brooklyn, N. Y.
Price Complete, $3.00 — Refilled Packages, $2.50
RHINOL COMPANY, Inc. 1416 Broadway, New York
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
[I' hi la., M.», IJB
USOUNE was the Aral mineral all put
h tha marks t Id this country. It Las
■war been axtanalvely advertised, and
Exaggerated claims have n-™* i— " M*j.
far it, therefore phyiicli
iteedily and Increasingly ■--.
lor internal uaa year by year.
r add itu purl tie ■. r
singly prescribing I
it USOL1NE a
" Hu.mle
»rly adjusted gray
taming no .ulphu
bloom sr -none
tea ellnicti
OIL PRODUCTS CO., Inc.
to Unlaa Square, New York, N. V
THE STORM BINDER
THE STORM BINDER la adaptable to an?
case where an abdominal supporter is needed for
"the STORM BINDER IS FOR GENERAL
SUPPORT IN Visceroptosis, Obesity, etc, etc
THE STORM BINDER IS FOR SPECIAL
SUPPOR- ■ ■ ■ - -
OPERATIVI
middle and li
'OR']' in hernia. Boating kidney, descent o
a and discomforts of
atwaoajar, ^ mortr»ted folder.
Ordera IBed In Philadelphia only — in 24 aonra
■CATHERINE L. STORM, ftLD.
These Advertising Pants are am
Honest Market -Place
Our Advertising Standards
Advertisements must give honest service to our ****•
ers and their patients ■- -is the basic principle for tbeM
standards and for the conduct of The A-jbjcu
Physician's advertising pages.
Our attitude in applying these standards is not oat
of narrow technicality but of practical service—
Advertisements must give honest service l» our fett-
ers and their patients.
Advertisements of the following classes are Ml
acceptable for the pages of The American Physioak:
Fraudulent pharmaceuticals; those making dishonest
claims.
Pharmaceuticals charging excessive price; price not
warranted by content and by trade conditions.
Pharmaceuticals and other mixtures containing nar-
cotics or other habit- inducing drugs in quantities suffi-
cient to promote their repetition on prescription -
(chloral-bearing proprietaries, etc.).
Potent pharmaceuticals which justly merit profes-
sional disapproval because of their lay advertising or
manifestly unethical exploitation.
Financial advertisements that claim returns not com-
patible with conservative investment Only <
e advertised
Further
Advertising copy is subject to revision by the
editorial staff.
The American Physician agrees heartily with the
principles of the Council on Pharmacy and Chemistry
of the American Medical Association and we exclude
from our advertising pages such pharmaceutical prod-
ucts as they have definitely shown to be unworthy of
professional confidence and the manufacturers of which
have not removed the cause of objection; but we do
not accept such findings as are based on acadernjc data
without due recognition of general clinical experience.
Concerning formulas, The American Physician is
urging pharmaceutical manufacturers to give full thera-
peutic data regarding formula;, stating quantitatively
active medicinal content, in order that physicians may
intelligently prescribe. We do not accept advertising
of secret phannacueticals.
But We do not Decline - - - .
Advertising of original drugs, compounds or preparations nu-
tated in current edition! of the U. S. Pharrrjicopona or NatknsI
Formulary (except habit-inducing preparations) ; new p™tur±i
that Ken to be honest and valuable, but which bare not btea
reported upon by the Council on Pharmacy and Chemistry, "
similar products whose manufacturer* have not yet submitted *■
■aim to them for approval ar rejection. We use onr own jnaT
ment in these cases, hut will always consider proper easrgai
against this class of remedies.
Preparations containing n limited number of drugs jn ass*
{Ceatinn id ant leaf mr\
n buy with Confidence— See "Service Guarantee to Readers" on page 392
The American Physician]
An Honest Market Place
391
Trade Mark
Re* U. 3. Pat. Of.
PYRAMIDON
After almost thirty years of service this drug stands out pre-eminent at an
antipyretic, analgetic, antmeuralgic and sedative.
Pyramidon if supplied in powder form in 1 ox., % lb. and I lb. cartons and
in tablets of 5 grains in aluminum tubes of 10, and in botdes of 100 tablets.
Prices to physicians are $1 .20 per ounce, 40c per tube of 10 tablets, and
$3.00 per bottle of 100 tablets.
ORTHOFORM
Utilizable as a local anesthetic for the relief of pain from wounds, burns,
ulcers, excoriations and all exposed nerve-endings, Orthoform is used as a
powder in insufflation, as an emulsion, or in tablet form. It is given in-
ternally for the relief of pain in gastric ulcer and gastralgia.
Orthoform is dispensed in I ox. bottles which sell to the physician at $4.50
and in 5 gram vials at 90c per vial.
ORTHO TROCHES
Are employed for the alleviation of pain and the mollification of irritation
following all operative procedures on the throat. They dissolve slowly,
thus producing a prolonged anesthetic elect. They are dispensed in bottles
of 100 tablets of one-quarter grain each or of one grain each at $1.00 and
$1.75 per bottle, respectively.
Literature can be obtained from
HAMETZ lABOMIXmiESM
One-Twenty TuK) Hudson Strnt,Nru)York.
■ wiiiimwinMiHniw mmmmmmmmmmmmmmmmmmmmmm
mmimmmmrmmmvmmm^'irmmrmmm
Campfo-Pfoninue
THREE DRESSINGS DE LUXE!
CAMPHO-PHENIQUE LIQUID.
A powerful AntUeptic and Germicide need *ucce**fulfy by Burgeon* in minor
and motor operations. Exert* a heating influence and induce* rapid granulation.
CAMPHO-PHENIQUE POWDER.
Posse* all the AntUeptic* and Germicidal prorertie* of the Liquid. It i* a dry
treatment for *ore*9 wound*, cut* and abra*ion* of the *hin.
CAMPHO-PHENIQUE OINTMENT.
Indicated in variou* disease* of the Mm and acalp.
Sample* and Literature on roemest.
If year DrmgfUt ie not •applied
Ordmr Direct.
PRICES
Liawid, to*. SOct 4 am. - $1.20
Powder 0 Sifter Top Cane 30c and . 75
Ointment, 4on. Cane 1.20
CAMPHO-PHENIQUE COMPANY.
St. Louis, Mo.
■B
Mentioning The American Physician Insures Prompt, Careful Service
An Honest Market Place
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Poinh
\ a inscription bill tnchiid.
tniti far you.
NOTE — If you ban Juat recently ™nitud and a hill u
idoeed ban. please Ignon it With a subscription bit ai
■rge aa ours It talwa a few day* for a nibscriptlon to p>u
h rough, be finally credited and the stencil transferred from
'You Have the Knack of Publishing
Just What the Every-day Doctor Needs
The journal has been of material help lo me in prac-
tice." And that's what another of our good friends, a
New York physician, said of us this month — at the same
lime, of course, tending in a two-year renewal.
But you, Brother— we don't seem to hear from you.
What's the trouble. Brother? Here's the envelope,
addressed and your name filled in, you don't have to
do anything but enclose $3.00 [or two years, and send
it along.
While we aim to be modest, that is, as modest as is
practical in the kind of world we live in — yet we hope
we have the knack of publishing just what the every-
II Sal Hepatica
THE
STANDARD SALINE
LAXATIVE
Briitol-Myer» Co.
NEW YORK
day doctor needs— that's our goal.
But it takes something besides knack and hard work
— it takes some cash as well, and we need your sub-
scription now
Now I know this little matter has just slipped your
mind in the rush of a busy practice — but Brother, if you
do il now — it won't slip again. We're counting on hear-
ing from you this time — pleas.;! And I thank you in
advance for your courteous and prompt a
Yours for greater succ
SHIFFITH'S GBMPOUND 1XTUHE
of Guaiac, Stiffing!*, ate.
A Powerful Alterative — Campoaed of Gnaiae.
Stillingia, Prickly Ash, Turkey Corn, ColchtcoaL
Black Cohoih, St Salicylate! of the Aft*
Ilea, Iodide of Potaua and other well known rea»
dies, combined in tuch a manner that it it tolerated
by all patient, suffering from Rheumatism. Goat
Lumbago. Neuralgia, Sciatica, etc
Proscribe It for "That Stubborn Case"
To Physicians only we will upon request, tend a
regular eight ounce bottle ($1.21 sue), for trial, apaa
receipt of 2S cents for expreu charges
Griffith'j Rheumatic Remedy Conpai*
New-burgh, New York
a
Pond's
Extract
Por cleansing the mouth and throat and Ireepi
oral cavity wholeiome and aseptic, there ii n
more pleasant and effective than a solution of
Extract— two tablespoon full to a half flail of
warm water uaed ai a month wash and gargle
three or four hours. If the mouth or tongue is
pain and irritation will «how prompt improT
The nie of this mouth wsih assure! a clean
H
every
nouth
Oral
POND'S EXTRACT CO., KiW Yom
You can buy with Confidence — See "Service Guarantee to Readers" on page 392
The American Phj-iicianJ
An Honest Market Place
Acute Infections of the Note and Throat
Every Winter and Spring bring their quota of nasopharyngeal infec-
tions. The great dangers of these extending to the various sinuses and ears,
or of being the fore-runner of graver respiratory diseases, particularly
pneumonia, make painstaking and effective treatment of even me simplest
cold both urgent and necessary.
The ease with which Dimogwn, when used as suggested, will quickly
control the great majority of colds, and not only avoid their obvious
dangers, but give the patient gratifying relief from local congestion, with
its often severe discomfort and distress,
emphasize the desirability of employing
it at the earliest evidence of an infection.
Owing its efficiency in overcoming in-
fections of the upper air passages to the
liberation of pure active oxygen — Nature's
own antiseptic — it is no wonder Dioxogen
fills the place it does in the treatment and
prophylaxis of nose and throat colds.
The Oakland Chemical Co.
59 Foartk At*., New York
"Two to tour Itaspoonfuls ofDfoxoarn
to a half gloat of warm water makes
an Moat gargle or nasal spray.-'
THE DIOXOGEN TREATMENT
OF NOSR AND THKOAT
COLD*
At tk* aurllnt paulbla Ma-
nual IS. mh and Ifarut •heald
b. iw<bb*d ihtrMthlr th*
l.ntli with toil on pltdf'ti aat-
araUd wilh Dinim.n, dllnOd
«ln!"wic'll «nr* Winl a**d
ta rnch back o( th. lanclal pil-
lar*. If th* candltfan In J it. U.
a HTtn inf«tlon. thht twaa-
Mn* bT th* a^M attendant
.ho. I J b. don* I. It. a day. In
addition to 1U*. th* pati.nt
antnM mpnj lb* b*h and throat
.T.rj hour or two wilh Diazanm
In a rinarih .( two lo Mr
) half (lax of
. utai! aalt aolatiwi. Th*
rapid tenlro] *f th* infactlan
atMna .r.l.f.l mitt and th*
•a*ctaal prevention of caatpUca-
tlaa* and aaaajalaa.
Mentioning The American Physician Insures Prompt, Careful Service
The American Physjcian
Here's where genuine Atophan is
manufactured by a special process
completely precluding the possibility
of unpleasant empyreumatic admix-
tures
This means a still further im-
proved Atophan for your cases
of Rheumatism, Gout, Neural-
gia, Neuritis, Sciatica, Lumbago
and "Retention" Headaches.
Amfte trial quantity and literature
Schering & Glatz, Inc.
160-152 Maiden Lane New York
AN IDEAL ARSENICAL
SODIUM DIARSENOL
SODIUM ARSPHENAMINE
Sodium Diarsenol marks a distinct advance in syphilology. It dissolves
very quickly in water, giving a solution ready for immediate injection. No
addition of sodium hydroxide is necessary. It has the therapeutic advantage
of arsphenamine with the solubility and convenience of neoarsphenamine,
and gives clinical results equal to or better than either of the two latter com-
pounds. Neutralization with alkali being obviated, there is no undue hand'
ling and consequent decomposition of the highly reactive solution.
SODIUM DIARSENOL has been accepted by the Council on Pharmacy and
Chemistry of the American Medical Association for inclusion in "New and Non-
official Remedies."
DIARSENOL COMPANY, Inc.
BUFFALO BOSTON ATLANTA
You can buy with Confidence— See "Service Guarantee to Reader?' i
tbt American Physician]
An Honest Market Place
399
Sherman's Polyvalent Vaccines
VACCINE therapy is based on two well-known factors: (a) That anti-
bodies develop, primarily, in the infected tissues during* the course of an
infection and when killed organisms are injected into healthy tissues
antibodies are also formed by the tissues into which the killed organisms
are iniected thus exploiting inactive healthy tissues and forcing them to become
actively engaged in antibody formation to aid the infected tissues in overcoming
the infection, and, (b) That killed organisms when injected into healthy tissues
are more dependable and safer agents towards stimulating tissue cells for
antibody formation than the live organisms responsible for infective processes.
Sherman's Polyvalent Vaccines are dependable antigens for destroying
or digesting the disease germs in
Acne Gonorrheal arthritis
Arthritis Hay Fever.
Asthma Mastoiditis
Bronchitis Nephritis
Erysipelas Neuritis
Gastritis Otitis media
Gonorrhea
Immunity to these bacterial diseases is aroused all along the line only by
numerous different strains of selected vigorous type-true virulent organisms
such as Sherman's Polyvalent Stock Vaccines contain.
Sherman's Vaccines are beyond the experimental stage.
Descriptiv e d a ta on r e quest to Ph y sicians
Bacteriological Laboratories of
G. H. SHERMAN, M. D.
Detroit, Michigan
Psoriasis
Rheuihatic fever
Scarlet-fever
Tonsillitis
Tuberculosis
Typhoid fever
Whooping-cough
The combination of tonics and stimulants ex-
plains the clinical results obtained in the
treatment of nervous ^disorders by the use of
FELLOWS' COMPOUND SYRUP
OF HYPOPHOSPHITES
44 A true stabilizer of shaken nerved9
It contains the ••mineral foods", Sodium, Potassium, Calcium, Manganese,
Iron and Phosphorous, and the stimulating agents, Quinine and Strychnine.
Samples and Literature sent upon request.
FELLOWS MEDICAL MANUFACTURING CO., Inc.
26 Christopher Street, New York, N. Y.
Vol. 27, No. 6, Published monthly — The Taylors; C. C. Tavlor, Publisher; Mrs. J. J. Taylor, Ed. Mgr. Entered as
second-dass matter Feb. 13, 1806, at the post office at Philadelphia, Pa., under Act of March 3, 1879. The American
Physician, "Most Widely Circulated Medical Monthly," continuing the quarter century of distinctive service of
COPYRIGHT 1922, by The Taylors. Publishers, 420 Walnut St., Philadelphia, U. S. A. All rights reserved.
MEDiCAL COUNCIL
The American Physician
Pertussis
Serobacterins
Whooping-Cough Prevention and Treatment
rotini on the remit*
With PBBTOgSIB
and Bloom lUte— "Coruparta
the 28 racdne-tneted mm
with the IB tnediceJij-Ireated.
the nipertoritj of the former
wmtbtt marked— to such an
extent the! even the nr~-
commented on the dUTen
«er"nhilfn1 Tl*h " '" u""—r-
Inc-Oonch.
PtmTCBBIB 8BBOBAOTBK1M
Miihd produce* » decne of
passive tinmnnit » immediate! j
Bordrt - Gwigoa BacHfut
Typho-
Serobacterins
Typhoid Fever Prevention
"The value of Tjphoid
Vaccine as ■ prophylactic la
second only to that
pox Vaccine. Aocnmnlated
evidence shown oonclosivelj
its high protective power."
I Weeklv Bulletin, Xew
York CUv Health DepU,
June It. losi.
. FwmMwta to irriWK vtakt and Hroo-Untta.
H. K. MULFORD COMPANY. Philadelphia, V. 8. A.
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LOESER'S INTRAVENOUS SOLUTIONS
EVERY
PHYSICIAN
SHOULD
READ
THE JOURNAL
OF
INTRAVENOUS THERAPY
A sixty-four page Journal, containing original article*,
reprint* and abtracts relative to Intravenous Medica-
tion from foreign and domestic medical journals.
The most comprehensive compilation on the subject,
laboratory and clinical reports.
Copy mailed on request.
New York Intravenous Laboratory
100 WEST 21ST STREET
NEW YORK, N. Y.
Utmtjeamg Tht Amtriem Phytitia* Iiuirtt Promt*, Cartful Srrvict
The American Physician
= AUTHORITATIVE EVIDENCED
Herewith it a photograph of Page
95. Vol. it, "Diseases of Women," as
edited by H. Marion-Sims, U D.and
in Dr Simj' own words, ii recorded
the high esteem in which he held
Hayjtn't Viburnum Compound and
the "great service" rendered in treating
DYSMENORRHEA
HOYDEN'S VIBURNUM COMPOUND
it as effectual therapeutically to-day
at in the day of Sims, and will give
you the same "great service" in treat-
ing your dysmenorrhea cues, as was
rendered to Dr Sims.
Prescribe, as recommended-by Sims,
in teaspoonful doses, "administered in
HEW VORI PHARMACEUTICAL CO.
Bedford Springs, Bedford, Mats
esr
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403
A Cough Sedative
and Antispasmodic
of Proven Value
When every other remedy fails,
try DIATUSSIN and benefit
through diminished individual
attention in all cases of per-
sistent cough ; particularly
whooping cough during pa-
roxysmal stage, when DIA-
TUSSIN administered regu-
larly will reduce expiratory
blasts and quickly terminate
the disease.
Literature and Samples
on request
Ernst Bischoff Co., Inc., 85 West Broadway, New York
Mentioning The American Physician Insures Prompt, Careful Service
404
Contents
Copyright, 19**, by The Teylers. Att rights reserved.
Editorial.
Take Care of the Spine, Especially In Thete Dayt of
Traumatic So-Called "Adjustments" 415
What About the Prolonged Use of Arsenic In Large
Doses and the Modern Treatment of Syphilis? 417
The "Other Side" of Benzyl Benzoate 417
Original Articles
Preventive Gynecology — Conserve the Procreatlve Function
of Womanhood.
By H. S. Lott, M.D 419
There is music in brooks, sermons in rocks — and poetry
in gynecology. Still, in spite of the artistic form of
this paper, it is loaded with instruction, utility snd
common sense.
Gastric and Intestinal Motility.
By J. C. Boodel, M.IX 421
Motility, secretion, digestion, pain, ulceration, spasm
and obstruction in the alimentary canal are conditions
encountered by every physician in his daily vocation.
We thoroughly approve of this paper of Dr. Boodel, as
the brief, but clear, descriptions on the mentioned points
will be of undoubted value to every reader.
Proper Interpretation of Symptoms.
By Alfred Brown, M.D 424
Symptoms are extrinsic expressions of intrinsic con-
ditions and are precious when properly understood.
However, when they run wild like a mob in alarm and
disorder, their interpretation becomes difficult and their
significance problematical. It is then that the physician
steps in and distinguishes between the informatlTe and
valuable and the rambling and confusing. These points
are skillfully discussed and vividly illustrated in Dr.
Brown's helpful paper.
Familial Eplstaxls. _
By Herman I. Goldstein, M.D>. 426
Dr. Goldstein says the diagnosis is not difficult One
must avoid the mistake of diagnosing these case* as
hemophilia, hemorrhagic diathesis, purpura, scurry, or
pernicious anemia, or the "phthisical state with hem-
orrhages."
"The Feather Pillow"— Is It a Factor In the Spread of
Disease?
By 8. E. Gibbs, M.D 4S1
Another indictment against the feather pillow is the
fact that protein matter exists therein and some cases
of asthma, in persons sensitised to proteins, are kept
up by inhaling the dried protein matter from the
feathers.
Ancient Fracture About the Elbow Joint and a Case of
Tuberculosis of the Foot.
By A. Mackenzie Forbes, M.D 432
(Content*
406)
Chinosol
"A POWERFUL ANTISEPTIC, SOMEWHAT STRONGER IN
THIS RESPECT THAN MERCURIC CHLORIDE AND CONSID-
ERABLY STRONGER THAN PHENOL."
(COUNCIL ON PHARM. AND CHEM. A. ML A.)
AseptikonS"
/ VAGINAL
\SUPPOSITORIES,
producing complete antisepsis
But
Non-poisonous, Non-irritating and No injury tcr membranes
Indicated in cervicitis, leucorrhea,
specific and non-specific vulvovaginitis, in all cases
where complete vaginal antisepsis is desired.
PARMELE PHARMACAL CO., 47-49 WEST STREET. NEW YORK.
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A comparison of Fleischmann's
Yeast with the laboratory standard
as concerns vitamin content
"As efficient as our very active
laboratory ye aft," said the sci-
entist after the careful testa
The dotted lines show the
normal growth rate of albino
rats. The heavy lines show
the growth rate of the rats
when fed Fleischmann's Yeast
— just the everyday little yeast
cake that is bought over the
SOME valuable vitamin studies have
been recently made with Fleisch-
mann's Yeast. The albino rat was the
experimental animal used in a series of
tests carried on over a period of three
and a half months.
Altogether 99 rats, young and sleek,
of from 60 to 80 grams, were used. They
were given a standard diet from which
only the vitamin-B was lacking. After
a certain decline in weight due to lack
of vitamin-B, Fleischmann's Yeast was
added to their diet. The yeast was fed
moist but on a dry weight basis. The
rats always ate the yeast greedily. Their
subsequent growth rate indicated the
value of this yeast as a source of B-
vitamin.
The chart with its caption tells the
story.
Fleischmann's Yeast is a pure food
product, containing no drugs of any
kind. It is a proven rich source of
vitamin-B. Try it out on your own
cases where vitamin-B is indicated. It
may be eaten plain, suspended in water,
milk or fruit-juices, or spread on crack-
ers. The physician" will regulate the
amount of dosage which will probably
vary with the individual needs. From
one to three cakes a day has usually
been found satisfactory.
Fresh yeast has therapeutic value en-
tirely aside from its vitamin content.
For full data on this interesting study,
send for the recently published brochure
on the manufacture, chemistry, physi-
ology and therapy of yeast. This book
is distributed free to physiological chem-
ists, physicians and hospitals. Address
The Fleischmann Company, Dept.S-6,
701 Washington Street, New York City.
Mentioning The At
i Insures Prompt, Careful Service
The American Physician
The New Violet Ray Tube
la a new and important advance in the
heat and light therapy, and will add to
jour professional prestige and income. It
produce* a pure Violet Ray entirely free
from other ray*.
It it giving excellent remits in the
treatment of Pain, Goiter. Lumbago,
Sciatica, Neuritis, Ulcere, Tumors of the
Breait. Prostatic troubles, and in all Gland
and Skin troubles.
Over 1 400 treatment* given in the paat
5 years without a (ingle failure to effect
a cure. It ia a RAY or Light that can be
Died with absolute safety to both physician
and patient.
No expensive equipment is necessary, a*
it can be attached to any socket or holder
that ha* a cone-shaped reflector, auch as
an ordinary reading lamp with a flexible
The price is only $10. Descriptive lit-
erature on application. Truly, Doctor, in
this New Light you have a wonder worker
in the curing of diiaeias.
THE NEW VIOLET TUBE CO.
Fred'ksburg,Va. Dr.W. J. Chowning, Pre*.
(contents — wn^nw/™ pop 404
Medical Diathermy.
By Elnora Cuddeback Folkmar, M.D 48
Diathermy la heat. And heat la essential to life, to
health, to function. Nature cures no disease. lepiln
no Injuries, repulses no Invading enemy, without u
Increase In the production of heat. Then is ■ natoril
basis far (he therapeutic Dse of diathermy.
Observation; Faulty Shoes and the Troubls They Cauet-
Thlrd Paper at "Footlights on the Feat."
By Charles Croat. M.D. *»
Efficient Future of Medical Practice
The Absence of Treatment In Institutions! Work 411
Bleed Ing from the Rectum: Its SI on Idea nee and
Treatment 441
Human Actinomycosis 4*1
The Prevalence of Free Hydrochloric Acid In Casts of
Carcinoma of the Stomach 444
Quinine and Urea In the Treatment of Internal Hemsr.
Money Back Guarantee to Subscriber!
1st Ahmicah Parti ci
rosily ktlpful in I
HVil don*, to be hnsn
able profit.
It 1. tomfl.t.ty frtl
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e problems of everyday practice, u°
e opporinniiiii and inttrati ol "'
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if be will wi
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due (yea
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n is continued whea a
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copy current ittue (back issues $1.00 a eotj-
avsSable): *2.00 for One Year; *><» for Twt
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for Ten Yesrt. (only fl.00 s jetrh ^^^^ Cafe
t. Canada and Foreign, 59c additional each year.
rtu oil caavna-ironoar and matt alt fumdt SsysWr w-
Tk* Amtrica* Phytidam,
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407
SERIES U
Hay Fever Memoranda
Late Spring Type. Patients whose hay fever develops in the
latter part of May, during June or early July, should be tested
with the pollens of sweet vernal grass, June grass, orchard grass,
timothy and red top. The one giving the major reaction should
be selected for treatment to the group. The unrelated rose
pollinates simultaneously and is the primary or secondary cause
in an occasional case — hence, should be included in tests especially
where direct exposure exists. The same is true of dandelion,
daisy and in some sections alfalfa.
Late Sumner Type. Patients whose hay fever develops in mid-
August and continues until frost should be tested with pollens of
local importance — primacy being given to the long distance wind
pollinated plants, e. g., ragweed. However, where contact is
unavoidable, as on a farm, the short distance wind pollinated
plants, e. g., corn — and the insect pollinated plants, e. g., sun-
flower, which are also atmospheric— cannot safely be ignored.
ARLCO-POLLEN EXTRACTS
For Cutaneous Tests and Treatment cover early
and late spring; also summer and autumn.
Literature and List of Pollens on Request
THE ARLINGTON CHEMICAL CO., Yonker., N. Y.
iiiiiiuiiiiimuSmffnffrifTffumuiiiiuuiuMuiu
uiuuBUiuiiuimmrmmiirof
OR SPRING HAY FEVER
Use Proteogen No. 4
United States Public Health Service statistics show
that the season for spring hay fever ranges from April
1 5 to July 27, depending upon the section of the country.
The immunizing treatment with Proteogen No. 4
should be begun from four to six weeks before the
customary onset of the hay fever symptoms.
Proteogen No. 4 has given very gratifying results both
in the curative and prophylactic treatment of hay fever.
It is a safe, simple and rational treatment which is aimed
at the underlying cause of the disease.
Supplied in boxes of 12 ampoules.
Send for our booklet on the Proteogen treatment of Hay Fever.
Give your hay fever patients the benefit of Proteogen
treatment this year.
M FOUNDED 1828
ERRELLcombuiy
CDOWUl U & A.
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Silvol and NeoSilvol
Two silver germicides used in the treatment of
mucous membrane inflammations
In the Family of proteid silver preparations
Neo- Silvol makes a strong bid for distinction.
The scales themselves are white in color, and
solutions have a milky opalescent hue. This
naturally means that you can apply effective
silver medication to mucous membranes with-
out staining everything within reach with the
characteristic dark brown color of other stiver
salts. Chemically, it is a colloidal form of
silver iodide.
Silvol, the dark colored silver proteid that
has become a standby in the practice of many
physicians, is, on the other hand, a colloidal
form of metallic silver. This explains the
difference in color.
Therapeutically, Silvol and Neo- Silvol are
on a par. They are indicated in solutions of
2% to 30% in the local treatment of inflam-
mations of the accessible mucous membranes,
such as those of the eye, ear, nose, throat
urethra, vagina, bladder, and rectum.
Parke, Davis & Company
Ju« Off iha Prat
The 1922 dialogue,
A Scientific Reprint
QlaJtt >ent pJijrictanj
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409
ANNOUNCING
A n«w NON-NARCOTIC Drug
ache
which is both
Hypnotic^analgesk:
AUQNAL which is administered orally in tabkt'
farm, if a prompt, efficient sedative, hypnotic
and analgesic, capable of Controlling
pain and producing sleep in the
many conditions in which Morphine and other
narcotics have hitherto been the on/yrecoune
Supplies and Literature will be
furnished on request
ThcHOffKAIW-UROCHtCHtMICAlWoPKS
NewYork
Mentioning The American Physician Insures Prompt, Careful Service
The American Physician
Diarrhea
The importance ofcnourishment in intestinal dis-
turbances that are so common during the warm weather
is now recognized by physicians, and it is also appreciated
that the nutrition furnished must be somewhat different
than the milk modification usually supplied to the normal
infant.
Food elements that seem to be particularly well
adapted, mixtures that are suitable to meet the usual
conditions, and the general management of the diet,
are described in our pamphlet — "The Feeding of Infants
in Diarrhea" — a copy of which will be sent to any
physician who desires to become familiar with a rational
procedure in summer diarrhea.
You can buy with Confidence— See "Servi
An Honest Ma
ANESK
This new intranasal
ointment gives de- 1
cided relief in Rhinitis, '
Colds and Hay Fever ]
THE ABBOTT 1
DEFT. 49, 4739 RAVCNSWOC
SI E. 17th St. 327 Cmitral Bids. SOS
hWwYoHt Suttl* St
Mentioning The Amtrican Physician 1
The American Physician
SANTYL
Tht Ntutrol Salicylic
Ester of Samtatol
lor the INTERNAL TREATMENT of
i@M@rr^n
Dew: 1 eapnlei t«4 timet daftr
B. BILHUBEK, Iw„ 46 John St, N«w T«*h
KtjXeco or "I Calm'
KELENE(
Pore \ For Local and General
cffi, J ANESTHESIA
In automatically closing tuba. Convenient to cany. Easily applied. Uniform result*.
Widely used for many years. For general anesthesia, useful in minor surgery and dentistry.
FRIES BROS.
»2 RiUa Stmt, New York
Sola distributor* lor tb> U. 3. A. ua
MERCK ft CO.
SLLaula NEW YORK
KgctUR)!
The Babies Will Be Thankful For The Comfort
Of McK & R Compound Stearate of Zinc
■ary
THE heated ica.on it particularly hard on babie*. Acid diachai
per*pirntion tend to cause chafing*, eruption*, and irritative i
lion*. "Diaper ra*h" n more frequently met with than in colder
the akin being more *u*ceptible to the excoriating effect* of
discharges.
You can minimize all these trouble* for the tabic. Doctor,
recommend the liberal u*e of McK ft R Compound Stearate of Zil
After the bath. Compound Stearate of Zinc, applied a* a
rcome prickly heat, and akin dl*-
in condi<
/eather—
A liberal d
rally.
with McK 6. R Com,
ind Stear:
liable aid In pravantlng *
the Irritation following n<
d Stearate of Zinc a* a v.
mine, (unburn, la adult*
(gcKTg)
McKESSON & ROBBINS
Now York City
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'hit rrry palatable
ivtritnt it put up
GEO. C. COOK
THE widespread use of Virol by the British Public
Health authorities, in their campaign against infant
mortality, forms a striking testimony to the influence of
this preparation on growth and development.
Virol is a well-balanced food, rich alike in all classes of
repairing material. It has been shown by the investiga-
tions of the Bio-Chemical Laboratory of the University
of Cambridge that vitamines are present in their active
state in Virol as manufactured and sold to the public.
Virol is of special value in Rickets, Marasmus, Atuemia,
and all wasting conditions, and in the diet of expectant
and nursing mothers.
Medical men are invited to try Virol in any obstinate
case of malnutrition, for which purpose free supplies will
be sent on application.
Sole Agents for United States
& CO., Inc., 59 Bank
Street, New York
Mentioning The American Physician Insures Prompt, Careful Service
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MENSTRUAL DISORDERS
A large proportion of the patients treated in a physician's prac-
tice are women suffering with some derangement of menstrual or
generative function. These disorders are due in large measure to
diminished or disturbed function of the glands of internal secre-
tion. Owing to the reciprocal relationship that exists between
these glands, a functional disorder of them is, in its last analysis,
always a pluriglandular disturbance — never a monoglandular
malady. It is now recognized that pluriglandular combinations
give better results than sin-
gle gland products. Clini-
cal results emphasize this
and physicians who use
Hormotone
are seldom disappointed.
In those cases that have a
tendency to a high blood
pressure
Hormotone Without
Post-Pituitary
is recommended. Both
products have the approval
of many leading physi-
cians.
Dose of either preparation:
One or two tablets three times
daily before meals.
Literature on request.
G.W. CARNRICK CO.
419 Canal Street New York, U. S. A.
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Take Care of the Spine
Especially in These Days of Traumatic So-called "Adjustments"
THE PHYSICIAN owes the same duty to the
spines of his patients as he does to their other
structures. There is no occasion for the spinal spe-
cialist, and k is incumbent upon both physician and
surgeon, more especially the orthopedist, to diagnose
lesions of the spinal structures — the osseous, ten-
dinous, muscular, vascular and nervous tissues — and
to give early and scientific treatment Especially is
it the duty of all of us to know spinal prophylaxis
and, when lesions of any kind occur, to guard the
patient against trauma of any kind, more especially
the commercially-prompted assaults against the in-
tegrity of these structures parading under the specious
name of "adjustments."
DepUdim* m At Spam •/ the ChUd
Faulty attitudes in children lead to round shoulders
And functional types of scoliosis, which if neglected
lead to structural changes which are incurable, as
was well set forth by Jacob Grossman in The Medical
Record, January 21, 1922. Scoliosis, kyphosis and
Jordosis are not merely affections of the osseous struc-
tures, for they depend quite as much on a lack of
harmonious co-operation of the several muscles wnich
maintain the spine in normal position. Kyphosis
may involve the whole spine, it may be due to rickets.
"The common type known as round shoulders shows
most deviation in the center of the dorsal portion of
the spine, but even the pelvic bones may be "off
.center" and the structures of the shoulder and chest
be involved. In fact kyphosis causes a disturbance
•of the normal anatomical relationships from the feet
upwards, as all surgeons know. The causes have
more to do with the muscles than with the osseous
•structures, as well as bad posture, etc. The treatment
has little to do with the osseous structures, per se,
•except that in neglected or severe cases braces or
•special corsets may become necessary.
Lordosis is usually of the secondary type, especially
resulting from hip disease and spondylitis. Scoliosis
is predisposed to by general debility, rickets, anemia,
overfatigue and faulty postures. It is weakness of
the muscles, not the bones, that is the factor here.
The deformity extends to the thorax, sometimes lead-
ing to compression of the lung on one side and dis-
placement of the heart and other organs. The treat-
ment of these conditions may cover a wide range in
case-management, hygiene, and sometimes medication.
Never does it include forcible manipulation of the
spine, which does nothing but harm.
After all, most deviations of the spine originate in
infancy or childhood, except those cases where ne-
crosis or accidental trauma occur or where tubercular
lesions develop. How foolish it is, then, to charge to
alleged subluxations or impinged nerves these devia-
tions so often neglected in childhood and incapable of
cure in later life! These conditions have long been
understood. Why are they so neglected f
Spbml DutoflttMS cm! SmUmxmtiiu
All anatomists understand the vertebral articula-
tions and how powerfully the vertebral bodies are
reinforced by thick broad anterior and posterior com-
mon ligaments, how laminae and processes are
anchored by the yellow ligaments and the inter- and
supraspinous ligaments; so that it is impossible to
dislocate the spine of an animal of any size by
manual manipulation* It cannot be done except by
violence or leverage. Nor is it possible to reduce a
spinal dislocation by mere unaided manual manipula-
tion unless the parts have been so fractured or torn
that normal anchorage is destroyed.
And all experienced surgeons know that pure dis-
locations of the spine can hardly occur except in the
cervical region. Even in this latter region disloca-
tions are almost invariably accompanied with frac-
ture, and it may almost be said that they never occur
without fracture in other portions of the spine proper.
Subluxations of the spine are very rare; they are
usually the result of actual disease of the bone and
come on gradually with the advancing pathology.
So rarely are these fracture-dislocation lesions of
416
Take Care of the Spine
[The American Physician
the spine unaccompanied with paralysis that Harts-
horn reported such a case occurring in the cervical
region as a rarity (Boston Medical and Surgical
Journal, February 2, 1922).
When these fracture-dislocation lesions occur from
direct or indirect violence there is pain, marked
shocks and paralysis. If the lesion is above the fourth
cervical the patient may die at once from respiratory
paralysis, and when lower down the prognosis is
airways grave, depending on the amount of damage
to the cord.
It has fallen to the writer's lot to subject to X-ray
photography a large number of patients coming from
the "adjustment" artists with diagnoses of dislocations
or subluxations of the spine, and in not a single case
was there revealed any spinal deviation whatever
other than those produced by scoliosis, kyphosis or
lordosis. In one case an impacted fracture was
shown which had never been diagnosed. The man
was a cripple who, years before when intoxicated,
had fallen off a bridge.
Impinged Nerve t
Thirty-one pairs of nerves originating in the spinal
cord leave it through the intervertebral foramin®,
and each has an anterior motor root and a posterior
sensory root, and the latter, provided by a spinal
ganglion, receives a branch from the sympathetic;
and it, in turn, is divided into two branches. The
posterior branches are distributed to the muscles and
skin of the cervico-dorsal region, while the more im-
portant anterior branches are associated with the
homologues of the pairs situated above and below and
form important plexuses (cervical, brachial, lumbar
and sacral ) . Look up any text on the diagnosis of af-
fections of the spinal cord and the spinal nerves, and
you will get the distribution of these nerves and the
motor and sensory affections produced by lesions
therein, and the sensory affections form four great
systems (proprioceptors, protopathic exteroceptors,
epicritic exteroceptors and enteroceptors), only the
latter involving the internal organs. Go into this
matter minutely in standard text-books and the
Handy Andy modern plates and diagrams of the
spine artists will appear as scientific as the erstwhile
claims of the phrenologists compared with the modern
development of localization of brain function.
Wilson Gill Bailey (The Medical Times, February,
1922) pointedly called attention to certain facts which
may be summarized as follows: The spinal cord is
about )half an inch in diameter and the sixty-two
nerves coming from it, if all gathered together and
compressed into one, could not be any larger in
diameter, and they are very small indeed compared
with the diameters of the foramina? through which
they have their exits. Yet the Handy Andy charts
show these nerves so large by comparison with the
facts, and in comparison with the cord, that it would
require a cord fifteen inches wide, in a man 125 feet
tall, to supply such large nerves as the diagrams
show. Of course, this is simply playing up the idea,
and Dr. Bailey is justified in making his strictures.
Furthermore, Dr. Bailey says, these nerves are on
the inside of the ribs and cannot be reached by
manipulation, and he pokes fun at the theory that
nerves carry "nerve energy" or nutrition to internal
organs.
Tke Clmmu •/ the CM**
Practically all physicians are familiar with the
claims of the cults and their followers, but some
physicians are not sufficiently familiar with the sci-
entific and clinical considerations merely touched upon
in this editorial. It is not the present purpose to
discuss the matter elaborately; it is merely aimed to
indicate to the reader the lines of reading he may
follow in order to have, not only a scientific reply to
cult claims, but, as well, so to perfect himself in the
diagnosis, prevention and treatment of spinal lesions
as to meet the competition of ignorant men with
real service to the people at large and his patients
in particular.
After all, it must be conceded that certain patients
actually are benefited by the manipulations of the
various types of mechano-therapists. Ultimately
these men will drop some of their foolish theories and
their all-inclusiveness, taking their proper place as
rubbers and manipulators in the way the writers on
massage and Swedish movements elaborated many
years ago, but which have been neglected by the
medical profession.
The serious matter, from the standpoint of the
public, is that these measures have been neglected,
and that is partly the fault of the medical profession.
Another important consideration is this: the people
do not understand spinal deviations and their causes
and hence run after the cultists who are playing up
the spine as their stock in trade. Herein is an op-
portunity for the medical profession to capitalize the
current propaganda by enlightening the people as to
the real facts and the far-reaching resources of medi-
cine and surgery to prevent and cure many of these
really distressing cases. Doctor, it will pay you to
study the subject in the rational and clinical phases
modern medical literature makes available. — T. S. B.
D. J. Davis says the influenza bacillus of Pfeiffer
is one of our common throat bacteria found in a high
percentage of persons at any time and often in large
numbers. It is found more frequently and more
numerous in respiratory infections. No convincing evi-
dence exists that it is the primary cause of pandemics
of influenza or of any other respiratory epidemics.
Biologically it is unique in its relation to blood and
requires not only the ordinary constituents of media hut
also the presence of a vitamine or vitamine-like body in
conjunction with the blood pigment for its existence.
PhiU., June, 1922]
Use of Arsenic mud Modern Treatment of Syphilis
417
WHAT ABOUT THE PROLONGED USE OF
Arsenic in Large Doses
and the
Modem Treatment of Syphilis
A TENDENCY to continue the use of arsphenamin
and other arsenieals over long periods is mani-
festing itself. Not necessarily in condemnation of
this practice, we venture to direct attention to a little
ancient history in medicine that may serve to throw
a little light on some reported clinical manifestations
of recent times.
Long ago in Lower Austria, especially in Styria
and the Hungarian-border hill country, the custom
of arsenic eating became common. In the smelting
of lead, copper and other ores white arsenic con-
denses in the long chimneys, and in Austria this
smelt-house smoke was called Hidri and was peddled
by certain people among the arsenic eaters, just as
bootlegging is conducted today. Many of these
arsenic eaters used this impure arsenic daily through-
out a long life and the practice was handed down
from father to son, whole families becoming arsenic
eaters.
The practice was alleged to give plumpness to the
figure, according to James F. Johnston, M.A., F.R.S.,
F.G.S., from whose book, published by the Appletons
in 1855, we take this data. Her vouches for the fact
that it did give a clean and soft skin, a fresh com-
plexion and plumpness to young women who aimed
to attract their lovers by their charms. Secondly, he
stated, arsenic gave "longness of wind" and improved
the breathing of both men and horses who continu-
ously used it, quite a desideratum in this mountain
country.
AtmmtE*mg
This impure Hidri dissolved very slowly and the
beginner in arsenic eating never took over one-half
grain two or three times a week, which was cautiously
increased, so that the confirmed eater took as much
as two grains and used more frequent doses, some-
times daily doses.
lake some of the drug addicts of today who care-
fully balance their doses to their cravings and never
go to dangerous extremes, these arsenic eaters ap-
peared to be hale and hearty, led active lives and
appeared in every way normal. But, alas, let their
supply of arsenic be cut off and a great feeling of
discomfort arose — indifference to surroundings,
anxiety, deranged digestion, cramps in the stomach
and bowels, loss of appetite, increased flow of saliva,
marked constipation and oppressed breathing — so that
the condition of the sufferer often became grave.
This whole symptom-complex was at once relieved by
the customary dose of arsenic.
That this train of symptoms was not all perverted
psychology was testified to by the fact that grooms
and horsemen in Vienna conditioned their animals,
making them plump and sleek and of long wind, by
feeding them arsenic Then, when purchased by some
one who was not aware of the arsenic feeding, the
animal promptly lost flesh and spirit and its strength
rapidly diminished, dying early if arsenic was not
continued in its ration or proper treatment given to
restore normal conditions, the treatment being prin-
cipally good feeding and prolonged rest.
Johnston attempted to explain the physiology of
the matter by contending that it is probable that
the continued use of arsenic in large doses diminishes
carbon dioxid output, and the fat of the food is not
burned up in supplying the CO, and is deposited in
the tissues. Be this as it may, arsenic eating was at
one time a serious menace to health and was more
or less sternly suppressed. It is believed that arsenic
was so used even in ancient times, credulous people
from time to time taking up its use only to abandon
it when its evils became manifest, to be followed in a
later age by the same experience among other peoples.
And now we have again reached a vogue for arsenic,
more scientifically used, of course; but what will it
do in the long runt
The((OtherSide"of
Benzyl Benzoate
THIS DRUG has been largely exploited and
many articles have appeared in support of
various therapeutic claims made for it That it pos-
sesses certain merit goes without saying, else so many
talented physicians would not testify to its efficacy
in certain cases carefully observed by them. We have
made it our care to ask many physicians their opinion
of the drug, and about half of those who have used
it give favorable report, but contend that relatively
large doses must be administered, the current dosage
being too small. The other half are more or less
dubious concerning its value, and three physicians
have expressed the view that it is a habit-inducing
drug, which is contrary to the usual claim.
418
Announcements
[The American Physician
Mason and Pieck, in the Journal of Laboratory and
Clinical Medicine, November, 1920, report elaborate
pharmacological studies performed on the intact ani-
mal, not on isolated tissue, as was done by Macht
and others, using the 20 per cent, commercial prepara-
tions diluted with an equal volume of water.
Several experiments showed that the drug does
lower the blood-pressure, but it is due to a weakening
action on the heart which may proceed to actual
death. Short of death, very marked depression of
respiration was produced, as well as lowering of
heart-tonus. Used intravenously, the animal does not
die of thrombosis.
Pushing the drug to the point of very obvious
depression of respiration and circulation, the action
on the uterus was very slight. Ordinary doses had no
effect on the uterus.
It was pretty definitely proved by the experiments
that benzyl benzoate does not cause a bronchodilata-
tion in the intact animal under the conditions of
their experiments.
As regards pulmonary hemorrhage, the experiments
did not bear out clinical contentions, for pulmonary
arterial pressure was very slightly influenced, though
the carotid pressure fell markedly.
It must be noted that these experiments proved that
benzyl benzoate is a respiratory and cardiac depress-
ant, and that when dosage sufficient to relieve bron-
chial asthma, excessive peristalsis, spasm, etc., is
given, the depression is often very great.
Our own clinical experiments bear out some of
these contentions, for while not negative clinically,
the usual dosage was not effective and the increased
dosage given was depressing.
It is, however, not safe wholly to depend upon
pharmacologic findings. The clinical test is the final
criterion. Since many physicians have reported most
favorably on benzyl benzoate, it is probable that from
the great mass of such reports may be culled some
definite data procured under proper control, and
that, despite unfavorable experimental findings, the
drug may merit a substantial place in therapeutics.
We await such credited clinical reports and will be
glad to hear from readers who have treated series of
cases with and without benzyl benzoate and kept
case records that clearly compare in a critical manner
the two groups of cases.
Coming In Next issue
Investigations by the U. S. Public Health Service
show that practically all bottle-fed babies thrive as
well on powdered milk as they do on natural cow's
milk, and that some who do not thrive on the cow's
natural milk, do finely on the powdered. The
National Commission on Milk Standards urges health
and food-control officials to encourage and not to
hamper the dried milk industry.
The Opportunity of the Family Physician Toward
the Insanity of the Young, by Bayard Holmes,
M.D.
"Whatever is to be done for the twenty thousand
and more youths who come down with dementia
praecox every year must be done before com-
mitment and before sanitarium segregation.
The problem of ddhientia praecox is in the hands
of the family physician where the problem of
every other disease which has been solved by
our profession has been safely placed."
The Relation of the General Practitioner to Mental
Disorders, by Samuel W. Hamilton, M.D.
When power of fancy over reason becomes un-
governable and apparently influences speech or
action, the patient's mind changes from normal
to abnormal— he becomes a menace to himself
and others, as is verified in this, Dr. Hamilton's
classical paper.
Emergencies in Obstetrics, by Chas. Mazer, M.D.
An obstetrical emergency is like a smouldering
fuse of the danger-laden bomb — in either, quick,
daring, dextrous action is pressing, or the bomb
explodes and the patient dies. With this in
mind, Dr. Mazer's paper, short, clean-cut, com-
prehensive, but practical, will be, we hope, duly
appreciated.
Some Sequelae of Fractures and Their Treatment by
Physical Measures, by Wm. Martin, M.D.
Dr. Martin, in this excellent paper on the use of
electro-mechanotherapy in the prevention of the
disastrous after effects incident to improperly
treated fractures, narrates how a patient would
meet his doctor in the street and silently and
scornfully hold up his ankylosed arm — to the
natural displeasure of the physician in question.
It is to prevent such "monuments" that we
recommend the utilization of the methods advo-
cated in this well-written, non-voluminous,
practical paper.
Prolapse of the Rectum, by Charles J. Drueck, M.D.
Few diseases are as annoying as is a rectal pro-
lapse—even if it is not, as such, fatal. Few
diseases cause as much discomfort, misery, suffer-
ing as does this distressing disorder. To render
the victim respite, relief, perhaps cure, we present
this highly instructive paper of Dr. Drueck. The
proctologist as well as practitioner will not, we
vouch, be disappointed with it.
Four Cases of Infection Through the Umbilicus,
Twenty-eighth Clinic, by A. Mackenzie Forbes,
M.D.
The prognosis in these cases of septicemic
arthritis in infants is very bad. The mortality
in this condition is, at least, seventy-five per
cent. This high mortality is due not so much
to the surgeon's inability to control the infection
as to the lessened resistance of the infant.
Cancer of the Liver and Gall-Bladder, by Hyman I.
Goldstein, M.D.
Cancer of the liver and gall-bladder, perhaps,
more than cancer anywhere else, is fatal. How-
ever, it is so easily confused with other dis-
orders of gastro-pylorio, duodenal hepatic or
cholecystic origin that a diagnosis without lapa-
rotomy is extremely difficult, often impossible.
The light, then, on this troublesome, but im-
portant subject shed by Dr. Goldstein in this
excellent paper will prove of highly practical
value.
The following papers
are contributed exclu-
sively to this journal.
Republication is per-
mitted if credited as
follows: AMERICAN
PHYSICIAN, Phila-
delphia.
Original Articles
Sntncn, Iti nifcaas, lin input ifcu Mtt earinstf
We are not respon-
sible for the views ex-
pressed by contribu-
tors; but every effort
is made to eliminate
errors by careful edit-
ing, thus helping the
reader.
Preventive Gynecology*
Conserve the Procreative Function of Womanhood
By H. S. Lott, M.D.,
Winston-Salem, N. C.
There is music in brooks, sermons in
rocks — and poetry in gynecology. StM, in
spite of the artistic form of this paper, it
is loaded with instruction, utility and com-
mon sense. — Editors.
GYNECOLOGY means not ablation, or distor-
tion of organs, but conservation of the pro-
creative function of womanhood. Function is the
soul of the human economy, giving to each organic
structure the power of procreation and the spirit
of perpetuation of its kind. Just as the glint of the
morning sun gives life to mountain top and ocean,
so function reflects the vital glow of the procreative
organs. Preventive gynecology, therefore, may fairly
deal with all causes, both intrinsic and extrinsic,
which either shorten or block the vital currents essen-
tial to physiologic performance of such function.
Chief among intrinsic causes is infection; and infec-
tion may be classed under two heads, the ones that
are inevitable, coming in the natural course of events
in the period of girlhood, and the ones that may be
avoided throughout all periods of life by prudence
and cleanliness.
Chief among the first, and of much importance
because they are inevitable, are the exanthemata, all
of which, through the ravages of their inflammatory
processes, sear the pelvic cellular structures, and dis-
tort the delicate anatomic arrangement of the pro-
creative organs. Thus the tubal fimbriae, which should
"float free" when the maiden stands erect — like the
fish's fins in water, become agglutinated to the sur-
face of the ovary, with the inevitable result of block-
ing normal circulatory currents, and abolishing
function.
We know about it, but have we thought about this
delicately beautiful and highly sensitive mechanism,
the floating fimbriae, and its spasmodic clasp of the
'Pretested at the annual meeting of the North Carolina
Medical Society. April. 1922. Winston-Salem. N. C.
ovary, and how serious a matter this agglutination
of structure with lessening of the lumen of the tube
will become in the life cycle of young womanhood,
and how often the effort is made to correct this
pathology and relieve this pain by removing the ap-
pendix, thus creating fruitful soil for reflex scar
tissue neuroses instead f
And again, at the menstrual epoch, have we framed
a mental picture of the ovary with its product just
matured and rising to its surface, here to rest a little
while in its clean transparent fluid, before rupture
of the capsule, which permits it to be caught within
the spasmodic clasp of the fimbriae and started on its
journey through the tubef The end of this journey
is the uterine cavity, and failing to find its mate in
the course of its travel, the ovarian product is swept
away by the monthly storm via nature's drainage
conduit, or, meeting its mate before reaching the
uterine cavity, an ectopic prestation is begun. The
old pelvic hematocele, shrouded in mystery, was noth-
ing more nor less than a ruptured ectopic gestation,
in keep of the pelvic cellular structures.
Knowing a thing, and realizing it, are quite differ-
ent. We know that this anatomy exists in the female
pelvis, and we have learned to recognize its gross
pathology, but have we thought about it, and come
to realize that these structures are far more delicate
and far more sensitive, and far more vital, because
of their dual procreative function, than are any
other organs in the economy; and that mental, social,
and atmospheric conditions in this, the maiden era
of effulgence, are equally causative in the initial
shock which disturbs currents and perverts function*
Functional Activity ami Trauma ami Infection
With marital relations established, assuring also
the era of functional activity, the woman confronts
again the dangers from infection and trauma, but
chiefly of external origin. The Neisserian infection,
with an established pathology that is recognized and
removed, is not the only one confronting woman
through marital relations. If the affectionate and
aggressive husband, upon returning to the home,
would take a bath first, the pelvic organs might be
419
420
Preventive Gynecology — Lott
[The American Physicia .
spared invasion by the mixed infection, from which
agglutination of structure, with localized pus foci,
and abolition of function, are far more fixed and
fatal, than from the Neisserian alone. Gonorrheal
pus tubes, pure and simple, may be lifted with ease
from their bed in the pelvis; but in pus conditions
from a mixed infection, tubes and ovaries are welded
to the pelvic floor in an agglutinated mass of cellular
structures from which their freeing involves much
surgical shock and trauma.
Obstetrics is surgery, demanding the same perfec-
tion of toilet and technique ; and while trauma at
times is unavoidable through disproportion between
the maternal outlet and its passenger, infection is
not;
The normal cycle of labor, beginning with concep-
tion, requires time and patience for safe completion.
And how beautiful it is, the delicate, almost imper-
ceptible contractile function of the uterine musculare,
tolerating to its limit of endurance. Ideal obstetrics
means the conduct of labor to safe termination, with
no interference at all; and the man who has not the
patience, and will not give the time to the woman
for safe delivery, should not practice this branch of
the service, in which two lives are at stake always,
and in which many of the accidents are due either
to ignorance or indifference on the part of the
accoucher. Forceps are life savers, but they are
used too often, and used as a matter of expediency,
forgetting the menace they bear to the maternal out-
let and the foetal head. Extensive tears, with de-
struction to cervix, posterior vaginal wall, and some-
times sphincter as well, while distressing and often
unnecessary, are recognized and an effort is made
at repair; but it is well to remember that the trifling
ones, just a break in the mucous membrane perhaps,
offer avenues to infection just as sure and just as
inviting for invasion of pelvic cellular structures,
with all of its distorting results. The severe cases,
with rigors and sweats, covering a critical period of
weeks and ending either in a fatality or a pus-focus,
are so evident in their origin that "he who runs may
read," but the mild infections, with just a slight
rigor within the first week, perhaps with a longer
period of convalesence and failure to furnish milk
the most marked clinical features, are insidious, and
fatal to function and fatal to physical comfort after-
ward.
In these mild post-partem infections the pathology
is much like that of the exanthemata — invasion, with
slight effusion perhaps of pelvic cellular tissues, con-
gestion of fallopian tubes, with complete or partial
occlusion of lumen, and agglutination of its fimbria
to the surface of the ovary. Thus function is abol-
ished and sterility established that cannot be ac-
counted for because of normal marital relations.
Puerperal Sterility — Repmr — Smbawelmtiam
"Post-puerperal Sterility, Its Cause and Surgical
Treatment," presented in a former paper, describes
more fully this pathology, picturing its clinical his-
tory with abolition of function, and also suggests a
surgical procedure by which the patency of the tube
is restored and the fimbrue freed from the surface
of the ovary.
Recognition and mechanical repair of injuries to
cervix, posterior vaginal wall and perineal structure
concern the obstetrician very closely. Plastic sur-
gery today is not given the prominence to which it
is entitled. For this there are two reasons, first, it
is less attractive, demanding much time, care and
precision in toilet, technique and material, if ideal
results are obtained. Second, it tells on us. Much
clumsy and unnecessary work may be done through
an abdominal incision and the patient remain in bliss-
ful ignorance of the fact, but a distressing eystocele,
a lax posterior wall, or a torn sphincter, breaking
down the first time a woman goes shopping, is a
living and lasting monument to the man who assumed
the responsibility of its repair.
The sub-involuted, post-partem uterus occurs more
often than we realize, and its baneful effects are
assured. But it behooves us to remember the im-
portance of the uterus, and especially in this era
of functional activity. For four reasons it should
not be removed; two of these reasons are anatomic
or mechanical, and two are physiologic or functional
The uterus is the keystone to the arch of the pelvic
cellular structures, and the living room of the pro-
creative center, and, most important of all, it is the
organ of menstruation and nature's drainage conduit.
May I tell you something, illustrating the attitude
of the people and emphasizing the importance and
responsibility of our service f One morning, just
seated in my office, a gentleman entered with his
wife, a young woman of fine physique, having ar-
rived from an adjoining county on an early train.
Approaching me at once he said, "Well, doctor, we
have decided to have our womb taken out." Cer-
tainly !" was my reply, "be seated, take it out while
you wait." In a nearby town he found the service
demanded, and is now a festive widower.
The uterus is the most intelligent organ in the
economy if given a chance; and the sub-involuted,
post-partem uterus, if bled freely from its endome-
trium and the woman kept quiet for a while, will
return to normal size and tone, preserving throughout
the era of functional activity the integrity of the
pelvic cellular arch, and the organ of menstruation,
with its most essential function as nature's drainage
conduit, and in the literature of today we find prom-
ise of the recognition of function as the most impor-
tant factor in the human economy.
Functiemml Decline — Preventive Gynecology
Retrogression of vital currents, with atrophic
changes, subsequent to this era, completes the life
cycle of womanhood. Such changes, with abolition
Phila., June, 1922]
Gastric mud Intestinal Motility— Boodel
421
of function, are in nature's plan, and, being inevit-
able, we may depend upon them. As the come and
go of circulatory currents throughout the eras of
effulgence and functional life, under control of cere-
bral centers, establish and perpetuate functional ac-
tivity, with its periods of rest, so the cycle is closed
by the recessional wave, and with atrophy of organic
structure, when its terminal duty is done.
Gynecology means safety and comfort throughout
this, the final era of woman's life; and witn recogni-
tion of these facts and the adoption of these prin-
ciples concerning trauma and infection, with present-
day toilet and technique, obstetrics will become pre-
ventive gynecology, and the gynecologist, the man
with high ideals, of altruistic mould, upon an estab-
lished plane of distinctive service —
"When the great Ship of Life surviving, tho shat-
tered, the tumult and strife
Of earth's angry element, drives safe into port/'
and the "last Bill of Health," is demanded,
its reading will show —
"How fared the ship through trials she pass'df
And what is the state of the ship at the last?*'
REFERENCES
Transactions, North Carolina Medical Society, 1914.
The American Journal of Obstetrics and Diseases of Wom?n
and Children. Vol. LXXV, No. 3, 1917.
Gastric and Intestinal Motility
A Brief, Clear Description of the Many Important Points Involved
By J. C. Boodel, M.D.,
The Kelley Clinic, Chicago, 111.
Motility, secretion, digestion, pain, ulcera-
tion, spasm and obstruction in the ali-
mentary canal are conditions encountered by
every physician in his daily vocation. We
thoroughly approve of this paper of Dr.
Boodel, as the brief but clear descriptions
on the mentioned points will be of undoubted
value to every reader. — Editors.
IN THE GASTRO-INTESTINAL canal of a nor-
mal individual the digestive secretions are put
forth quantitatively and qualitatively within limits
that are most elastic but remain normal for that
individual and depend to a great extent upon the
patient's habits, size, his customs of life, character
of food, alcoholic and venereal excesses, occupation,
family and business cares, anxieties and sorrows,
temperament and other factors which may modify
the output. These facts are far more elusive than
tumors or chemical data, but they are frequently
far more important. In diseased conditions there
would seem to be no variation limit, both as to time
and secretion.
Of late, gastric analysis seems to have somewhat
fallen into disrepute; analysis of the gastric contents
being considered too lightly, the interpreters not
always fully understanding the meaning of the dif-
ferent reactions in the digestive process, it may be
far better, in the diagnosis of chronic ulcer, to de-
pend upon a good history and Roentgen examina-
tion than on acidity or traces of blood, but when
nine out of every ten dyspeptics examined show no
organic lesion a knowledge of the gastric functions
in this large group would seem to prove helpful
both in prognosis and treatment.
Gflsfrt-ntejtiMf Motility mU Fmctert W Sccrrtim
Gastric and intestinal motility seem to be the most
potent and constant factor that modify gastric secre-
tion both as to quality and quantity. If the motility
of the gastro-intestinal canal is normal, the stomach
will put forth a secretion within normal variations
for that individual, provided that some constitutional
disease or other outside modifying influence is not
active, but if the motility is increased or decreased,
the character and quantity of the secretion of gastric
juice will change. Rapid emptying time from what-
ever the cause, will decrease the quantity, acidity,
and enzyme content of the gastric juice. A delayed
time will have the opposite effect, depending upon
the degree of delay. When the motility is not seri-
ously interfered with, but a reflex pyloro-spasm is
active at a time when the stomach is empty, a con-
tinuous secretion results. In ulcer near the pylorus,
a hypersecretion with or without hyperchlorhydria
results from an irritable pylorus with spasm which is
active during the stay of gastric contents within the
stomach. Given a malignant stenosis where all the
gastric cells have not been destroyed by the disease or
complications, an increase in the secretion and acid
will usually be found. In benign partial stenosis
there is not only retention but increased secretion
and acid values also. In gastritis the acid values are
usually determined by the type or the tone of the
organ. In malignant disease of the body of the stom-
ach, there is usually rapid emptying time. This,
itself, would tend to diminish the acid content. In
422
Gastric and Intestinal Motility — Boodel
[The American Physician
ulcer of the body of the stomach, the motility not
being affected, the acid values are usually normaL
With early carcinoma of the pylorus with obstruc-
tion, when all the gastric cells have not been de-
stroyed! a normal or even increased acidity is usually
found. The low transversely placed stomach that
empties quickly, even though the cells are only
slightly damaged, will produce a secretion much less
in quantity and acid than an organ that is more
vertically placed with slightly impaired motility in
which the cells are badly damaged. The few cells
that remain in the latter seem to be stimulated by
the slow emptying time.
Ma
The greater part of the distress experienced by
those suffering from function or organic disease of
the stomach or intestines is brought about through
irregularities in the motor mechanism of the canal,
secretory disturbances usually being secondary to the
motor influences.
It is practically proven that the pain or gastric
distress of ulcer of the stomach is not the result of
high acid, but rather increased gastric contractions
and tensions caused by increased peristalsis working
against either a spasm or organic obstruction at or
beyond the pylorus. At Laparotomy under local
anaesthesia the nerves of the stomach or duodenum
are insensitive to such physical injuries and chemical
irritants that are likely to produce pain when applied
to the surface of the body. This has led a number to
believe that the distress or pain is produced in the
same manner as that of renal colic or entero-spasm.
That gastric contractions are important factors in
the production of pain is recognized by the term
cramp-like used to express the character of pain that
is usually present in the obstructive type of ulcer.
If a patient suffering from gastric or duodenal ulcer
is given a barium carbohydrate meal and the stomach
contents removed by means of fractional extraction
carried on simultaneously with fluoroscopic observa-
tions, the greatest distress of pain will be found to
coincide not with the peak of the acid curve but at
the time when the pylorus is in the most pronounced
spasm. This usually occurs when the last of the
meal is being propelled through the pylorus and for
sometime after the stomach is empty. Combined
hydrochloric acid of the highest grade found in the
stomach does not produce distress, and that the free
acid alone is incapable of producing the pain of
ulcer, is shown by the fact that the same degree of
free acidity may be present in the same case with
or without distress on different occasions not very
far apart.
Food and alkalies introduced into the stomach at
the time when distress is most pronounced, relaxes
the spasm and the intragastric tension subsides. An
altered secretion perhaps also relaxes the spasm.
There are as many people taking soda for the relief
of gastric distress whose gastric juice is low in acid
as there are those with high acidity. The relief of
the peristaltic unrest, spasm, or other motor disturb-
ances, which the food and soda give, even when there
is a total lack of acid, causes the distress to subside.
Obttrwcti— mmi Crtc
Pain further along the canal in the intestine is
caused by irregularities in the tension of the walls
of the canal due to spasm or obstruction of one kind
or another. Here the pain is sharper, more colic in
character due to the limit of compensatory stretch-
ing of the intestinal walls, which, owing to the differ-
ence in the histological structure or arrangement of
the muscular layers will not allow of so much
stretching. Colicky pain is then only rarely intra-
gastric; however, it may occur when food is tempo-
rarily isolated in the antrum from spasm, obstruc-
tion or other pathological conditions of the pars
pylorica. In radiographic studies by Wheelon and
Thomas, it was found that the antrum and pyloric
sphincter are rhythmical in action. Contractions and
relaxations follow each other regularly at the rate of
three to five per minute. The phases of activity of
the sphincter supplement those of the antrum so
that the motility of these two parts may be consid-
ered as constituting a cycle of the pars pylorica.
Given a disease of the pylorus a temporary isolation
may give rise to a marked increase of tension in the
antrum, causing increased tensions or colic, but this
is never so severe or of as long duration as intestinal
colic.
R*itx Sptum
Pyloro-spasm is often reflexly excited. The contin-
ual gastric distress, hyper-secretion and continuous
secretion of chronic appendicitis and other inflam-
matory processes of the adjacent tissues and the ilio-
ca?cal valve can be explained through the ilio-pyloric
reflex. The pylorus is automatically closed when the
contents of the ileum reach the ilio-canal valve and
does not open until the contents of the ileum pass
into the caecum, thus releasing the tension in the small
bowel. When this reflex has been disturbed, the re-
sulting difficulty and symptomatology above the ilio-
caecal valve can be readily understood.
Odber Fmcton Inimemcimg Moidity
In the inflammatory processes in the abdomen, a
kidney stone, malposition of the uterus, pregnancy,
etc., may affect the gastric motility one way or
another. Pulmonary tuberculosis and beginning
cardio decompensation affect the gastric motility re-
flexly, most frequently of the extra-abdominal dis-
eases. The variation in the gastric motility caused
by functional cardiac diseases, the arythmias, etc^
are not directly reflex but are due more or less to
a faulty nerve control. While the digestive tract is
supplied with nodes such as the plexuses of Auerbach
and Meissner, nevertheless, a general nerve control
is invested in the autonomic system, comprising the
Phfla., June, 1922]
Gastric mud Intestinal Motility— Boodel
423
cranio-sacral system or vagus on the one hand, and
the general sympathetic system on the other. These
two systems are supposed to counterbalance each
other in tonicity. This nervous disturbance either
causes or accompanies a cardiac distress.
There is, in all probability, a reflex connection
between the gall bladder and gastric motility. The
deep peristaltic waves observed in pyloric obstruc-
tion can be demonstrated fluoroscopically in gall
bladder disease; however, that no real obstruction
exists is shown when the opaque meal passes with
undue rapidity into the small intestine. This coin-
cides with the acid values, for in most gall bladder
cases, the acid content is low.
JtocrM ftruteftit
Reverse peristalsis, as a rule, is more common in
those portions of the gastro-intestinal canal of small
caliber. The exceptions are in the act of vomiting
in pyloric obstruction and where there is organic
obstruction in the large bowel. In the act of vomit-
ing, we have the most frequent example of a reversed
peristalsis. The fundamental causes of vomiting act
either on the vomiting center or act reflexly. The
latter is the most frequent. It may occur as a symp-
tom in nearly every possible disease. It is of diag-
nostic importance and value only when carefully
studied in its relation to other symptoms and to the
body functions. In the oesophagus, reversed peristal-
sis is fairly common, even when no organic disease
exists. The slight cardio-spasm of neurosis is suffi-
cient to excite the act (regurgitation). In certain
oesophageal abnormalities, food may be swallowed
and after a time returned in a manner resembling
true vomiting". In malignant disease, stricture, pres-
sure from without and idiopathic dilatation, food
may be returned through the mouth promptly or
after several hours. If there exists a long standing
incomplete obstruction at the cardia, the ejection of
the food may be delayed considerably. Roentgen ray
will be able to diagnose them. The returned matter
is undigested. It is not acid and may contain mucous
or blood or even portions of new growth.
Elt—fi Cemeewmti im V—utimg
In vomiting, the vagus to the muscular coats of
the stomach, the phrenic to the diaphragm and spinal
nerves to the abdominal muscles are all concerned.
The efferent fibers of the vagus convey the vomiting
impulse. The muscular coats of the stomach con-
tract, the diaphragm is pushed violently downward
while the contraction of the abdominal muscles oc-
curs, the cardiac sphincter is usually relaxed, the
pyloric sphincter closed. If the latter is open, bile
and intestinal contents may be contained in the vom-
ited matter. In pyrosis the cardiac sphincter relaxes
but there is no violent muscular action. In retching,
the sphincter does not relax.
As to the central causes of vomiting, drugs, anaes-
thesia and uremia, diabetes, acute yellow atrophy,
Addison's disease, acute infections, pregnancy and
cyclic vomiting are most important. Cyclic vomiting
in the young is usually a sign of acidosis. Preg-
nancy may be partly reflex or toxic. Persistent
vomiting when jaundice is present should always lead
to a suspicion of yellow atrophy of the liver. In
the reflex causes, the numerous diseases of the stom-
ach, both acute and chronic, irritating food, drugs,
poisons, dilatations and deformities, are the most
important. In portal obstruction it arises from
venous congestion. Further causes are intestinal
obstruction, appendicitis, intestinal worms, perito-
nitis, biliary and renal colic, and acute pancreatitis.
In pulmonary tuberculosis and pert us is, it arises
from irritation of the bronchi and fauces. A blow
in the epigastrium or a kick on the semi-lunar car-
tilage of the knee, may cause vomiting. Disturb-
ances of the senses of smell, taste and sight may
cause it Concussion, cerebral tumors, meningitis,
hydrocephalis, cerebral sinus disease, tabes and cord
disturbances bring it about. So does migraine and
epilepsy, and, last but not least, hysterical vomiting.
Gastric and intestinal motility seem to be the most
constant factors that modify gastric secretion and if
the above simple principles are considered and too
much dependence is not placed upon the analysis of
the gastric juice, but a better knowledge of gastric
and intestinal motility is obtained through the use of
the fluoroscope and fractional test meal, the solution
of many diagnostic problems will become a more
fascinating procedure.
Early Diagnosis in Tuberculosis
R. T. Pcttit (///. State Jour.) says while only one
case of advanced tuberculosis in fifty gets well, 90 per
cent, of the incipient cases under proper conditions, arc
cured and again become useful members of society.
It is, therefore, self-evident that one of the most
important factors in dealing with this disease is its
early accurate diagnosis.
But in tuberculosis, the earlier the disease, the fewer
the signs and symptoms, the less certain and exact are
their character and the more difficult their interpretation.
The diagnosis of advanced tuberculosis is easy — it can
frequently be made across the room — but in the early
case, in the case that offers a good chance of recovery,
the symptoms are vague, the signs indefinite and ordinary
casual observation and examination are not sufficient.
More exact and careful methods must be used, more
prolonged and careful study must be made; in fact,
every possible method, instrument and device must be
utilized.
It is not sufficient to determine whether or not the
patient has tuberculosis — it must be determined whether
the tuberculosis is active, quiescent, latent or healed. It
is also necessary to determine whether the patient is
in need of sanatorium treatment, or merely observa-
tion and repeated examinations at stated intervals, or
whether he should be treated for something else or not
treated at all. This is not easy and the physician that
makes a diagnosis and recommends treatment should
realize the importance of his decision to his patient,
to the patient's family and to himself.
424
Proper Interpretation of Symptoms—Brown
[The American Physician.
Proper Interpretation of Symptoms
Gives an Early and Accurate Diagnosis
By Alfred Brown, M.D.,
Candler Building, Atlanta, Ga.
SyapfMMtic Sigmicamce
Symptoms are extrinsic expressions of in-
trinsic conditions and are precious when pro-
perly understood. However, when they run
wild like a mob in alarm and disorder, their
interpretation becomes difficult and their sig-
nificance problematical. It is then that the
physician steps in and distinguishes between
the informative and valuable and the ram-
bling and confusing. These points are skill-
fully discussed and vividly illustrated in Dr.
Brownfs helpful paper. — Editors.
IRRITATION of a sensory nerve at its periphery,
or at any point along its course produces the same
sensation at its center in the brain; because of this,
pain will always be intangible and indefinite as to
its exact cause, very often misleading as to its sig-
nificance, making rational therapeutic relief very
difficult and sometimes impossible.
Unless this fact is throughly understood and not
only borne in mind, but applied when an occasion
arises making a rational diagnosis urgent and vital,
grave mistakes will continue to be made, surgical pro-
cedures undertaken, and even the life of the patient
jeopardized unnecessarily.
To my colleagues having had years of practical
painstaking experiences these words are not needed,
but to those amongst us with limited opportunity for
observation and clinical study I choose to impress the
vital need of accuracy in interpreting the meaning of
symptoms from their mode of onset, relative to mak-
ing a diagnosis.
New text books will have to be written before per-
sonal clinical observation as the real means of obtain-
ing scientific and positive conclusions can be dispensed
with. No book that I possess, or that I have ever
read attempted to impart information obtained from
a visual impression of the facial expression moulded
by nature to convey human feelings or emotions, an
expression that defies voluntary substitution.
Any grave or serious malady of the human body
is always reflected in the facial expression, and when
we have learned to interpret those eye-beams and
stolid cadaverous reflections only produced by nature
and fear of impending dissolution of body and soul
will we be able to realize the difference between
exaggerated verbal descriptions and a real cause for
alarm.
lUttHrathm ♦/ Midttdmg /afenMtJM
Altogether too much effort is exercised in attempt-
ing to prove preconceived ideas or opinions, and a
false value is so often placed upon some evidence
obtained through the various methods of procedure
such as palpation, auscultation and various labora-
tory tests. "This class of information is truthful and
absolute when correctly interpreted and it may a!so
be diabolical." It so often errs in that it can be mis-
leading so far as its being a causative factor produc-
ing the condition we are trying to locate and define.
Perhaps I may better illustrate by quoting from a
case history of recent date. An unmarried woman
twenty-three years of age of a very emotional dis-
position giving vent to hysterical convulsions on small
provocation ; during an acute illness she was examined
treated and advised by several physicians, and to
their embarrassment all made different diagnoses;
all this she experienced in about ten days. Her
trouble, as she explained, was nausea and violent
vomiting, and in this condition we, in turn, found
her. Her physician was first called in the evening
and found patient without fever but with a persistent
vomiting. Immediate relief was given, and after due
consideration came to the conclusion that some diges-
tive disturbance had caused the trouble, and pre-
scribed and gave the usual treatment.
Next morning, the patient presented no symptoms,
pulse and temperature normal, and as she stated, she
felt fine. Examination gave no evidence of trouble
so she was dismissed with the usual directions, and
to be called if needed. On the second day following
this, the same symptoms reoccurred, and. not being
able to locate her physician, another one was called.
He very promptly answered the summons and found
the patient as his predecessor had, except she in-
formed him of her previous attack and what had
been said and done. He gave her relief, and after his
examination made a diagnosis of some gall bladder
trouble and suggested calling a surgeon for an im-
mediate operation. At that time he made a blood ex-
amination and informed her that some infection was
present, and as he was not a surgeon no further prog-
ress could be made by him. The following fortnight
the same symptoms reappeared and needing the
warnings of her former adviser a surgeon was called
He examined and prescribed for her and finally con-
cluded that she was suffering with appendicitis,
Phila., June, 1922]
Proper Interpretation of Symptoms — Brown
425
especially as she was very sensitive over McBurney's
point and the previous laboratory findings favored
this, and as the patient's financial status excluded
the possibility of compensation, he rightfully sug-
gested the City Hospital, and so referred the case
and departed.
Her next experience was with a pair of young
physicians who proceeded to make a diagnosis by
elimination. Somehow they discarded the gall bladder
and the appendix, and on finding tenderness over
the right ovary associated with a alight vaginal dis-
charge, felt reasonably sure that a Neisserian in-
fection confronted them and promptly informed the
patient, who in turn more promptly dismissed them
as preposterous and without consideration, as she
stated that was impossible.
At this point 1 was recalled; I say recalled, as I
was the first one summoned to attend her, and about
ten days had elapsed between my first and second visit.
The following picture presented itself:
Nausea and vomiting, two or three degrees of fever
every evening, pain over the entire abdomen, ex-
aggerated by colicky paroxysms, followed by bowel
evacuations of quantities of mucous. No distention,
and, during her periods of quietude, she did not pre-
sent the expression of a person fearing impending
danger. Every morning I would find her sitting up
in bed enjoying breakfast and feeling fine, but as
the day wore on the symptoms would reappear.
The urine contained a trace of bile, specific gravity
was high, otherwise normal. White cell count ranged
between seven and nine thousand, the vaginal dis-
charge was red and only slight.
Expectant treatment, watchful waiting and further
discussions during the next ten days yielded nothing
more definite and very little change in the behavior
of the complexity of things.
About two years previous to this I had attended
this patient, suffering with some pelvic affection which
I had diagnosed right salpingitis. An acute re-
occurrence of this condition, together with adhesions
of the gut would produce a colitis as described by
Osier, and a colitis of this type would produce the
fever, nausea and vomiting and the mucous in the
stools.
Armed with this theory, I felt justified in urging a
laparotomy which I performed on the twentieth day
of her illness. The pelvis was a mass of adhesions
incorporating both tubes and ovaries, and a part of
the small intestine and the coecum, the appendix and
the pall bladder appeared quiet, unoffending. This
condition was treated in the usual manner. Con-
valescence was uneventful and she was up and out
in a month. She has regained her usual avoirdupois
and is, as she stated, feeling her best.
The diagnosis I made in this case was not absolute,
but logical and in accord with positive facts. My
personal acquaintance with this patient and the
knowledge obtained from bedside attendance at the
onset of her trouble defied deception and supplied
very reliable proof of what she probably did not nave.
DmUeimg ikm Chief OitmUr
That a patient may have several diseases at one
time is common knowledge, that a trained clinician
will discover and recognize all existing pathology is
probable. But to state which would be the offender
that compels the patient to seek relief, the observing
practicing physician will forever hold the deciding
information.
I stand guilty of a sin of omission. Had I more
seriously considered the presenting symptoms when
I first called to attend this patient, perhaps with
little help the true nature of her malady might have
been detected.
Vomiting as a symptom accompanies a multitude
of diseases, some within and some without the abdo-
men, and if it is not relieved, or is allowed to persist
for any length of time, it produces enough general
disturbance to deceive all but the trained clinician,
and to make possible a diagnosis of almost any
disease affecting the abdominal cavity. Furthermore,
information derived from palpating an abdomen
made sore or painful after several days of vomiting,
is of little value and is apt to mislead, as it did in
this ease.
No censure is due the men who visited this patient.
They in turn made as much of an examination as is
generally made, and arrived at their varied conclu-
sions with sufficient evidence to warrant their diag-
nosis. The expressions of the patient with her verbal
exaggerations formed a syndrome which would
deceive all but a God of Wisdom.
The presenting symptoms when they called were
out of relation with the cardinal facts ; in other words,
the onset of this condition had nothing in common
with diseases of the gall bladder or the appendix, the
adhesions of the gut in the pelvis produced a reverse
peristalsis, nausea and vomiting, the persistence of
this condition brought about the inflammatic fever,
leucocytosis and general abdominal pain.
Tkm Vmlme of mm Emrly Drngmmw
It is not my desire at this writing to give a detailed
description of the cardinal symptoms of the various
diseases or to describe their course. I merely wish to
emphasize their existence and a possibility of detect-
ing the true nature of a given disturbance by recog-
nizing them and understanding their significance at
the very outset, after a lapse of several days compli-
cating symptoms manifest themselves, "not always,
but too often," and then a syndrome exists which
defies the most efficient observer to make a correct
diagnosis. Without any reservation, I most emphati-
cally assert that until the general practitioner real-
izes that in his field lies the real opportunity for
investigation and research, "little will be accom-
plished in the art of early diagnosis."
Here we will eventually construct the foundation
426
Familial Epistaxis— Goldstein
[The American Physician
for the pivotal point in a patient's life, whether the
invading disease will end life, or will give away to
treatment. A disease is curable or incurable just in
relation to the time it is recognized.
How many diseases exist today that are hopeless
from the very onset f How much time is spent in
studying the significance of the presenting symptoms
of what is generally termed minor complaints f All
diseases which end life get their start from some
infinite cause.
What symptoms are significant of the invasion of
a grave malady and how shall we classify them as
to their behavior f A headache is insignificant unless
its character is considered. Our close attention to
these trifles will eventually create an appreciation of
their diagnostic value, and when we have reached
this stage, the utilization of modern appliances and
the assistance of an efficient laboratory technician
will be of greater service.
Familial Epistaxis
A THOROUGH PRESENTATION OF THIS RARE AND INTERESTING DISORDER
By Hyman I. Goldstein, M.D.,
Camden, N. J.
Assistant Visiting Physician and Chief of the Medical
Clinic, Northwestern General Hospital, Philadel-
phia; Assistant in Medicine, Graduate Medical
School, University of Pennsylvania, Philadel-
phia; Assistant Visiting Physician,
Philadelphia General Hospital.
Dr. Goldstein says the diagnosis is not
difficult. One must avoid the mistake of
diagnosing these cases as hemophilia, hemor-
rhagic diathesis, purpura, scurvy, or per-
nicious anemia, or the "phthisical state with
hemorrhages." — Editors.
SEVERAL INSTANCES of familial epistaxis in
one family recently seen by me and also eleven
occurring in another family which I studied lead me
to report these cases.
There are only about thirty-three or thirty-four
families suffering from this form of epistaxis (with
skin lesions) on record in the entire medical litera-
ture of the world. It will therefore be of consider-
able interest, I hope, to go into details concerning
this clinical entity, and to review the literature on
the subject.
Repvrt of Amther'M Cm$*9
I. The first family I wish to report showed three
cases, the father and two children (a daughter and
a son). These cases appeared to be similar to those
reported by Wolf Freudenthal, of New York, and
by Paul, of Australia.
(1) Mr. H. Z. C, aged 33 years, white, adult, male.
Auto-parts machinist. Past history negative, except
that he has had frequent attacks of nose bleed for
many years. In the past three or four years he has
been complaining of severe headaches, particularly
a left hemicrania. He is married, has four children,
two boys and two girls. His wife has not had any
miscarriages. Venereal disease denied. One son and
one daughter have had repeated attacks of nose bleed
for a number of years. General examination nega-
tive. The X-ray findings reported by Dr. M. K.
Fisher are as follows:
Teeth — Periapical abscess at the root of the last
upper left molar. This should be extracted. An
incipient abscess at the root of the last molar (lower
left). This tooth, I believe, can be saved by early
instituted treatment. Sinuses — distinct clouding of
the left antrum and the right frontal sinuses. This
condition is due to the presence of a fluid exudate or
pus. The other accessory sinuses are normal.
Nose and throat examination by D. N. Husik
showed free discharge of a muco-purulent nature
from the left nostril and a degenerated middle tur-
binate of a colloidal character with obstruction to
free drainage from the ethmoid and frontal sinuses.
There is distinct evidence of a frontal sinusitis and
disease of the left antrum of Highmore.
(2) Dorothea C, aged 8 years. White girl, daugh-
ter of the above patient. Has had measles, chicken-
pox and whooping cough. Has enlarged tonsils and
adenoids. General examination negative. Has had
repeated attacks of epistaxis and more often than
her little brother. On examination thirty-seven small
brownish spots were found scattered over the trunk,
neck and legs. One small telangiectatic spot about
two inches below the right ear on the side of the
neck and the left ear. Numerous very fine and
dilated capillaries (arborescent and spider-like) over
both cheeks. A few dilated capillaries are seen over
the left nasal ala. One dilated capillary visible over
the sternal end of the right clavicle and one over
the right shoulder. There are some visible capillaries
over the space between the left scapular spine and
vertebrae.
(3) Harry C, aged 6 years. White boy, brother
to the above patient. Has had measles, chicken-pox
and la grippe, whooping cough. Has attacks of
Phila.,Junet 1922 J
Familial Epistaxis— Goldstein
427
hemorrhage from the nose. These attacks are not
very frequent of late. General examination nega-
tive. Has a pale pink nevus on the back of the neck,
2 inches by 1% inch. Has another ''birth-mark" over
the middle of the back 1% by % inch. He has
twenty-eight brownish spots scattered over the body,
resembling dark pigmented freckles. There is visible
one area of dilated capillaries over the left cheek.
The father had several telangiectatic lesions, one
or two on the neck and about thirty-five or forty
dark pigmented spots, dark brown in color, scat-
tered over the neck, trunk and arms. His tonsils
were removed about eight months ago by Dr. Levi
Hirst, of Camden.
II. The second family showed eleven cases, and
these appeared to be similar to those reported pre-
viously by Legg (1876), Chiari (1887), Rendu
(1896), Osier (1901 and 1907), Steiner (1917),
Hanes (1909), Kennan (1902), Hutchison and Oliver
(1916), Gundrum (1919), Weber (1907), Babbing-
ton (1865), Langmead (1909), Richardson (1917),
Kelly (1906), and a few others. This was a typical
instance of familial epistaxis with hereditary
telangiectasia.
Case 1 — Mrs. R. W., aged 42 years, white, married,
has had severe persistent and recurring attacks of
epistaxis since childhood. She has two daughters
and two sons. One daughter, aged 20 years, has
bled from early childhood. The other daugnter, aged
11 years, has bled from the nose nearly all her life.
The patient has telangiectatic lesions on the nose,
nasal septum, lips, tongue, chin and cheek. There
are a few lesions on the left side of the neck, and
one on the middle finger of the left hand. None are
seen on the thighs and legs. The larger spots on
the tip of the tongue have bled on several occasions.
Bleeding from lower lip occurred on one occasion.
Sometimes the hemorrhages from the nose are very
profuse and uncontrollable. The patient received
ferrous carbonate, sodium arsenate, calcium lactate
and calcium chlerid at various times. She also used
thyroid and lutein for a brief period. Secondary
anemia is present. Her eldest daughter has a few
spots on the tongue and one over the right clavicle
and some on the forearm. The younger daughter
has none on the face or body, and only two very
small ones are seen on the tongue. The patient's
mother, who is dead, also had recurring attacks of
epistaxis and red spots. Three sisters are married.
Two sisters have nose-bleed; one sister, 34 years of
age, bleeds profusely from the nose.
Her four children, J, H., 13; A. H., 11; M. H., 6,
and I. H., 3, all suffer from epistaxis. Another sis-
ter, A. L., aged 32, bleeds from the nose. Her son,
M.L., aged 8, does not bleed. A third sister, Mrs.
M. C, aged 30, and two children, J. C, aged 10, and
E. C, aged 5, apparently do not bleed.
Mrs. R. W. (the oldest sister), had a "stroke" and
hemiplegia January 20, 1918, after a little giddy
spell. This attack was due to defects in the small
vessels, like those occurring in other parts of Uie
body, or a peripheral sclerosis. Blood Wassermann
tests were negative on several occasions. Blood
chemical tests showed urea nitrogen 18 mg. in 100
cc of blood; nonprotein nitrogen, 35 mg., creatinin,
2.20 mg.
Urine, January 26, 1918 — Trace of albumin ; sugar,
less than 0.1 per cent.; chlorids, 0.5 per cent.; spe-
cific gravity, 1.005 ; granular and hyalin casts; fiat
and round and caudate epithelial cells; urea, 1 per
cent.; acid.
March 11, 1919 — Albumen present; urea, 0.5 per
cent.; amorphous urates present; total solids, 16.3
gm.; faintly acid; specific gravity, 1.009; no casts;
no sugar.
July 24 — Acid; specific gravity, 1.015; no acetone;
no diacetic acid; indican fifteen times normal; urea,
0.6 per cent.; no diazo reaction; slight excess of uro-
rosein; no casts and no cylindroids; many red blood
cells; many renal epithelial cells; large number of
leukocytes (pus). Thirty-five ounces of urine were
voided in twelve hours.
Eyes, April 30, 1919 — Posterior polar cataracts in
both eyes.
Blood — Coagulation and bleeding time normal
February 15, 1918— Erythrocytes, 3,980,000; leuko-
cytes, 12,600; hemoglobin, 61 per cent. Differential
count: polymorphonuclears, 64 per cent.; small mon-
onuclears, 26 per cent; large mononuclears, 4 per
cent.; transitionals, 2 per cent.; eosinophils, 3 per
cent.; mast cells, 1 per cent. July 24, 1919 —
Erythrocytes, 3,000,000; leukocytes, 14,600; hemo-
globin, 68 per cent.; polymorphonuclears, 60 per
cent.; large mononuclears, 12 per cent.; small mon-
onuclears, 24 per cent; transitionals, 2 per cent.;
eosinophils, 2 per cent.
The phenolsulphonephthalein renal function test
was practically normal The blood pressure varied
during the past three years between 128 systolic, and
90 diastolic, and 110 systolic and 80 diastolic.
At the time she had the stroke it was difficult to
decide as to the cause. One could not easily differ-
entiate between embolism, thrombosis and hemor-
rhage. There was no evident source of an embolus.
A faint murmur could be heard over the heart, and
at times it was faintly audible at the apex, but it
could be attributed to the anemia. Shortly after the
cerebral hemorrhage the systolic blood pressure was
140; however, at no time during the past three years
has it been higher than the normal average, often
below. She now complains of a heavy feeling and
numbness in the limbs, and "heaviness with giddy or
dizzy feeling in the head." She has crying spells
occasionally, worrying over her condition.
There is no history of hemophilia in the family
and none of the family bleed excessively from cuts.
428
Familial Epistaxis — Goldstein
[The American Physician.
One son, A. W., aged 12 years, has several small
telangiectases, and a large pale reddish nevus on the
baek of the left shoulder and one telangiectatic lesion
below the right lower eyelid. He does not bleed
from the nose. The eldest son, L. W., aged 23 years,
apparently has neither epistaxis nor many telangiec-
tases. There are a few over the scapular regions
(supraspinous), and one lesion about four inches
below and to the left of the left nipple.
Case 2 — Mrs. Anna L., aged 32 years, married
seven years, had one miscarriage at six months, and
one premature birth at eight months, the child living
only twenty-four hours. Her husband had a positive
Wassermann test. The patient too had a positive
Wassermann nine years ago. She has one boy, M. L.,
aged 7 years, living and well. The boy does not bleed
from the nose. The patient has had nosebleed since
early childhood, very frequent; bleeding stops of
itself. Had influenza and pneumonia and measles.
She bleeds very profusely from the left nostril. Her
hands are cold, and she gets short of breath on exer-
tion. Occasionally, she bleeds from hemorrhoids.
She has seven or eight small spots over the back, on
the shoulders, two small spots back of ears, several
on the left side (anteriorly) of septum of nose and
one or two on right side of septum. There are a
few radiating dilated capillaries around the alee of
the nose. She also has clubbed Angers; these are
cyanosed and cold; the lips are cyanosed and get
"blue" very often. Blood pressure: systolic, 95;
diastolic, 70. No cardiac murmurs were heard at
time of the examination, but the heart sounds were
not of good quality; they were weak and muffled.
She is a sister to the above patient of Case 1, Mrs.
R. W., and to Mrs. E. H. (Case 3). Numerous Was-
sermann tests have been negative, following specific
treatment taken up to a few years ago.
Case 3 — Mrs. Eliz. H., aged 35 years, has four
children. She had one miscarriage. One infant,
aged 1 month, died of whooping cough. She was
operated on four years ago for ruptured gastric
ulcer with intestinal obstruction. She had been
bleeding from the nose almost daily since childhood.
She says her mother bled "terribly" from the nose
for a great many years, and she thinks her death
was due to these severe nasal hemorrhages. She has
a pinpoint lesion above the right eyebrow, three or
four spots on the right cheek over the malar bone,
one pinpoint lesion on the left cheek, one inch to the
left of the outer angle of the left eye; three or four
lesions on right half of the lower lip ; one spot on the
under surface of the upper lip; one on upper gum;
one spot on neck at base (right side). She gets
attacks of nosebleeding even during her sleep.
Case 4 — Marvin H., aged 5 years, was always well,
except for severe nasal hemorrhages. He has had
nosebleed daily, and during sleep, since 2 years of
age. He has one spot on left cheek, one inch below
outer angle of left eye, and one on right cheek, one
inch below and in front of right ear. Several dilated
capillaries are noted on light side of septum of nose.
He had measles. Mother says boy "bleeds in stream*
from the nose" daily, which stops itself, after bleed-
ing for five or six minutes. In these cases epistaxis
was the first manifestation of the disease. While
the hemorrhages have been severe and prolonged
there is only a comparatively mild secondary anemia.
In appearance the patients do not look very anemie
at all. Sometimes washing the face, or using a hand-
kerchief or other very slight trauma is sufficient to
bring on an attack of epistaxis.
Blood examination, October 11, 1920 — Hemoglobin,
70 per cent.; erythrocytes, 2,900,000; leukocytes,
8,000. Differential count: Polymorphonuclears, 51
per cent.; small lymphocytes, 45 per cent.; large
mononuclears, 3 per cent.; eosinophils, 1 per cent.
Marked poikilocytosis and amisocytosis. Blood Was-
sermann negative.
Cases 5 and 6 — Aaron H., aged 11 years, and
Jeanette H., aged 13 years, bleed very profusely
from the nose since 2 years of age. They are chil-
dren of E. H. They have "spots."
Blood examination, October 11, 1920 — Jeanette H.:
Hemoglobin, 75 per cent.; erythrocytes, 3,500,000;
leukocytes, 7,400. Differential count: Polymor-
phonuclears, 72 per cent.; small mononuclears, 25
per cent.; large mononuclears, 2 per cent.; eosino-
phils, 1 per cent.; some anisocytosis and poikilocy-
tosis. Blood Wassermann negative.
Aaron H.: Hemoglobin, 80 per cent; erythro-
cytes, 3,250,000; leukocytes, 11,000. Differential
count: Polymorphonuclears, 61 per cent.; small
mononuclears, 36 per cent.; large mononuclears, 2
per cent.; eosinophils, 1 per cent. Some poikilocy-
tosis and anisocytosis. Blood Wassermann negative.
Coagulation Time
Bogg,s Method Test Tube
Marvin H 5 min. 6 min.
Jeanette H 6 min. 7 min.
Aaron H 5 min. 4 min.
Hereditary Telamgiectmses With Epuiaxu
The hereditary type of telangiectases with epis-
taxis is principally of three forms: (1) pinpoint, (2)
spider form, the most common, and (3) nodular.
Strictly speaking, telangiectasis is a dilatation of
the terminal vessels, i. e., capillaries — but it is a term
used also to describe dilated venules.
Osier speaks of a type of lesion occurring often
on the cheeks, nose and ears in persons exposed to
the weather, and in heavy drinkers. Often there
occur arborescent, distended venules on the skin of
the thorax along the line of the attachment of the
diaphragm. Or the lesion may occur as small pink-
ish spots from 2 to 5 mm. in diameter, perfectly
smooth and uniform, without visible venules, which
disappear completely on pressure. They may be
only pinpoint in size, and are often of a vivid pink
color. They may appear suddenly and last for sev-
Phila., June, 1922]
Familial Epiitaxis— Goldstein
429
end years and then disappear. Then, again, they
are small nodular forms, raised, bright purple or
crimson in color, from 1 to 5 mm in diameter. They
may be congenital. They are supposed to occur
sometimes with cancer of the abdominal organs es-
pecially of the stomach, but they are common in old
persons and in many different conditions. The
spider form is made up of a central dot, from which
radiate five or six venules, or rather toward which
some vessels converge (nevus araneus). Spider
nevus is often associated with cirrhosis of the liver.
The spots are from 2 to 3 cm. in diameter. They
may occur following a Roentgen ray burn and in
scleroderma. The mat form is from 1% to 4 inches
in extent. It is vivid pink in color. It may occur
in cirrhosis of the liver. Osier has also seen it in
a case of leukemia. Generalized acquired telangi-
ectases, telangiectases essentielles en plaques of the
French, occur in large numbers over the trunk and
extremities as numerous stellate venules. This is a
rare form. Stokes found about thirty-three cases.
Multiple hereditary telangiectases with recurring
hemorrhages is the form under discussion in this
paper.
Osier, Brocq and Vidal recognized the rare form
of generalized telangiectases or telangiectases cir-
cumscripta universalis involving the skin of the
trunk, the arms and legs.
Paul reported the first family with this condition
from Australia: —
A woman, aged 32 years, had had epistaxis
since childhood. At about adult life, angiomas ap-
peared, and increased in size and number with ad-
vancing years. A dozen or more of bright red
angiomatous lesions appeared on each side of the
patient's face, varying from a pinpoint to a millet
seed in size. The mucous membrane of the lips was
extensively involved. The tongue showed numerous
angiomas. A few lesions were present on the hard
palate and on the conjunctival surfaces of the eye-
lids. An angioma on the nasal mucous membrane
was present, from which hemorrhage frequently
took place. This was destroyed by radium, with the
result that the epistaxis was greatly diminished.
There were also a few telangiectases on the palmar
surface of the left hand and on the dorsal surface
of the fingers.
In spite of the long-continued and persistent at-
tacks of epistaxis, the patient was not anemic. Blood
count: Erythrocytes, 5,110,000; leukocytes, 12,200.
There was no tendency to hemophilia.
Twenty-one members of this patient's family suf-
fered from the disease, from the great-grandmother
down to the two children of the patient, a boy, aged
3 years, and a girl, aged 7 years. The patient's
great-grandmother, grandmother, grandmother's sis-
ter, mother and mother's three brothers and one
sister, the patient's six brothers and one sister, and
her two children were all affected. These two chil-
dren had recurring attacks of epistaxis, but no
angiomas.
As to the hereditary form with hemorrhages, it is
described by Osier, Weber, Hanes, and Steiner. In
this group of cases the lesions of dilated capillaries
are confined largely to the skin of the face and the
mucous membrane of the mouth and nose. The
tendency to recurring nasal hemorrhages (familial
in type) is a prominent feature and there is a
hereditary history of recurring hemorrhages and
telangiectases in the family. Angiomas of the skin
associated with acromegaly have been reported only
by Head.
The lesions in the hereditary group of cases are
more apt to become prominent and increase in num-
bers between the ages of 35 and 50. Most of these
patients suffer from symptoms of a profound sec-
ondary anemia. The most common seats of the
telangiectases are the cheeks, lips, ears, nose, fingers
and tongue. They first appear in the skin or mucous
membranes as pinpoint spots, like pinpricks, a little
beneath the surface, and then they increase in size
and become more prominent and darker in color. A
tine vascular network may be seen under the skin
iu some places.
Dimgmtit
The diagnosis is not difficult. One must avoid
the mistake of diagnosing these cases as hemophilia,
hemorrhagic diathesis, purpura, scurvy, or pernicious
anemia, or the "phthisical state with hemorrhages."
The clotting and bleeding time is always normal, and
there is no history of hemophilia in these cases.
The blood platelets are not appreciably reduced, and
the erythrocyte resistance remains at the normal level.
Treatment does not confer much relief from the
hemorrhages and lesions. Iron, arsenic, calcium salts,
thyroid extract and corpus luteum have all been
tried with little effect. Osier once gave hypodermi-
cally 250 c.c. of a 1 per cent, gelatin solution.
Calcium chlorid, 15 grains, three times daily in cin-
namon water has been the remedy frequently used
by me. As the bleeding seems to become more severe
after the fourth decade, we must double our efforts,
especially in women reaching the climacteric period,
to try to stop the attacks of epistaxis, because of
the high strung and tottering nervous system. Some-
times, epinephrin, antipyrin solution, or hydrogen
peroxid, may check the bleeding. Kephalin, throm-
bokinase, coagulen, thromboplastin, blood serum,
whole blood, or even blood transfusion mav be tried.
The chromic acid bead, electric needle, radium and
even excision may be resorted to, for some of the
telangiectatic lesions. The carbon dioxid stick has
been used with .some success.
Somu Ftrntmrt? of the Aiection
This rare affection of the skin and mucous mem-
branes of the nose and mouth, which may involve
also the cheeks, ears, tongue, lips, fingers and other
430
Familial Epistaxis — Goldstein
[The American Physician
parts of the body, is associated with recurring epis-
taxis of the lamiiial type. In one of my cases,
hemorrhage in the brain occurred, causing temporary
hemiplegia and other symptoms of apoplexy. I have
been able to find only thirty-two cases reported.
Steiner found twenty-eight, including three of his
own. Osier, in one of the best contributions to the sub-
ject, reported three cases; and at that time (1901)
he could find only one reference to a similar case,
reported by Rendu. Six years later, Osier reported
an additional case. However, he overlooked the
cases reported by Chiarai and J. W. Legg. Only
eight cases were found by A. Brown Kelly, and he
reported two cases of his own. None of the numerous
works on dermatology, rhinology or medicine men-
tion this condition. Hartzell speaks of "inherited
hemorrhagic telangiectasis," and also makes refer-
ence to papers by Hyde,- Crocker, Mandelbaum,
Osier, Gjessing, Hutchinson, Stokes, and Majocchi
on telangiectases.
Among the most striking characteristics of this
disease is the tendency to affect more than one mem-
ber of a family, and the marked tendency of a
large number of the patient's relatives to suffer from
epistaxis for many years. For example, two of
Osier's patients were brothers and frequent attacks
of epistaxis occurred in five other members of the
family. Legg's patient had always shown a tendency
to bleed from traumatic causes, and had painful
swelling of the joints at regular intervals, resembling
the "hemophilic" state. There was a history of
epistaxis in three generations, and developmental
telangiectases were present on the patient's face and
trunk, but there was no history of hemophilia. This
was the first family in which telangiectases were
found. Babbington reported a case of hereditary
epistaxis in a native of Lincolnshire. The patient
had been subject to frequent and violent attacks of
epistaxis during all her life. She had four children,
two of whom (man and woman) likewise had habitual
and severe attacks of epistaxis. Recurring epistaxis
had been observed for five generations. Rendu was
the first to associate the tendency to epistaxis with
multiple telangiectases as manifestations of a dis-
tinct clinical entity. . The condition must not be con-
sidered as being hemophilic, nor should it be con-
founded with the so-called hemorrhagic diathesis, nor
with the acquired angiomatous lesions occurring in
cirrhosis of the liver.
Hanes described fifteen cases, including cases of
his own, occurring in two families. He overlooked
Josserand's and GottheiFs cases. He defines the con-
dition as a hereditary affection, manifesting itself
in localized dilatations of capillaries and venules,
forming distinct groups or telangiectases, which oc-
cur especially on the skin of the face and the nasal
and buccal mucous membranes, and give rise to pro-
fuse hemorrhage, either spontaneously or as the
result of trauma. A hereditary tendency, both as to
the formation of telangiectases and epistaxis, is the
only factor constantly present. Syphilis, alcohol and
other infections or intoxications do not appear to
have any definite relation to this condition.
Further ElmcUmtmm
A number of cases have been reported, but with
no other instances in any of their families, isolated
examples, in other words, of a similar clinical entity,
but not truly of the typical hereditary and familial
variety. In some cases telangiectases, of hereditary
nature, were noted in one or several members of a
family, but without recurring epistaxis; in others,
persistent severe recurring attacks of epistaxis of
familial type were mentioned, but no telangiectases
reported in the patient or any of the members of
the family. Such isolated instances have been re-
ported by A. Brown Kelly, T. Corlett Fox, E. Vidal,
L. Lack, J. Galloway, H. G. Adamson, Chauffard,
Babbington, Lane, K. Kop, J. N. Hyde, Frick,
Letienne and Arnal, J. H. Stokes, Osier, Morrow,
and several others.
Hanes believes the three factors of etiological im-
port are heredity, repeated traumatisms and the
abuse of alcohol, and that the hereditary tendency
to the disease is by far the most striking and constant
Males and females are affected alike, and both
are equally capable of transmitting it to their off-
spring. Hemorrhage is the one constant symptom
of the disease and the source of all the other symp-
toms. Secondary anemia may become quite serious.
Hemorrhage in the great majority of the cases oc-
curs in the form of epistaxis. But epistaxis may be
entirely absent. Thus, hemorrhage may occur from
the telangiectases on the tongue, lips, or fingers, or
buccal mucous membrane, and even rectal bleeding
may occur. In my case, the patient had a "stroke,"
along with severe attacks of nosebleed, and on two
occasions bleeding from the tip of the tongue and
lip, of a quite pronounced character occurred.
Multiple telangiectases constitute the sole charac-
teristic sign of the affection. Most commonly they
occur on the buccal and nasal mucous membranes
and lips. They have been noted on the face, feet,
hands, ears, scalp, neck, forearms, and chest Coe,
Chauffard, Chiari and W. Legg have mistaken these
cases for hemophilia.
Dr. Pringle, on April 17, 1913, in discussing
Sequeira's case before the dermatological section of
the Royal Society of Medicine, reported a case of
telangiectases of the skin associated with hemorrhage
from the throat and severe hemoptysis — from large
dilated blood vessel on epiglottis. No phthisis was
found to be present. Nearly all the recorded heredi-
tary cases that I was able to find in the literature
have been carefully and completely epitomized by
F. Parkes Weber, F. Hanes, A. Brown Kelly and
W. Steiner; Stokes reviewed many of the isolated
instances, particularly the generalized telangiectasia
cases.
1. Thirty-three families afflicted with this disease
J
Phila., June, 1922]
'The Feather Pillow"— Gibbs
431
are on record in medical literature. Several cases
are on record which are not altogether typical of
this condition. They have been mentioned in this
review, but are not included in the thirty-three cases.
2. No general treatment seems to be effective,
owing to the congenital developmental defect of the
vascular system inherent in these patients.
3. Local treatment may reduce the number and
severity of the hemorrhages and improve the gen-
eral conditions of the patient.
4. Dermatologists, rhinolaryngologists and in-
ternists should examine patients who complain of
these skin lesions (telangiectases) or recurring
hemorrhages more thoroughly and analyze the family
histories. In this way, some previously undiagnosed
or undiscovered cases may be brougth to light.
5. A case of hereditary telangiectasia with severe'
recurring nasal hemorrhages is recorded and eases
are mentioned of two married sisters, seven children
and the patient's mother, all in the same family,
suffering from the same disease, a total of eleven
cases in one family, and another family in which
father, son and daughter are suffering from this
condition is reported.
ReftremceM &mi BiMitgrmpky
Ballantyne, Arthur J., Glasgow Med. Jour., P. 256, Oct., No.
IV, 1908, Vol. LXX.
Kelly. A, Brown, Glasgow Med. Jour., June, 1906, LXV., P.
411-422.
Fox. T. Corlett. British. Jour. Dei-mat, May. 190S. I. P. 145.
XX.
Osier. Win., Quarterly Jour, of Med., 1907-1908, P. 53.
Osier. John Hopkins H. Med. Bull.. Vol. XII, P. 333. 1901.
Baboington, B. G., Lancet, Sept. 23, Vol. II, P. 362-3.
Hutchison, R. et Oliver, W. J., Quarterly Jour, of Med.,
1915-1916. P. 67. 9.
Bligh, W., Lancet. Feb. 23. 1907, P. 506.
Smith, F. J., Trans. Med. Soc'ty. London. Vol. XXI, P. 358.
Fearnsides. E. G., Brit. Jour. Dermat, Feb. 11. 1912, P. 35.
Stokea. J. H., Amer. J. Med. Scs., May, 1915, P. 669. "Gen-
eralized Telangiectasia and Syphilis." P. 149.
Leg*. J. W., Lancet. Dec. 16 1876, P. 856. Vol. II.
Chiari, O., Erfahrungen auf dem Gebiete der Hals-und-Nasen-
fcrankheiten. Vienna, 1887. P. 60.
Coe, John W., J. A. M. A., Oct 6, 1906, P. 1,090.
Gundrum, F. F., Calif. State Jour. Med., Vol. XVII, No. 3,
March, 1919. P. 78.
Weber, F. Parkes, Lancet, July 20, 1907. Vol. II. P. 160.
Steiner. Walter R.. Arch. Int. Med. II, P. 194-219, Vol. XIX,
Feb, 15, 1917.
Hanes, Fred. M., John Hop. H. Bull., March, 1909, Vol. XX,
Ho. 216, P. 63.
Lack, Lambert, Proc. Royal Soc'ty of Med., Laryng. Sec.,
1908-1909. H. 2, P. 109.
Adamson, H. G., Proc Royal Soc'ty. Med., 1908-1909, II. 2, P.
128. Dermat Sec.
Richardson, H. B.. Am. J. Med. Scs., P. 95, July, 1917, Vol.
CLTV, No. 1.
Brack. F., Habituellen Nasenbluten; Med. Klin., Berlin. 1917,
Xm, 505.
Head, G. D.. Arch. Int Med., July, 1917, XX. P. 24. No. 1.
Rendu, Gazette des Hopitaux, Paris, Nor. 24, 1896. 49, 1322.
Gaucher et Crouxon, Annal. de Dermat, 1902, P. 52.
Mosny et Malloixel, Bull. Soc. Med. des hopitaux de Paris,
1905, P. 847.
Levi et Delherm, Gaz. hebd. de Med. et de Chir.. Jan., 1901,
Trawinski, H.. Monatsh. f. prakt Dermat, 1910. I. 45.
Majocchi, D. R., Acad, delle Science dell Institute di Bologna,
1905.
Longcope, W. T., Med. Clinc. N. A.. Sept, 1919, P. 279.
"Cerebral and Spinal Manifestations of Purpura Hemorrhagica."
Josserand, Bull, de la Soc. Med. d. hop. de Lyon, 1902. I,
-244.
Rev. de Med., 1911, 30, 22.
Laffant Presse Med.. 1909. 17. 763.
Lane, Jour. Heredity. 1916, 7, 182. (Hereditary nosebleed
ior three generations.)
€€
The Feather Pillow
tt
IS IT A FACTOR IN THE SPREAD OF DISEASE?
By S. E. Gibbs, M.D.,
8 W. 128th St., New York.
Another indictment against the feather
pillow is the fact that protein matter exists
therein and some cases of asthma, in persons
sensitised to proteins, are kept up by inhal-
ing the dried protein matter from the
feathers. — Editors.
FROM TIME IMMEMORIAL the feather pillow
has held its place at the head of the bed; genera-
tions have laid their heads to rest upon it, have
breathed, perspired, wept, and died on it The
infant with gastro-intestinal trouble has vomited on
it, the children with various infectious diseases,
mumps, whooping cough, chicken-pox, measles, scarlet
fever, typhoid, diphtheria, and in some cases tuber-
culosis, to say nothing of minor ailments, have added
their quota to its insanitary condition.
It is true good housekeepers are particular about
having the pillow cases regularly washed and care-
fully ironed. But what about the feathers they con-
tain? In many families they are not cleaned once
in a generation.
Now a feather is an animal substance plucked
from the fowl; the quill, no matter how small, con-
tains organic matter, sometimes even a trace of blood ;
organic material, even if kept dry, has a tend-
ency to decay, the downy part of the feather absorbs
and retains moisture, often loaded with perspiration
and germs.
Our New York Board of Health has decided that
it is almost impossible by fumigation to destroy all
disease germs in quilts and blankets; it is therefore
impossible to destroy them in pillows. The question,
therefore, arises how far is the feather pillow respon-
sible for the retention of disease germs and the sub-
sequent spread of disease t
A chain is no stronger than its weakest link, and
with all our efforts by disinfection, immunization with
serums, and quarantine regulations, are we not over-
looking at least one link in the chain that may render
futile our efforts to prevent the spread of the various
infectious diseases?
W. Frendenthal. Internat J. Surg., N. Y., 1917, XXX, 34-86.
Hartsell. M. B.. Dis. of Skin, P. 591. Second Ed.. 1919.
Saunders, Philadelphia.
Osier (McCrae), 1920, 9th Ed., Pract of lied., P. 604.
Wolff. Frendenthal, N. Y. Med. Jour., March 16, 1921.
Doctor Mackenzie Forbes9 Post-Graduate Diagnostic Ginks
A Sent* of Thirty Clinics Emphasizing Diagnosis thai Should be Mot! Helpful to the General Practitioner
By A. Mackenzie Forbea, M.D., 615 University St.. Montreal. Canada
Twenty-sixth Clinic
Ancient Fracture About the Elbow Joint
ON SEPTEMBER U, 1920, P. B., number 760,
aged thirteen years, was brought to the Chil-
dren's Memorial Hospital.
The history given by the mother was that he had
fractured his left elbow a month and a half before.
He was taken to a bone-setter and treated by him
for some weeks.
He was brought to the Children's Memorial Hos-
pital suffering from deformity and pain.
There was swelling in relation to the left elbow.
Normal extension of his forearm was possible, but
flexion was limited to more than a right angle. This
limitation seemed to be due to bony obstruction.
Pronation and supination were normal.
On palpating the elbow it was noticed that as the
examiner's fingers travelled up the radius and ulna,
when they approached the elbow joint a large mass
of bone was felt on the anterior surface.
This mass felt very much as if the lower end of
the humerus at its junction with the forearm has
been dislocated forwards. On the other hand, when
the examining fingers were brought down the an-
terior surface of the humerus, this mass of bone
was felt to lie more superficially than the shaft,
suggesting that the lower epiphysis of the humerus
had been pushed forward.
An X-ray was taken which showed a supracondy-
lar fracture with a dislocation of the lower frag-
ment forward and inwards, thus causing obstruc-
tion to flexion by the impinging of the ulna against
the lower fragment. There was, in addition, a frac-
ture of the outer condyle of the humerus.
Treatment
A careful examination was made of both patient
and X-ray in order to see what possibility there
would be of reducing this fragment by closed
methods.
While the evidence considered did not give much
hope of the possibility of being able to do this, it
was felt advisable to try to secure at least a false
reduction in preference to performing an open opera-
tion.
These false reductions have been recommended by
Sir Robert Jones, who, in his article published in the
Clinical Journal, October 26, 1904, says:
"Good resurts will be recorded in old cases of
neglected supra- and intra-condyloid injuries. The
method is ve 7 gratifying when applied to old and
apparently If >peless cases."
Sir Robert Jones draws our attention to the
production of "sham" reductions exercised upon old
cases of backward displacement of the forearm. He
says: "As you know, an ancient dislocation of the
elbow is difficult to reduce. 1 have succeeded in a
few cases after two months. 1 have failed in some
as recent as a month. In these cases, however, it
matters but little whether one fails or succeeds,
for an equally good range of movement can be
secured by a sham as by a real 'dislocation' (redac-
tion). A patient, young or old, is brought to the
surgeon with a history of some months. Both the
ulna and radius are displaced backwards, the arm
slightly flexed, with only a few degrees of motion.
In making a 'sham' reduction we endeavor to bring
the arm into a flexed position for two reasons:
in the first place, it is more useful there; in the
second place, the olecranon process is nearer its
normal habitat, and the range of movement will be
increased. Ether is administered, and slowly but
forcibly slight flexion is attempted. This may prove
difficult and require much power. When a cer-
tain degree has been accomplished and the surgeon
feels that a fracture might follow more, the arm is
fixed in that position for a few days and again an
anaesthetic is administered. Quite easily by this
time a few degrees more can be obtained and the
operation is repeated until at length acute flexion
results. The arm is then kept in this position for
two or three weeks, passive movements avoided, and
under suitably applied tests, to be again referred to,
the joint is released."
History el the Patient
To return to the history of our patient, P. B., age
thirteen years. We have tried to secure a false
reduction of the deformity present, as suggested by
Sir Robert Jones.
On three occasions we have anaesthetized this pa-
tient and three attempts have been made to assure this
false reduction. The first was made on September 29,
Phila., June, 1922]
A Case of Tuberculosis of the Foot — Forbes
433
1920, the second on October 6th and the third one
October 20th. After each of these manipulations the
patient's arm could be flexed to a greater degree than
before the manipulation. At the same time examina-
tion made after these three manipulations demon-
strates that the forearm cannot be flexed to a right
angle. Supination and pronation are, however, nor-
mal.
It is impossible to flex the elbow to a right angle.
This movement seems to be prevented by the anterior
position of the lower fragment of the humerus.
Tou will notice that a little more flexion is possible
at the elbow joint than was possible at the time of the
first examination made at the Children's Memorial
Hospital, but is there sufficient flexion to assure that
he will have a really useful armt
Examination of an X-ray taken of the elbow sug-
gests the impossibility of being able to increase by
manipulation the amount of flexion possible.
The lower fragment of the humerus is placed so far
anteriorly that it would seem to be mechanically im-
possible to secure further flexion without operative
procedures.
In our last clinic we suggested that there is a type
of case where operation is imperative. Sir Robert
Jones has reported the removal of obstructing con-
dyles, exuberant callus, the heads of displaced radii
and prominent over-hanging diaphyses in unreduced
supracondyloid fractures. Do you agree that this is
one of those patients where open operation is now
indicated because repeated attempts at manipulative
redactions have failed f
A Case of Tuberculosis of the Foot
Twenty-tcrentli Clinic
WU! At Operdtwm Impf9* At Pttiemts Cmikhm?
No one is justified in persuading his patient to
undergo an operation unless he can be reasonably
certain that the patient's condition will be improved
by operation.
In the patient whom we have examined I would say
that open operation should be performed if we can be
reasonably certain that we shall improve the patient's
arm. On the other hand if there is only a possibility
of improving the patient's arm and an equal possi-
bility that our operation shall be followed by less
motion in the elbow than is presently possible one
must be very careful about advising operative pro-
cedures.
Perhaps we have erred in the past in being too
cautious. We have felt diffident about recommending
operative procedures in this boy, and we have brought
him to your notice in order to have the benefit of your
opinion as to the advisability of trying by operative
procedures to increase motion in his elbow joint.
THE PATIENT, C. B., age 31 years, number
4968/19, reported at the Montreal Hospital with
the following history :
She twisted her left ankle in February, 1916. This
was followed by a swelling and ecchymosis. She did
not consult a doctor until September, 1916, when she
presented herself at the hospital, saying that she had
not ceased to have pain and swelling since her acci-
dent. A clinical examination was made. This revealed
much thickening about the ankle. This was especially
noticed below the internal malleolus where also there
was tenderness. The foot was held rigidly by muscu-
lar spasm. Movements in all directions were re-
stricted. An X-ray was taken at this time. This,
however, gave us no information.
Tubtrcwltu •/ At AtMt
The patient was considered to be suffering from
tuberculosis of the ankle and she was treated for this
in the Out-Door Department for one year without
any real benefit. She reports that at the beginning
of the second year she began to get a little better
and soon ceased to have any trouble whatever, thus
during the second year she did not present herself
for treatment.
Early in the third year she began once again to
complain of pain and tenderness. She now returned
to the Out-Door Department of the hospital where
treatment was resumed.
An X-ray taken in September, 1919, three years
after the onset of her trouble, showed marked erosion
of the anterior inferior portion of the astragalus. A
Wassermann was negative.
In October, 1919, it was decided that as the patient
had been suffering from tuberculosis of the foot, prob-
ably since 1916, and as she had received all ordinary
treatment without benefit, it would be advisable to
amputate her foot.
The result of the examination made at this time
is recorded. It states that there was swelling about
the left ankle. There was pain on the slightest move-
ment. There was tenderness especially in the position
just posterior to the external malleolus. The skin was
not red. Muscular spasm was present.
A student: Have we not often heard you say that
the treatment of tuberculosis of a joint is by rest,
both local and general, by fresh air and a suitable
diett If so, why should you have recommended am-
putation in the case of this patient f
The clinician : While I have always agreed that the
treatment of tuberculosis of a joint is by rest, fresh
434
A Case of Tuberculosis of the Foot — Forbes
[The American Pkyncm.
air, diet and all other simple means at our disposal,
[ do not think that this form of treatment should be
carried on indefinitely if the patient is not improving
under it.
TmberadetU u Never Cwrei; It it Oaljr Arretted
I think that it is most important that we should
realize that tuberculosis is never cured, that it is only
arrested. If we keep this before us we realize that a
patient who has once suffered from tuberculosis of a
joint is always prone to a recurrence of the disease
in the joint.
It is, then, simply a case of relative value. If it is
possible to get arrest of the disease and a useful joint
in a reasonable time by non-operative methods I feel
that such should be our aim, although I realize that a
useful joint may be useful only for a limited time
in that exacerbation may interfere with its usefulness
because as we have said, the disease. has simply been
arrested.
It is, really, a question of results and what the pa-
tient must suffer to get these results. For instance, if
a child has tuberculosis of the ankle the surgeon may
place that ankle in a position of local rest by means
of plaster or a brace. The child is incapacitated for
two or three years while this treatment is being carried
out. At the end of this time the child may have a
fairly useful foot. The sacrifice has not been great
because nothing really depends upon the child's being
100 degrees capable and if in later years we get an
exacerbation, it can be dealt with, but, if on the other
hand, an adult comes with tuberculosis of the foot, can
that adult devote two or three years of what should
be the productive period of life to the treatment of
the disease, especially when it is appreciated that
nothing can be promised except that at the end of
treatment the disease will be arrested and an exacer-
bation might occur at any time during later years.
It seems to me that this is an important point. If
our patient suffers from tuberculosis of the vertebrae
the patient's spine may be maintained in a position of
immobility even after arrest has been secured and
this immobility will tend to prevent exacerbations of
the disease, but how can we guard against exacer-
bations in an ankle which has once been affected with
tuberculosis t
For the reason stated above I cannot help feeling
that there are many cases where amputation of the
foot is to be preferred to expectant treatment.
Amtpmtatiom the Beet Treatment
In the case of C. B. which we are considering, as
she was 31 years of age and had suffered from an in-
creasing tuberculous infection of her foot for three
years, it was decided that amputation was the best
treatment. Her leg was then amputated about nine
inches below the knee on November 8th, 1919.
A student: Why did you amputate so high upt
Could you not have amputated at the junction of the
middle and lower thirds t
The clinician: In as far as amputating at the
junction of the middle and lower thirds is concerned,
experience has demonstrated that one cannot hope for
good results in this position. The circulation is poor.
Union is apt to be bad and it is very doubtful whether
an artificial leg suited to such an amputation is to be
preferred to one suited to an amputation performed
about eight or nine inches below the knee joint,
because a stump of this length seems to be quite suf-
ficient for the function possible when using an
artificial extremity.
You have asked why I did not use a Syme's oper-
ation. This operation, as you know, is, practically
speaking, through the ankle joint, thus if the soft
parts about the heel are affected, a Syme's amputation
is contra-indicated, as these are used for the flap in
this operation.
Perforated a Sjme'i Ammvtmtiem
Sometimes, however, one is able to use this opera-
tion. A patient of about forty years of age came to
me from the country not many months. ago. Her his-
tory was that she had suffered since her early child-
hood from tuberculosis of the forepart of the foot
with a sinus which had been discharging for years.
Examination demonstrated that only the small bones
of the foot were affected. The ankle was free from
disease and there was nothing to show that the soft
parts about the heel were diseased. In this case I
performed a Syme's amputation but I performed this
with great care in that I operated in two stages,
adopting, indeed, the method of the Lahore Indian
Medical Service Hospital. I amputated the foot as
ordinarily advised in Syme's operation, but did not
remove the lower end of the fibula and tibia during
the first seance, but, rather, packed the wound with
gauze soaked in a solution of flavin for a week. After
this time I removed my flavin soaked gauze, examined
the flaps, and finding that they seemed clean and un-
affected, completed my operation in the ordinary way.
A student: Why did you perform your Syme's
operation in two stages f Did you not trust your
judgment that the soft parts about the heel were not
affected by tuberculosis t
The clinician: Do you not think that the tubercle
bacilli may be lurking in them and that because of an
operation the circulation may be so disturbed that the
organism may become more virulent or the resistance
in the tissues less strong and the tuberculous infection
become manifest t
In the patient whom I have just mentioned we had
a very good result and I felt that the extra care, and
the precautions used had not been in vain.
CemchuienB
In surgery, perhaps as in all the responsible posi-
tions of life, judgment should dictate our actions. In
some cases of tuberculosis of the foot we may treat
by expectant measures. In others it is wise to am-
putate. In some we must amputate high up. In
others a Syme's operation is all that is necessary. The
Phila., June, 1922]
Medical Diathermy — Folkmar
435
amputation suggested through the leg and the ampu- cated. Amputations of the fore part of the foot and
tation of Mr. Syme are the two operative measures excisions are of no avail. The practice of these m
which should be considered when operation is indi- only causing delay and increased suffering.
Medical Diathermy
Gives Technic That Is Safe and Effective
By Elnora Cuddeback Folkmar,
M.Ph., D.S.S., M.D.,
1730 Eye St. N. W., Washington, D. C.
Following Nature
Diathermy is heat. And heat is essential
to life, to health, to function. Nature cures
no disease, repairs no injuries, repulses no
invading enemy, without an increase in the
production] of heat. There is a natural
basis for the therapeutic use of diathermy. ■
— Editors. |
Dmtktnmy in Hjwerteumhm
BEFORE treating a case of high blood pressure
with diathermy one should ascertain the cause
of the hypertension. If it is a compensatory phe-
nomenon, no attempt should be made to reduce it.
In this ease treatment should be directed to the renal,
hepatic, cardiac, pelvic or other disease of which it is a
compensation. The author has reduced many cases of
hypertension — 190 to 240 mm Hg. — by first treating
the constipation and mucous colitis which was the
source of the toxemia. In these cases after the bowel
is cleared of debris and entero-toxins, diathermy may
be employed — general diathermy by means of the
condenser couch or chair, or better still, local
diathermy through the abdomen. In general di-
athermy use 400 to 800 milliamperes of current dur-
ing a period of 15 to 25 minutes. In local diathermy
use large electrodes and pass a slowly increasing
current of 500 to 2,000 milliamperes during a period
of 20 to 30 minutes.
The blood pressure will usually be found to be
reduced after this treatment from 10 to 30 mm Hg.
The skin will be warm and often bathed in perspira-
tion, and the body temperature as indicated by a
thermometer in the mouth will be increased from one-
half to one and one-half degrees. What takes place
during the treatment t The peripheal vessels are
dilated by relaxation of muscular spasm. The relief
from engorgement of internal organs is shown by
profuse diaphoresis and diuresis with increase in the
amount of solids in the urine. There is an increase
in oxidation and elimination of toxic materials. The
character of the pulse is changed. It is soft and
more regular. Improved metabolism is soon shown
by increase in the physical and mental strength of
the patient.
Dr. de Kraft maintains that "moderate doses of
high-frequency currents applied by the method of
autocondensation (general diathermy) will effect a
reduction in blood-pressure in all cases of simple
hypertension."
Diathermy in Hjpntenmwm
There is a class of cases that gives the physician
even more trouble than the high blood-pressure cases.
These complain of chilly feelings, have cold hands
and feet, no appetite, insomnia, mental depression,
no energy, lack of physical strength. They have low
blood-pressure and subnormal temperature. For
these cases diathermy is a very rational treatment,
per se, or as an adjuvant to endocrine, diet, or drug
therapy. Diathermy gives the thermogenic mechan-
ism a rest, by supplying the heat which the body
cannot produce, and thus permits it to resume nor-
mal functioning. Daily treatments of fifteen minutes
to one-half hour should be given on the condenser
chair or couch. Use 500 to 800 milliamperes of cur-
rent. At first, special care must be taken not to
give too vigorous a treatment or the patient may
faint. The oral temperature should be taken before
and again after treatment. There should be an in-
crease of .5 to 1.5 degrees. When the patient re-
tains the increase in temperature until the next day,
treatments may be given on alternate days.
Diathermy in Angina Pectoris
Diathermy through the heart in angina pectoris
is most efficacious for the relief of arterial spasm.
A large indifferent electrode is placed under the
back behind the heart. A smaller electrode is placed
on the chest over the cardiac area. A mild current
of 300 to 800 milliamperes is passed. In a few min-
utes all oppression, all pain, all feeling of anguish
•Read before the Tenth Annual Meeting of the Amer. Aaao. for Medico-Physical Research, on Sept. 27. 1921.
436
Medical Diathermy — Folkmar
[The American Physician
ceases. Nagelschmidt says that if this prompt thera-
peutic effect is not secured, "we may always expect
an aneurism or grave myocarditis." A portable
diathermy apparatus may be carried to the bedside
if a patient is too ill to come to the office.
Diathermy in Myocarditis
The author uses local diathermy through the heart
on alternate days in the treatment of myocarditis.
Cases with weak heart muscle, skipping pulse, ex-
haustion after slight exertion, are in a few weeks of
diathermy treatment made strong, with normal mus-
cle tone to the heart, and have a full, even pulse.
The electrodes should be placed as in angina pectoris,
and a current of 300 to 800 milliamperes passed for
a period of twenty minutes. The benefits of di-
athermy treatments in cardiac conditions may last
for months or even years. In some cases very few
treatments are needed; in others, treatments have to
be prolonged for months.
Local Diathermy in Circulatory Disturbances of the Brain
Drs. Titus and de Kraft, in a paper read before
the American Electrotherapeutic Association in 1920,
recommended diathermy of the brain in some forms
of chronic headaches, especially when due to syphil-
itic lesions, in conditions occurring in people beyond
middle life variously described as cerebral endarter-
itis, nervous breakdown, cerebral neurasthenia, and
in certain cases of epilepsy. Small electrodes about
2 by 3% inches are used. One is placed on the
forehead above the eyes, the other at the back of the
neck against the occiput. The electrodes are held
in place by compresses and a folded triangular band-
age. Dr. Titus uses moist kaolin pads between the
skin and the electrodes. A current of 200 to 300
milliamperes is allowed to pass for a period of
twenty minutes. The author has had most excellent
success with this method, not only in the treatment
of chronic headaches, but also in the treatment of
early paresis. Saberton has noted that this treat-
ment causes the disappearance of the Argyll-Robert-
son pupil. Drs. Titus and de Kraft follow cerebral
diathermy with cerebral galvanism. [The physician
inexperienced in technic must be most careful in
passing an electric current through the brain. —
Editor.]
Local Diathermy in the Treatment of Internal Hemorrhoids
Diathermy relieves the pain of internal hemor-
rhoids. The patient should lie on the side with the
legs well drawn up, the upper one farther than the
lower. A large indifferent electrode is placed on
the hip, the sacral region, or the abdomen. A rectal
electrode warmed and lubricated is inserted with
gentle pressure while the patient bears down. The
uninsulated portion of the electrode should be passed
well beyond the sphincters. A current of 800 to
1,500 milliamperes may be permitted to flow for ten
minutes daily. The electrode should be allowed a
few minutes to cool before being withdrawn. The
same treatment may be used for an inflamed or an
enlarged prostate.
Diathermy in Diseases of the Nervous System
The author has had most excellent results in treat-
ing paralyses due to pathological changes in the
spinal cord. When we consider the pathology of the
cord in certain forms of paralysis it is quite easy
to understand why a general heating of the cord will
relieve the condition. The heating causes increased
circulation, and with increased circulation stasis dis-
appears, fibrosis is removed, there is better cell metab-
olism, cell regeneration, and the resumption of nor-
mal cell function.
Local Diathermy in Ataxia
In the treatment of cases of shuffling, uncertain
gait, cases with a pronounced Rhomberg sway, and
the loss of plantar sensation, the author has found
diathermy an efficient remedy. A long narrow elec-
trode (3Vk by 8 to 10 inches is placed over the
dorsal and lumbar spine) and a large indifferent
electrode is placed under the abdomen. A current of
1,000 to 2,500 milliamperes is allowed to pass for a
period of 30 to 40 minutes. The treatments are given
three times a week over a period of six weeks to
six months. This diathermy treatment may in cer-
tain cases alternate with a diathermy treatment along
the course of the sciatic nerves. In many of these
cases the diathermy treatment is supplemented by
one of galvanism or of f aradism.
Local Diathermy in Infantile Paralysis
Dr. A. C. Geyser reports a number of cases of in-
fantile paralysis, one of them of 17 years' duration
which were greatly benefited by diathermy. The one
thing necessary in these cases is perseverance. The
treatments should be given daily for months. Be-
tween the treatments the limb must be kept warm by
suitable clothing. Diathermy should be applied "di-
rectly and primarily over the site of the spinal lesion
and incidently throughout the entire paralyzed
region."
Diathermy in Neuritis ami Neuralgia
It is easy to understand why diathermy gives such
wonderful results in neuritis. The heating causes in-
creased circulation, and with the increased circula-
tion, stasis in the region of the nerve disappears and
with it the pain caused by it. A temporary increase
in pain is often noted when treating a nerve about
which there is a stasis or when treating a joint in
which there is stasis and fibrosis. This temporary
increase is a welcome symptom, as it warrants a
favorable prognosis. In cases of sciatica accompany-
ing lumbago large electrodes should be used, one over
the lumbar and sacral regions and one under the
abdomen. A current of 800 to 2,000 milliamperes is
passed for a period of 30 to 40 minutes. In cases
where great pain is experienced along the course of
the sciatic nerve, this treatment may be supplemented
by placing a large indifferent electrode over the lum-
PhU*.. Jane, 1922]
Medical Diathermy — Folkmar
437
bar sacral region, and a roller or condenser electrode
applied with firm pressure along the course of the
nerve.
A most distressing neuralgia for which drugs and
surgery have failed to give satisfactory relief is
chronic trigeminal neuralgia or tic douleureux. Dr.
A. C. Geyser recommends diathermy. An active elec-
trode about the size of a silver dollar is placed just
in front of the ear on the affected side. The face
lies on a large indifferent electrode. A current of
200 to 400 milliamperes is passed. The comfort of
the patient determines the amount of current used.
The treatment is repeated daily. The author has thus
treated two cases successfully. Another method of
applying diathermy in tic douleureux is for the phy-
sician to throw himself into the circuit by holding
the active electrode in one hand and applying the
fingers of the other hand after the manner of Dr.
Owen to the affected area. In this way the amount
of heat is controlled to a nicety.
Lumbago, a painful inflammation of the fascia and
fascial sheaths of the muscles of the lumbar region,
yields like magic to local diathermy. Have the
patient lie on pillows on a couch or table. Place
under the abdomen a large indifferent electrode, and
an active electrode, about 5 by 7 inches, over the
lumbar region. Hold the latter in place by sand
bags and small blankets, the ends of which are tucked
under the pillows. Cover the patient with a blanket.
When all is ready turn on a current of 500 milli-
amperes. Every one to three minutes increase the
current 300 to 500 milliamperes until a maximum of
2 to 2% amperes is reached. Allow this current to
flow for 20 minutes and then gradually reduce the
current during a like period. The author follows
this diathermy treatment with ten minutes of faradic
rhythmic massage of the lumbar muscles. The first
treatment often gives relief from pain. A few treat-
ments relieve all symptoms. A similar treatment is
used by the author in treating fibrocitis of the
trapezius.
Dittkermy im At Trtrntme* of Unom of At Bom$ mmi Johd$
For case histories and technic in the treatment of
stiff and painful joints by diathermy, the members of
the Association are referred to papers presented by
the author in 1920 at the annual meetings of the
American Electrotherapeutic Association and of the
Central Society of Physical Therapeutists. Since the
presentation of these papers the author has treated
three cases of fractures of bones of the foot with ex-
cellent results. In one case with three bones fractured,
a plaster east was applied. Before applying the cast,
flexible electrodes of proper size and shape were ap-
plied and held in place by adhesive strips. These
electrodes were connected to small strips of tin which
passed through the plaster east. Treatments of 20
minutes, 400 to 500 milliamperes, were given daily
for 20 days. Result : when cast was removed a week
later there was found an abundant formation of
callus, and there was no limitation of motion due to
fixation. The patient suffered practically no pain
after the first diathermy treatment.
Dr. A. B. Hirsh reports in the September, 1921,
number of the American Journal of Electrotherapeu-
tics and Radiology, a number of cases of bone lesions
which were successfully treated at Fox Halls, Staten
Island, by diathermy. Among the eases reported were
a number of delayed union and others complicated
by infection. Dr. Hirsh concludes: "Based on the
now undisputed fact that diathermy brings about a
marked enlargement locally of existing blood vessels,
if not also in actual growth in their number, and
judging from the cases . . . quoted, it is rea-
sonable to anticipate more and more increase in bone
deposit for cases of delayed union or bone graft; re-
moval of osteomyelitis, where present; cessation of
infection, and closure of the cavity by granulation."
The author believes that the time is past when it
is necessary for a patient to suffer for days from a
bone or joint trauma, when it is necessary to expect
a fibrous ankylosis as the sequel® of trauma, of artic-
ular rheumatism or of dental infection. Diathermy
is destined to become quite as important to the sur-
geon and orthopedist as are splints and bandages.
The layman now demands the X-ray as a confirma-
tory diagnosis. He will soon demand diathermy treat-
ments in bone and joint lesions.
Dwikermy m Imfectmm of the RttpirMorj SytUm
Diathermy is one of the most valuable aids in the
treatment of acute and chronic infections of the res-
piratory system. A number of prominent electro-
therapeutists have reported cases of pneumonia, bron-
chitis, empyema, and pleural adhesions in which di-
athermy was used with gratifying results.
Dr. Geyser read before this Association last year
an "Address on Phthisis Pulmonalis," in which he
recommended diathermy as the physiological method
for the local treatment of tuberculosis. It is the only
way in which the amount of blood circulating through
the lung tissue can be increased. The entire pul-
monary area is heated through and through, the pul-
monary capillary system is dilated with the result of
diapedesis of the leucocytes. This leads to the forma-
tion of giant cells around the bacilli and of wander-
ing cells around the giant cells, thus completing
nature's method of tubercle formation. Oyster and
clam broth are given to furnish the necessary lime
salts for tubercle formation. And when the hemo-
globin percentage is below 80 per cent., intravenous
injections of cacodylate of iron are given twice
weekly.
The diathermy treatments are given at least every
other day. Large flexible electrodes are placed on
the posterior and anterior surfaces of the chest, and
the current is turned on and gradually increased to
1,500 milliamperes. The duration of treatment is
from 30 to 45 minutes. After the second week if
438
Medical Diathermy — Folkmar
[The American Phynctan
there are no counter-indications the current strength
may be increased to 2,000 or 2,500 milliamperes.
The diathermy treatment is followed by sponging the
parts with cold water and allowing the patient to
rest in a recumbent position for an hour. Dr. Geyser
reports that incipient cases show 100 per cent, cures,
that from 60 to 80 per cent, of second-stage cases
become closed cases, and that third-stage cases are
made more comfortable and their lives prolonged. In
cases with a history of hemorrhage, diathermy must
be used very guardedly. Only mild currents for short
periods can be used the first few weeks.
Diatkermy in Infection* of the Genite-Urinary Trad
Nagelschmidt used diathermy for the successful
treatment of gonorrheal urethritis. A sound passed
into the urethra is used as the active electrode. A
iarge plate is placed on the abdomen for the indif-
ferent electrode. Cumber batch reports successful
treatment of three cases of gonorrheal urethritis by
diathermy.
Cumberbatch devised a method for the treatment
of gonorrheal cervicitis. "The vagina is kept patent
by a tubular glass speculum. As an active electrode,
a copper rod is used. It is inserted into the canal
of the cervix. Instead of the rod a metal disk elec-
trode, % to % inch in diameter, may be pressed
against the cervix, with a felt disk of rather larger
size, soaked in salt solution intervening. . . . The
indifferent electrode is placed on the back or ab-
domen." Treatments were given twice a week and
the duration of treatment was 10 minutes. The suc-
cess of diathermy as a treatment in gonorrheal in-
fections is due to the fact that the gonococci cannot
live in a temperature above 101 degrees. The author
has had no experience in treating gonorrheal infec-
tions with diathermy.
Several physicians have reported good success in
the early treatment of gonorrheal infections of joints
with diathermy. If the infection has progressed to a
point where permanent structural changes have taken
place, such as the destruction of inter-articular carti-
lages, diathermy cannot be expected to yield good
results.
Diatkermy in Nephritis
The author has had most excellent results with
■diathermy in cases of nephritis. Cases showing large
amounts of albumin and casts in the urine with more
or less pronounced symptoms of uremic poisoning
have cleared up under diathermy through the region
of the kidneys.
Diathermy in Malignancy
This is too big a subject to receive proper attention
in this paper. Dr. Geyser presented a paper before
this Association last year on "Diathermia and the
Physiological Treatment of Cancer." He maintains
that the important thing in the treatment of cancer
is so to change the nature of the growth that it will
produce less and less toxin. Cancer growths are
firmer, harder, and less vascular than normal tissue.
For this reason "the malignant mass is always of a
higher temperature after applying diathermy than
the surrounding normal tissues.'9 Dr. Geyser gives
treatments daily or on alternate days for sixty min-
utes with the current turned on to the point of toler-
ance. He sums up the result as follows: "Cachexia
is prevented or removed; the tumor mass undergoes
a retrograde metaphormosis; individual nodules
soften and they become smaller and disappear; pain
ceases entirely; discharges lessen and lose their of-
fensive odor. . . . The patient gains weight and
appears to all intents and purposes normal."
The author wishes to offer the caution that great
care should be exercised in using diathermy in the
treatment of cancer, for it must be remembered that
low degrees of heat stimulate the growth of cells.
Diathermy does give new life to the sick cells about
the cancer which are bathed in what Geyser calls
"cancer juice."
At the last meeting of the American Electrothera-
peutic Association two papers were read which will
have a considerable bearing on the treatment of can-
cer by X-rays. Dr. Sampson has demonstrated that
if the patient is subjected to a course of exposures to
actinic rays until there is a good tanning of the
skin, an X-ray dermititis is impossible, no matter
what dose of X-ray is given. And Dr. de Kraft
gave a preliminary report on the use of diathermy as
a means of localizing and increasing the efficiency of
deep X-ray therapy. He says : "Diathermy seems to
render tissues more sensitive to X-rays. . . .
This activating use of diathermy is possible only
when it directly precedes the X-ray, and it is neces-
sary to heat the part thoroughly and extensively, but
short of actual damage to the tissues." He believes
that the beneficial effects of this combined method of
treating malignant growths is due to the fact that an
active hyperemia favors the migratory excursions of
the wandering ions of the tissues, and that this in
turn favors the ionization effect of the X-ray. More-
over, diathermy revitalizes the sick impoverished cells
bathed in the pathologic juices surrounding the can-
cer tumor, and increases their resistance to the de-
structive action of the X-rays. Dr de Kraft re-
ports a case of sarcoma of the femur which he treated
over ten years ago with combined diathermy and
X-ray applications. The tumor was absorbed and the
patient restored to health. The patient is still in
good health.
Cemehumm
To recapitulate : medical diathermy is a therapeutic
means of increasing the general body temperature or
any portion of the same within physiological limits by
the passage through it of a very high-frequency cur-
rent. Its indications are many. Yet, it is not a cure-
all. In some cases it is the indicated remedy. In
Phila., June, 1922]
Obeerratfoa: Faulty Shoes — Cross
439
others it is a most excellent adjuvant or antecedent
to other therapeutic measures; for we must ever re-
member that diathermy is heat and heat only. Heat
is essential to life, to health, to function, nature cures
no diseases, repairs no injuries, repulses no invading
enemy without an increase in the production of heat.
This increase is called fever or inflammation. Di-
athermy furnishes the needed heat for nature's
processes without taxing the heat regulating forces.
And it furnishes it, when it is wanted and where it
is wanted. Diathermy is truly a wonderful hand-
maiden to medicine.
Concluding paper on "Diathermy in the Treatment
of Lesions of Bones and Joints" will appear in next
issue.
Observation
Litcrater*
Many articles on diathermy have appeared in the medical
journals and in the proceedings of medical socities daring the
past three years. These are too numerous to enumerate here.
Among the earlier books should be mentioned :
Denoyes, Le Docteur, J. "Les Courantes de haute frequencie.
Proprietes physiques, physiologiques et therapeutiques. Paris,
1902.-
Kowarschik, Dr. Joseph. "Die Diathermic. Berlin, 1913/'
Nagelschmidt, Dr. Franz. "Lehrbuch der Diathermic fuer
Artse und Studierende. Berlin, 1913."
,WHhin the past year two books on Diathermy have been pub-
lished in London.
Cumberbatch, Elkin P.. M.A., M.B.. M.R.C.P. "Diathermy.
Its Production and Uses in Medicine and Surgery."
Saberton, Dr. Claude. "Diathermy in Medical and Surgical
Practice." The latter has an excellent bibliography on Diathermy
in the appendix.
A book by Bucky has appeared in German. This is being
translated by Dr. Geyser and will soon be published with addi-
tions by Dr. Geyser.
Three books which have appeared within the last two years
should be mentioned because each contains a valuable chapter
on Diathermy.
Jacoby, George W.. M.D., and Jacoby, J. Ralph, A.B., M.D.
"Electricity in Medicine." Philadelphia, 1919.
Humphries, Francis Howard, M.D. "Electro-therapeutics for
Practitioners." London. 1921.
Grover, Burton B., M.D. "Hand-book of Electro-therapeutics."
Philadelphia. 1921.
Oxygen Inflations of Peritoneal Cavity in
Tuberculous Exudative Peritonitis
Stein (/. A. M. A., March 14, 1922) reports what he
believes to be the first case to be reported in the United
States of an apparent cure of tuberculous peritonitis of
the exudative type by the sole means of therapeutic pneu-
moperitoneum. The patient was a woman, age 32, who
five months after a laparotomy manifested acute symp-
toms of tuberculous exudative peritonitis. A roentgeno-
gram was taken following artificial pneumoperitoneum.
Roentgenograph ically, the case presented evidence of
tuberculous peritonitis. The oxygen which was injected
at the time of the pneumoperitoneal roentgen-ray
examination was not withdrawn. Thirty-six hours later
there was still some oxygen present. The whole pro-
cedure did not cause the patient the slightest discom-
fort, and the improvement in her general condition after
this single inflation was most marked. Three additional
injections were made, two, four and six days later.
The patient, apparently, made a complete recovery.
Faulty Shoes
and the
Trouble They Cause
By Charles Cross, M.D.,
Fifth Avenue and California Street,
San Francisco.
FOLLOWING THE STUDY of anatomy, ac-
cumulation of knowledge about feet and foot
ailments is continued by cultivating the power of
observation.
"As men after all
Are only boys grown tall."
Rule IV, Sanitary Service, Boy Scouts' Training
Camp, Cazadero, California, covers the ease very
well : "Cultivate the power of observation and make
your head save your heels." Therefore: look at the
feet you meet as you greet, on the street. This tells
how to begin, and just where to find ample clinical
material, to cultivate the quality of observation.
Cmttwcte Power of 0h**r9mtwm
Just coming in from an early morning scouting
tour of observation, I will relate some of the things
I saw. They are just what can be seen any day, on
almost any street, and in any city or town.
Mentioning names, by way of an introduction, may
enable the reader to more readily recognize some of
the feet we meet.
Stories Shut TtU
To be seen in the morning, probably on the way to
work, is Peggy Pinch Toe. It is easy to see "the
price she paid" — not for her shoes, nor even for her
stockings, nor any of her garments, or her troubles,
but for the grouch she will have about 5 P. M.
Then there is Birdie Short Shoes. Birdie weighs
about eighteen stone, and looks the part. She wears
shoes for weight about eight stone less. If she works
in a store, and stands at her work, I will bet she is
never late at quitting time, and God help the cus-
tomers who appear before Birdie after 4 P. M.
There goes Willie Worn Heel, heels worn down and
half as thick on the outer side as on the inner. Also
Willie's brother, smaller and younger, right heel turn-
ing to the outside, left heel to the inside. Both grow-
ing up to be afflicted and inefficient.
Now comes Hortense Wabbly Foot. Watch the
wabble action of foot and ankle, and the wasted leg
energy, generators of reduced efficiency. At each
step her high-heeled majesty takes, she adds to her
inefficiency. She will not feel well at 3 P. M.
There goes Ben Slow Foot, probably crippled for
Observation: Faulty Shoes — Cross
[The American Physician.
life. After him comes Sarah Grind Heel. Sarah is
on the way to being crippled for life.
Here comes Dowager Antique Society-Bud. The
Dowager is out on a shopping tour. She walks on
her heels. Why doesn't she go over on the A. M. A.
(Anterior Metatarsal Area) and give her step the
elasticity of jazz!
There is Mary Wise One. Mary thinks she knows
much about shoes, but today she is limping. She has
on new shoes. From appearances, they have flexible
shanks. Trouble is brewing in the E. L. A. (External
Longitudinal Arch). The distress seems to extend up
get something besides new shoes and shoe elerk treat-
And thus the processions winds painfully on. Each
pair of feet tells a story, and each face registers age-
lines caused by foot ailments.
The symptoms observed in the cases mentioned are
a'most pathognomonic of the ailments which cause
them. A little practice in observing feet on the
street and ability to make sight diagnosis is readily
acquired.
Now continuing the "observatory" part of this in-
A re*l foot inspection by Dr. Churl™ Cm
■nd staff at Boy Scouti Training
the entire leg and thigh. I wonder why Mary limps T
Coming across the way is Mrs. K. Lee Bird and
her five-year-old daughter. They are out early.
Mother's feet are badly pinched and she is raising a
fine crop of corns and bunions. But her feet are not
interesting this morning. It is the child's feet. Oh,
yes, the child has other shoes. They look the part of
many pairs of shoes. But the feet, and the manner
of the child's walk, are not in keeping with the rest
of the make-up. The heels both turn out, the ankles
wabble, and walking is difficult. That child may be
suffering from retarded bone development. She is on
the way to be crippled for life if those feet do not
struction, if the student cannot do any better, he can
begin closer inspection on his own feet. This is the
one time that studying anatomy in a swivel chair, or
in a drawing room, is recommended.
' In the next Footlights on the Feet, No. 4, another
step of interest will be taken. Approaching the sub-
ject in a manner never before attempted, and bring-
ing under scientific consideration a humane service
the world calls for, every physician and surgeon can
aid in this work.
The prevention of foot ailments is to the human
race one of the most important and valuable prophy-
lactic measures ever undertaken by medical graduates.
While surgery, the specialties, hospitals, people are to bo served, tho primary tm> ordinated m constructive co-operation wish
institutional medicine, public kcolth work, portance of tho function of tho Gtncroi the essential service of the Family Physician,
industrial medicine, etc., home their definite Practitioner must be recognised. Other dwi- This is an integral purpose of The American
functions, if the best health interests of the sions of medical service must be properly ce~ Physician.
The Absence of Treatment in Institutional Work
ADVISORY to a commission on lunacy, in a case
in which recovery from lethargic encephalitis
was incomplete, leaving a psychosis, we were struck
by the fact that the sufferer, despite the fact that she
had spent all her money in various institutions, really
had received almost no definite treatment. Frequently
we eneounter cases of more or less advanced tubercu-
losis that have "graduated" from special institutions
for the treatment of tuberculosis, and we discover
complications that have been allowed to develop
almost without any sustained treatment thereof. Five
years ago we appeared as an expert for the common-
wealth in a murder trial in which the defense set up
an insanity plea and sustained it, we may add with
our help. The boy was committed to an asylum for
the insane. Today we met his father, who complains
bitterly that while the boy is well taken care of and
likes the institution, he has received almost none
but custodial care, and he feels that both medical
and surgical treatment was, and is, needed in the
case, a lay opinion with which we agree. Such com-
plaints are common. We have much contact with
penal institutions and are often grieved over the
medical and surgical neglect of prisoners. Correc-
tional institutions are better, but even in them there
is an un justified neglect of definite treatment in many
cases.
Why
There are institutional and professional reasons for
this neglect of treatment. First, the institutional
ones. An institution gradually attains to a factory
point of view; it is standardized, dehumanized, card-
indexed, and managed more from the office than from
the ward, and the result is the stressing of material
rather than the human angle. Where boards of man-
agement are politically selected the matter is worse
than if free selection is practiced, and it must be
noted in passing that ecclesiastical and organization
politics, when it rules an institution, possesses all of
the evils of state and municipal politics and is even
more narrow and less subject to review. Another
factor is that of shortage of money and the small
budget provided for professional service, resulting in
an indifferent and numerically inadequate personnel.
It is common observation to find in institutions an
up-to-date laundry and an out-of-date operating
room, oriental rugs and art features in the reception
and Board rooms and a poorly stocked drug room,
beautiful grounds and a fine garage and a very de-
fective treatment room, every possible office appli-
ance and instruments that ought to be junked out in
the wards and nurses' offices.
Professionally, there is, perhaps, more therapeutic
nihilism in institutions than is found outside; this
is a big factor in the neglect of treatment. Then,
too, entirely too much detail is left to young internes
and advanced students; they lack in initiative and
get into ruts and are not sufficiently supervised.
Worse yet, the bulk of the work, even the treatment,
is too commonly left to nurses. Nurses are very use-
ful as nurses, but they are not doctors; many of
them .have complained to us that they are up against
it and are doing the best they can and often feel that
their patients should have technical care they are not
receiving. Marble walls, clean sheets, elaborate bed-
side charts, never-followed-up laboratory reports by
technicians who never see the patients, and even a
good dietician, do not cure the patients; cure requires
the constant and everlasting attention of a very hu-
man and really interested physician or surgeon actu-
ally at the bedside.
Doctor, Your Duty!
Doctor General Practitioner, when you send your
car to the garage for repairs, do you leave it all to
the garage man and his assistants? You certainly
do not. Then why, when you send one of your
patients to a hospital or other institution, do you
forget the case and keep outf
Perhaps you feel that your presence will be re-
sented. What if it is! There is something wrong
in an institution or hospital that resents a follow-up
by the medical attendant of the admitted patient.
There is no occasion to be hypercritical or officious
in your attitude when visiting your patient in the
ward of an institution in which you are not a staff
441
442
Absence of Treatment in Institutional Work
[Phila., June. 1922
member; but the institutional physician owes the
same courtesy to you as a consultant that he is in
duty bound to show to a consultant in outside prac-
tice.
Perhaps some of the faults encountered in insti-
tutional work, more especially the fault of neglect of
definite treatment, will be promptly corrected if the
institutions know that attending physicians are apt
to step in at any time and go over the cases.
The Other Side
The harassed medical superintendent of a hospital
or institution is a very busy man. He knows the
lapses and defects; he runs the risk of being "fired"
many a time when he "fusses it out" with cheese-
paring trustees, and, like as not, he will be delighted
if you get acquainted with him and his work and
help him to get things changed. He wants a little
outside pressure to be exercised; it lets in daylight
and fresh air. Perhaps, if you are tactful, fraternal
and courteous, you can help him and the patients you
send in. We general practitioners are well aware of
two needs in the country at present. The first is the
imperative need, in governmental and public affairs,
that business be placed in the hands of business men ;
and the other imperative need is to place medical
affairs in the hands of doctors. We have too many
amateurs and bureaucrats in charge in both direc-
tions. Now that medicine and health affairs have
become so much of a public concern, it is up to the
doctors— up to you — to get out of the individualistic
shell and mix in. We have pointed out one way to
do it.— T. S. B.
Actinothcrapy in General Practice
F. J. Kern (in the Ohio State Medical Journal), con-
cludes :
"1. Actinotherapy (actinic rays — artificial sunlight) is
an effective mode of treating many chronic and obscure
cases which the general practitioner heretofore had to
refer to the specialist."
"2. Ultraviolet rays are antiseptic, bactericidal, mark-
edly analgesic, nerve sedative, and greatly assist in pro-
moting general metabolism.
"3. Actinotherapy is one of the best treatments in
early stages of tuberculosis wherever found, and far
superior to natural sunlight on account of its applica-
bility at all places and in all climates. It is of special
merit to patients who are unable to go to sanitoria and
who wish to be with their families during the treatment.
"4. In simple neuralgia and neuritis the actinic rays
are almost specific, giving, in many cases, immediate
relief.
"5. Severe reactions and prolonged treatment are
often necessary to obtain satisfactory results in some
chronic cases.
"6. Only the men who use this modality persistently
and conscientiously know its real value."
Bleeding From the Rectum: Its Significance
and Treatment
Joseph F. Saphir (Amer. Proctologic Society, June 3.
1921) said that blood passed through the anus from
any part of the gastrointestinal tract is a most alarm-
ing symptom. The nearer the source of the bleeding
is to the anus the brighter and fresher the blood is,
and the further away, the darker and more clotted it
is. The general appearance of the patient is often an
index of the importance and severity of the bleeding.
He described as sources, internal hemorrhoids, rup-
tured external hemorrhoids, fissures and ulcers, pro-
lapse of the rectum, polypi, multiple ademonata, intus-
susception of the sigmoid, chancres, chancroids, anil
condylomata, villous growths, systemic diseases as
malaria, scurvy, tuberculosis, etc, hemorrhagic proctitis
and carcinoma,
He then considered primary and secondary operative
hemorrhage, describing how such accidents occur, how
they may be avoided, and how treated; and laid par-
ticular stress on the danger and deceptive character of
concealed secondary hemorrhage, the possible need of
hypodernioclysis or transfusions in its treatment
He said that bleeding from the rectum is so common
that many patients neglect it so long before consulting
a physician, and the physicians when consulted, neglect
adequate examination so long, that serious hemorrhage
and profound anemia often result before proper atten-
tion is given to it. For similar reasons carcinoma is
often overlooked till it is too late. And he concluded
that the fault lies in the lack of proper teaching of
digital and proctoscopic examination, so that students
are sent out from medical schools unprepared to inter-
pret the importance of significance of rectal bleeding,
and unprepared to give the sufferers the proper care
and treatment.
Effect of Organ Extracts on Blood Pressure
According to Roger in Presse Mi die ale, all tissues
and organs yield substances which act on the heart and
blood vessels, those from the adrenals, thyroid and
pituitary having, in particular, been studied. The action
varies according to whether the substance has been ex-
tracted by trituration and maceration in salt solution,
or obtained by antolysis. For example, lung extract
obtained by maceration lowers the blood pressure owing
to the presence of colloids in the filtrate; but lung
extract obtained by antolysis raises the blood pressure.
A more dependable method than antolysis is extrac-
vary according to which of these groups of agents is
tion by acids or alkalies. But here, also, the effects
used.
Health Department and the Medical Profession
Donald D. Shira (in The Ohio State Medical Jour-
nal), says that an ideal system for solving the public
health problem and for delivering the maximum of
service to any community can only be perfected by tbe
closest kind of co-operation between the medical pro-
fession and public health agencies. The consummation
of this union can only be accomplished by a health com-
missioner whose relationship to the physicians is deter-
mined not by mandates spread upon the statute books,
but by broad sympathies with the aspirations and ideals
of the medical profession. Because, after all, this group
is the keystone in the arch of public health work, and
public health work must co-operate with the physicians
in the community to their advantage and betterment as
well as the advantage of the people in general.
The American Physician]
The American Physician
443
Sluggish Bowel Action in Childhood
is usually due to errors in feeding. Subjecting these fundamentals to the cus-
tomary careful correction,
INTEROL
may be administered coincidentally to relieve the immediate condition.
This pure, tasteless and odorless mineral oil — notably free
from the greasiness common to such products — has proved
of exceptional value as a safe and dependable means of
moving the bowels of young children, and this without the
griping, straining and after-constipation by which the use
of castor oil and other drastic cathartics is so frequently
attended.
The constantly growing number of physicians who prefer
INTEROL to any other media in the routine management of
constipation in early life is its own best endorsement
Sample and Interol brochure on request
Allied Drug and Chemical Corporation
2413 Third Av». New York City
Manufacturers of
OKASEPTINE — Internal «nd External Antiseptic, Wash, Spray and Douche.
ADACCO SALT— Effervescent Saline Laxative and Uric Acid Solvent.
VELOGEN— "The Doctor's Handmaid and Household Emollient."
DoMft ia Children
Begin with a half to
one teaspoonful, 3 times
a day before meals. In-
crease or decrease dose
until one food movement
is obtained daily. Then
gradually decrease to the
point where a small dose
at bedtime will maintain
this result.
DEFINITE DIURETIC DEPENDABILITY
combined with strengthening and regulating action upon the
heart, thus securing resorption of effused fluid, is brought about
and maintained by
ANASARCIN TABLETS
which exert the valuable physiological action of squill, oxy-
dendron and sambucus, without however producing stomachic
or renal irritation or circulatory disturbance. Action is prompt,
efficient, prolonged.
ANASARCIN is invaluable in ASCITES, ANASCARA, CARIAC VAL-
VULAR LESIONS, ALBUMINURIA OF PREGNANCY, POST-SCAR-
LATINAL NEPHRITIS, CHRONIC BRIGHT'S DISEASE; also to
prevent tachycardia in EXOPHTHALMIC GOITRE, CARDIAC NEU-
ROSIS, etc.
Sample and literature on request
THE ANASARCIN CHEMICAL CO. Winchester, Tenn.
Mentioning The American Physician Insures Prompt, Careful Service
444
Human Actinomycosis
[Phfla., June, 1922
Human Actinomycosis
Mattson (Sur., Gynand Ob., April, 1922) conclusions
are:
1. There is but one true species of micro-organism
capable of producing actinomycosis in man and lower
animals and this is the one isolated by Wolff and Israel
and later more fully described by Wright.
2. There is no convincing clinical evidence supporting
the theory that this organism is a normal inhabitant of
the oral cavity and gastro-intestinal tract of man.
3. There is much clinical and biological evidence that
this micro-organism has its source outside of the
human body and is capable of a dual existence: first
as a saprophyte in old sod soil from which it gains
access to grains and grasses and through this medium
or intermediary host, so to speak, it becomes capable of
infecting man and lower animals.
4. In order for infection to take place two things
are necessary: first, an abrasion of the tissues; second,
the fungus must in some way be brought directly in
contact with this abrasion.
5. Animal-to-man infection is far more common than
we have been led to believe it was by earlier investigators.
6. Human actinomycosis is not a rare disease, but a
disease which is often overlooked or incorrectly diag-
nosed.
7. Every inflammatory swelling of chronic or suba-
cute nature with persistent and recurring sinus forma-
tion should be carefully investigated for this disease.
8. A negative smear, on first examination, does not
rule out infection as the fungus, in the presence of
mixed infection, is often very difficult to find.
9. The disease should always be kept in mind in
every case atypical pulmonary tuberculosis and should
be looked for in cases suffering with chronic purulent
bronchitis or bronchiectasis.
10. Early treatment of superficial lesions are highly
successful. Internal infections are extremely fatal and
hopeless.
Treatment of Entero-Colitis in Infancy
The indications for treatment, according to W. W.
Harper (Southern Medical Journal) are:
1. Prompt cleaning of the intestinal canal by cathar-
sis and enema. An
2. Withdrawal of all food for 24 to 48 hours.
3. Sowing intestinal canal with virile strains of lactic
acid bacilli.
4. An abundance of water by (a) Mouth; (b) Rec-
tum; (c) Hypodermoclysis.
5. Free administration of alkalies and if acidosis
threatens, the use of carbohydrates.
6. Adopting measures to prevent urinary suppres-
sion.
7. Early return to the breast or bottle.
As an initial purge, castor oil is to be preferred. A
soda enema (two teaspoon fuls of soda bicarbonate to
a quart of warm water) is given every six hours for
the first 24 to 48 hours. All food is withdrawn at once
and water forced — the minimum amount of water to
equal the amount of milk taken in health. To encour-
age the drinking of water, it may be given as iced
tea, lemonade or orangeade sweetened with saccharin,
one tablet to the pint. If the baby refuses to take the
fluids, or if there is marked nausea or emesis, the fluid
should be supplied by hypodermoclysis, giving 6 to 8
ounces every 6 to 8 hours to an infant six months old.
As soon as the castor oil is out of the stomach give
a lactic acid bacillus tablet in sweetened water every
two hours. These should be continued until stools are
normal. As acidosis is the greatest danger in this type
of infection the urine should be kept alkaline with bi-
carbonate of soda, or soda citrate, 5 to 10 grains every
2 hours to a child six months old. It is rarely necessary
to continue the alkali longer than 48 hours. If the baby
is on the breast, nursing is resumed at end of 24 to 48
hours. Carbohydrates must be given in threatened
acidosis, as evidenced by acetone in the urine, cherry-
red lips and hyperpnea. Toxic nephritis with impend-
ing anuria is best combated with hot baths, hot packs
and warm soda flushes of the colon. For restlessness,
give chloral by enema or morphine by needle. As a
stimulant, atropine in fairly large doses is useful. Where
the stools are large, frequent and watery, .opium is
often a life-saver, either paregoric by mouth, or mor-
phine by hypo. Intestinal antiseptics and astringents
are to be condemned.
The Prevalence of Free Hydrochloric Acid in Cases
of Carcinoma of the Stomach
(Hartman, Harold R., Am. /. Med. Sc.t Feb., 1922.)
The author points out the habit we have acquired of
considering achlorhydria as a diagnostic sign of carcinoma
of the stomach, until at present one hesitates to make a
diagnosis of carcinoma in the presence of an appreciable
amount of free HC1 in the gastric contents.
A study was made of the cases of gastric carcinoma
occurring at the Mayo Clinic during the years 1918, 1919,
1920. During these years, there were 551 patients with
gastric carcinoma and 80 patients with carcinomatous
ulcer operated on. Forty-five per cent of the cases
were diagnosed ulcer, 41.25 per cent, cancer, and in 12.15
per cent, the diagnosis was suspected gastric malignancy.
The normal amount of free HC1 was estimated at
from 20 to 40. With regard to location, in 51.85 per
cent, of pyloric lesions, achlorhydria was present In
5.05 per cent, of pyloric lesions there was hyperacidity.
In the cardiac portion, the achlorhydria was 61.54 per
cent, and the hyperacid 5.12 per cent, from which it is
apparent that the location of the lesion does not influence
the degree of acidity. In all cases recorded, 21.95 per
cent, had a hyperacidity, that is to say, hyperacidity ex-
isted in more than one case out of every five.
When the cases of gastric ulcer undergoing malignant
changes are included, it is found that 26.93 per cent,
or about one case out of every four, had normal or
hyperacid findings. Over 42 per cent, had some free
HC1 present, which means that one should expect to
find free HC1 present in about every other case.
In a word, therefore, achlorhydria is present in a
little less than one half the cases of carcinoma of the
stomach, and normal or hyperacid values in more than
one-fourth.
The acid values are the highest readings obtained by
the fractional method.
Both syphilis and gonorrhea may cause blindness, says
the United States Public Health Service, the first
usually through inheritance and the second by infection
of the new-born child. The latter may become blind
in a single day if the attending doctor has failed to
cleanse its eyes with a few drops of a one per cent
solution of silver nitrate. Most states have for some
time required this treatment. Six more — Idaho, Mis-
souri, Nevada, New Mexico, Oklahoma and Texas-
passed laws requiring it at their latest legislative sessions.
Doctors failing to obey these laws are liable for damages
if blindness to the new-born results. Insistence on the
treatment will practically remove this source of
blindness.
{continued one leaf over.)
The American Physician]
An Honest Market Place 445
Perhaps it is coffee that
S
increases their "nervousness
UCCESSFUL treatment of the neurasthenic is one
of the perplexing medical problems.
In most cases tension-producing drugs are contra-
indicated, as generally any agent that increases tension
tends to increase nerve irritability.
There is now no doubt in the minds of many careful
clinicians, but that caffeine tends to raise blood pressure,
increase nerve irritability, induce insomnia, disturb di-
gestion, and predispose to under-oxidation disorders.
With these facts in mind, may it not be well to
instruct your neurasthenic, and your blood tension cases
to stop tea and "coffee for awhile, and drink rich, deli-
cious Instant Postum?
Postum is a pure cereal beverage with a coffee-like
flavor, preferred by many former coffee-drinkers even
to coffee itself ; and Postum is entirely free from caffeine
or drugs of any kind.
Your patients can order Postum in any first class
hotel or restaurant. Also on dining cars, ocean and lake
boats; and it is sold by grocers practically everywhere.
Samples of Instant Postum for individual
and clinical test will be sent on request to
any physician who has not received them.
Postum Cereal Company, Inc.
Battle Creek, Michigan, U. S. A.
Mentioning The American Physician Insures Prompt, Careful Service
446
Book Reviews
[Phila., June. 1922
Quinine and Urea in the Treatment of
Internal Hemorrhoids
Emmet H. Terrell (Amer. Proctologic Society, June
3, 1921) stated that he has used quinine and urea
hydrochloride in the treatment of selected cases of
internal hemorrhoids for the past eight years. He finds
it a safe and dependable remedy, but calls attention to
the fact that there are a few individuals with an idio-
syncrasy to quinine. Three of his patients were found
to have such susceptibility, and developed annoying but
not alarming symptoms following the injection of hemor-
rhoids with a fwe per cent, solution of the drug.
The remedy causes a gradual atrophy, not a slough-
ing, of the hemorrhoidal tumors, probably by diminish-
ing the blood supply to the parts through pressure.
He uses the remedy only in simple, chronic, internal
hemorrhoids, and advises against its use in the presence
of inflammation or where there are complications de-
manding surgical intervention. Only about fifty per
cent, of cases, he said, are well suited for this ambula-
tory form of treatment.
The technique used, which is rather simple, he de-
scribed in detail.
He maintained that approximately one hundred per
cent, of absolute cures will be obtained from the use of
this remedy, if the operator will use proper discretion
in selecting for treatment only such cases as are suit-
able.
*Book <Iie7>iews
If a dog and a child were both in eminent danger and
only one could be saved, which one would you save?
The Anti-Vivisection Bill saves only the animal and will
cost many human lives if it is not defeated.
The Physician Himself
The Physician Himself, by D. W. Cathell, M.D„ Bal-
timore. Published by the Author, Emerson Hotel,
Baltimore, Md. Cloth, 360 pages Price, $3.00. For
sale by the book trade and by the author.
When a medical student, over a third of a century
ago, the reviewer read an early edition of this book,
and the teachings therein saved him from many an error
in tactics in later practice. Now, after its many editions
have each and all served to guide the footsteps of pro:
f essional men, this final or "Crowning Edition" brought
out when the author is eighty-three years of age, was
read and approved just as it helped us long ago. There
is no senility manifest in this very philosophical and tact-
ful work, for the author has kept up with the times and
his teachings are just as potent now as they ever were.
Every physician should occasionally pause and take
account of stock, seeing himself as others see him. This
book, if sincerely received by the reader, holds up a
mirror for him to view his conduct, his ethics, yes, his
very medical soul. The book is an inspiration to better
things, a stimulus to higher attainment; its lofty teach-
ings are sound and reasonable. Would that every physi-
cian in America would read it and practice its precepts.
— T. S. B.
(Book Reviews continued one leaf over.)
@Pil. Cascara Compound— RobinsA
MILD, 1 GR— STRONG, 4 GRS.
9
It is the failure of the secretory function of the bowel, together ^^
with a poor bile secretion, which, in nine cases out of ten, i*(JHB
responsible for constipation. 5S.
Most cathartics altogether overlook this factor and address \9
0 themselves solely to a stimulation of the musculature. Some even^f^
inhibit intestinal secretion. The result is a rapid, unsatisfactory \tf
j^^ bowel movement, followed by paralytic reaction. /5^
^■^ Pil. Cascara Comp. (Robins) is a rational therapeutic formula. \0
fA which promotes a natural flow of secretions, which is, in turn, the/ZB
jj£ physiologic stimulant of peristalsis. Thus a normal evacuation is 3c
mSm produced, without subsequent inhibition. iMf
^^. Samples and descriptive literature on request ^^^
§#} A. H. ROBINS COMPANY Richmond, VirginiaMW
You can buy with Confidence — See "Service Guarantee to Reader/* on page 468
The American Physician]
The American Physician
447
Proscribe BRAN
J8r mild or chronic
CONSTIPATION
vrith confident expectations
of satisfying results
fSUEVESOONSIVMIKM
ssajriOEAT
BUitsiMsn*J
An Analysis of
KtUogJM BRAN
knunbbd
Aside from its regu-
latory value, Kellogg's
Bran commands atten-
tion as one of the most
valuable foods known.
Read this analysis:
Moisture 2.50
■INEIIAL SALTS 8.4 1
Protein 15.8
Pat 2.8
Crude Piber 8.9
Carbo-hydrates 61.6
Calories 1480.46
(per pound)
Great increase has been made in the use of
Kellogg's Bran, cooked and krumbled, for the treat-
ment of mild and chronic constipation cases.
Kellogg's Bran overcomes the objection to common
bran that becomes so irksome to the patient to eat.
Kellogg's is actually delicious, its nut-like flavor
adding an appetizing touch when sprinkled over the
patient's favorite hot or cold cereal. Yet, Kellogg's
contains all those food and regulatory elements
which make it invaluable in many illnesses.
Kellogg's Bran, through its ability to absorb
water, giving bulk and moisture, is nature's way of
assisting in elimination of waste matter. Peristaltic
action is increased and in a very natural way the
patient's condition improves.
Authorities, as you know, point out that prema-
ture old age and much preventable illness has its
beginning in the intestinal tract. And, the best way
to ward off these enemies of mankind is to rid the
system of waste materials at the earliest possible
moment Through the consistent use of Bran belief
grows that the average life can be considerably
lengthened. All grocers sell Kellogg's Bran.
We would be pleased to mail physicians a large package
of Kellogg's Bran, cooked and krumbled, without the
slightest obligation. Kindly send ns a request card today.
tHe original BRAN
initf Arwinfrfeff
Mentioning The American Physician Insures Prompt, Careful Service
448
Book
[Pbila.Juoe.1923
Medical Notes. — By Sir Thomas Horder, M.D. (Lond.),
F.R.C.P. (Lond.). (Physician, with charge of Out-Pa-
tients to St. Bartholomew's Hospital). Henry Frowde,
Oxford University Press, Hodder & Stoughton, 20, War-
wick Square, E. C. 4, London, 1921, price, $2.50.
A valuable collection of little notes surcharged with
common sense.
The Surgeon General's Library
The number of volumes contained in this library is
tremendous. These books are procurable through
what is known as the inter-library loan. It is the
policy of that institution to loan to medical men
throughout the United States through the medium of
their local library. The transportation charges are
paid both ways by the borrower.
There is a file of the "Index Catalogue" of this
library at many places and also of the "Index Medi-
cus" which is published by the Carnegie Institute. It
is truly astonishing how convenient it is to obtain
valuable information once you haye become familiar
with the plan.
Chaulmoogra Oil and Leprosy
The United States Public Health Service has felt it
necessary to prevent the too optimistic and extravagant
claims recently appearing in the newspapers in regard
to the curative effects of chaulmoogra oil derivatives on
leprosy. While the use of the oil and of its derivatives
has resulted in a considerable number of apparent cures,
it is as yet too soon to tell whether these will be
permanent
The ethyl esters of chaulmoogra oil, the use of which
has largely supplanted the oil itself, constitute a most
valuable agent in the treatment of leprosy. In treating
young persons and those in the early stages of the dis-
ease, the improvement has been rapid and striking; in
older persons and older cases it is less so. Of the
cases paroled from the leprosy stations in the Hawaiian
Islands so far, about eight per cent, have relapsed and
returned for treatment. This was to be expected; and
on the whole the results have been so favorable as to
make treatment of the disease hopeful. But only time
can tell.
A negative Wassermann reaction is merely pre-
sumptive evidence of the absence of syphilis. It
does not in any sense constitute proof. The blood
may at times be negative, with the spinal fluid posi-
tive. A negative Wassermann may occur in the
presence of tertiary skin or visceral lesions. After
the Wassermann has become negative, intravenous
treatments may be suspended (in the absence of
visceral or neurosyphilis) and mercury used to com-
plete the cure. — Jay F. Schamberg, M.D., V. and C.
Review.
A New Salt of Marked Value
in Gonorrhea
Zinc Borosalicylate (C H BO) 2Zn— NEISSER-SAN-KAHN—
by a fusing process in manufacture, the germicidal properties of the
drug are retained with elimination of its irritating properties.
KI2SSZR-SfcN->ifctfK
(ZinoBorosalicylate)
Has distinct advantages in treatment of urethral infections.
Definitely Germicidal Non-Toxic
Power of Deep Penetration into the Epithelium
Does Not Stain Forms Stable Solution
The definite gonococcidal strength of NEISSER-SAN-KAHN with its freedom
from irritation and other objectionable features — stamps this new agent as an
outstanding drug for use in genito-urinary diseases.
Procured on prescription (druggists not stocked being supplied through
the regular trade channels) or direct from our Laboratory.
Write for Literature
YORK LABORATORIES COMPANY
COURT AVE. AND JACKSON ST. YORK, PENNA.
You can t'ty with Confidence — See "Service Guarantee to Readers" on page 468
■n* American piiyneUo] The American Physician
Six $1 Sterili Thermometers FREE
Physicians! Here is an unusual opportunity to get one-half
dozen one-minute thermometers without cost. Three Sterili
Brand thermometers in metal cases with chains and three Sterili
thermometers in rubber cases. Exactly the same thermometer
as listed in our catalog at $ 1 each. Guaranteed perfect in every
respect.
Special Offer, 25 Days Only
The six thermometers will be included free with each cash
order of $18 or more received prior to July 1. This offer
includes any item listed in our 1922 catalog. The only pro-
vision is that the order must total $18 and be sent within
25 days with cash, check or money order. Each customer is
limited to one set of six thermometers.
Order
oday while you think of it. Send Ic
«I bra
CHARLES A. BREON & COMPANY
PHYSICIANS' SUPPLIES
Coca Cola Building
Kansas City, Missouri
BRANCH OFFICES:
Cor*. A. Bmoa A Co.. 20B Rhode* Building, Alls;
Gtoria A. Brwn A Co.. 1018 S. Wabaab An, Chici
iDtnvnoui DJtti-fbutiiif Co., SB Fourth Ave., N.w
Mentioning The Ai
t Insures Prompt, Careful Service
Helpful Points
[Phil j.. June. 1922
Six $1.00 Thermometers Free!
Doctor, an unusual opportunity is offered this month
to get one-half dozen one minute thermometers with-
out cost. They are exactly the same thermometers as
listed in the Geo. A. Brcon catalogue at $1.00 each-
guaranteed perfect in every respect. It is a special offer
for 25 days only ; turn to page — and see it.
Prompt Gonococcocidal Action
Physicians are finding that a prompt gonococcocidal
action without irritating effect follows the use of Xeisser-
San-Kahn (zinc-borosalicylate) in gonococcal urethritis.
Its advantages lie in its powerful inhibitory action
upon the growth of the gonococcus, its marked pene-
trating properties, minimum of irritation and the sta-
bility of its non-staining solution.
The gonococcocidal action of Neisser-San-Kahn brings
about an early cessation of the discharge ; as a result of
this prompt effect danger of complications and cbronicitt
is materially reduced.
Literature will be sent to American Physicmx
readers gladly on request. Address, York Laboratories
Company, Court Ave. and Jackson St, York, Pa.
New Non-Narcotic Hypnotic and Analgesic
In writing on Allonal 'Roche,' the new non-narcotic
hypnotic and analgesic, Dr. M. A. Burns, in an article
read before the Philadelphia Neurological Society and
published in the New York Medical Journal, concludes:
"The unpleasant by-effects familiar with the other
were absent. There is no effect on respiration, not any
apparent depressant action on the circulation.
''From the experiences quoted it seems safe to enn-
clude that the new drug is a remedy of real value (or
controlling insomnia and pain, and that it will enable
us lo get along with less of the narcotic pain allaying
remedies. It worked better than morphine in man?
cases, and in others better even than morphine and
hyoscine together."
This new discovery, Allonal 'Roche,' has ail the
advantages of an opiate without the disadvantages-
Literature will be sent to American Physician readers;
address : The Hoffman- La Roche Chemical Works, Sew
York City.
New Price List Ready
Word comes from the Abbott Laboratories that their
new 1922 price list is now ready for distribution to the
medical profession. This list contains the new medicinal
chemicals and Council -passed synthetics, such as Butyn.
Acriflavine, Cinchophen, Barbital, Procaine, Chlorazenc
and Dichloramine-T.
This new list, representing, as it does, the results of
years of commendable research and scientific work, will
be sent to American Physician readers on request
Address : The Abbott Laboratories, Dept. 49, Chicago,
111.
"Run Down" Patients _
Has it ever occurred to you that your "run-down
patients who are tired all the time, whose oxidation
and elimination are slow, temperature subnormal and
blood -pressure low, especially in cases following W>
attack of grippe, pneumonia or even a bad cold, art
suffering from hypoadrenia? You can modify these
common symptoms by supporting the adrenals.
Adreno-Spermin Co. (Harrower.)
Interesting booklet, "Adrenal Support," will be sent
to American Physician readers on request. Address:
The Harrower Laboratory, Glendale, Calif.
(Helpful Points continued one leaf over.)
i buy with Confidence — See "Service Guarantee to Readers" on page 468
An Honest Market Place
Had Infantile Paralysis
— now plays ball, roller skates and swims
This child would have been a hopeless, helpless cripple for life
if the family physician had not fitted him with a Philo Burt
Spinal Appliance. Here is what the doctor says:
jacket far Alveh Band. The wart
> I hate
tee, 1* mm tntUjintr i
[ thank Tea. I akuad
wearina; tin AppHanc
ueaai rattan hUa iradaallr la plarln*
wtT* ball, roller akatia*-, ana bavtne;
■"'»■■ reached tha matara a*, of twelve.
Pklli be la new a Baa Scant and a nw
Jan. **r •' «*• V. M. C. A., wbin he hi
, T„ lakiae ewlauaina leeeona. Tbt An-
th«ranchl7 inetiled ia aavJns l
it an bl_. Tha carratare tta-alf
InipaajlUt el correction, kauv
^ 7j*i«il Case Until* Paralymta, the epei of i
WE MAKE THE PHILO BURT APPLIANCE TO
ORDER FOR ANY CASE AND SEND IT ON
The Appliance Ilfta tba weifht off tba eplna .-Int.
— 1 correct! any deflection In tba vertebra*,
don not caafe nor irritate : wehrha oaneeo
....era other inpporta weigh pound* and la
nxily adjoeted to meet improved Condition!
wbara the eplne fa itralahtenina"
k mnioliiH Ita normal ihape
be token alt in • moment :
[ teal
■ aaau tuna iDawa hlai to ba
active and ba Ilka th« other
■b* bar* aved hacha. I •hall
» heel lane r la placbut roar
where It la la ear decree
30 Day Trial
local phv.iciane, and will i
oar Phntciana' Portfolio of lettere 1
our plan of hearty co-operation with
• icien in Charge. We guarantee perfl
< aiain
t M auickljr. Dora not ebow through tha
PHILO BURT CO., 115-18 Odd Fellow. Temple
iijimiin 1 1 1 1'irni 1 1 i i;i i ! i ':: 111111111:1 1:111 1 1:1 r; i 1 : 1 1 i i ■ i : 1 : i 1 i , : i : 1 : 1 : ; 7 ' ' :-i: •■; r.\ mum
end of 30 dayi.
ntUns
patient I* diaaatk.-
lira,
Home Treatment In
Tuberculosis
With over a million active cases of tuberculosis, home treatment is
absolutely necessary. It consists of rest, food and fresh air supple-
mented by proper medical attention and medication.
Dr. Beverly Robinson has stated "that we have absolutely no medi-
cal treatment of pulmonary tuberculosis at all equal to the creosote
treatment properly used and insisted upon."
Mistura Creosote Comp. (Killgore's) contains the genuine wood
creosote unchanged by the addition of chemicals and will meet all the
requirements of the creosote treatment,
Dose :— Teaspoon ful in one-third of a glass of milk or water after
Sample Sent To PhgtleUtiu On Reqttal
CHARLES KILLGORE
Manufacturing Chemist Establiehed 1874
55 West Third St., Cor. West Broadway New York
Mentioning The American Physician Insures Prompt, Careful Service
452
Helpful Points
New and Effective Violet Ray Tube
After testing out his new Violet Ray Tube for five
years in daily use, giving over one thousand four
hundred treatments without a failure. Dr. Chewning
has been persuaded by his colleagues to make this
available for the profession.
Physicians who have seen the new Violet Ray Tube
in use are enthusiastic about it — so much so that Dr.
Chewning has gradually taken up the task of supply-
ing physicians with it. With many satisfied owners,
the Doctor states he has yet to receive any "kick."
See the advertisement on page 406. The price is
only $10 and can be attached to any socket or holder
that has a cone-shaped reflector, such as an ordinary
reading lamp with a flexible arm, so no expensive equip
ment is needed. Address: The New Violet Tube Co.,
Dr. W. J. Chewning, Fredericksburg, Va.
The Pharmaceutical Chemistry of Silver Proteins
Silver is a favorite gonococcide. And the manufac-
turing chemists are doing their part to render it of the
utmost service by supplying compounds which are, in
the first place, effective; in the second place, non-irri-
tating, and, finally, free from staining tendency. Soluble
silver salts darken under the influence of light, as a
rule ; but we are offered, in a preparation called Neo-
Silvol, a very freely soluble silver combination that does
not darken as the solution dries, but assumes a pale
as well.
Neo-Silvol is used in the same way as Silvol— not
only in gonorrhea, but in any infection of accessible
mucous membrane. Both are supplied in powder and in
6 -grain capsules ; and the quality of both is guaranteed
by the manufacturers, Parke. Davis & Company.
Concerning Cathartics
To the layman, a cathartic is simply a cathartic and
nothing more. One thing is as good as another as long
as it "moves the bowels." To the physician there is a
vast difference between "moving the bowels" and
inducing normal bowel action.
For years strychnine was the stock ingredient of
cathartics for the purpose of sitmulating the muscle
to peristalsis. But nowadays we realize that strych-
nine more often inhibits peristalsis by over- stimulation,
and that the best stimulant of intestinal muscles is the
intestinal secretions.
Pil. Cascara Comp. Robins contains no strychnine to
force the musculature nor belladonna to inhibit the
secretions. On the contrary, it stimulates the flow of
secretions and normalizes peristalsis. It is, in fact, a
normal cathartic. For samples and descriptive literature,
address A. H. Robins Co., Richmond, Va.
(Helpful Points continued one leaf over.)
onaxy tuber-
re containing
of creosote and lime.
CALCREOSE differs from creosote in that it does not have
any untoward effect on the stomach; hence patients do not
object to its administration.
Price:— Powder, lb., $3.00. (Prepared hj adding I lb. to I gallon of
water.) TabUta: 4 gr., 1000, $3.00; 500, $1.60; 100, 40c
THE MALTB1E CHEMICAL CO. Newark, N. J.
You can buy with Confidence — See "Service Guarantee to Readers" on page 468
Tk American Physician]
An Honest Market Place
FIDELITY TO AN IDEAL
has won
PROFESSIONAL COMMENDATION
for
MANSFIELD AGAR AGAR WAFERS
A DRUGLESS LAXATIVE FOOD
Originally produced at the suggestion of physicians, these wafers have
been manufactured for ten years with a persistent endeavor to merit the
confidence and approval of the medical profession. That we have succeeded
is demonstrated by continued and increasing sales, unstimulated by any
advertising during the last four years.
We believe that the hygroscopic properties of agar and the vitalizing
qualities of the entire wheat grain, combined, have resulted in a product of
proven value in the treatment of constipation due to intestinal atony. As
evidence of this belief, we gladly offer any physician a package of the wafers.
THE MANSFIELD LABORATORIES. Inc.
18 CHANDLER STREET BOSTON, MASS.
What Makes the Hogan High Frequency Superior?
•at?
The improved Spark Gap illustrated is
" responsible for the great satisfaction experi-
enced by users of the apparatus. This con-
sists of a series of discs of a highly refractory
metal mounted upon insulating material of great heat-resisting qualities with a
sliding rod running through the central apertures regulating the length of spark.
The Hogan High Frequency Apparatus
offer, triple service, affording Oudin, Tenia and d'Arsonval cur- ^
acuum electrode effects, diathermy, auto- /
condensation, f ulguralion,
lending operators.
ileetro-coagulation, etc. Used by /
e liter.
Manufactured by
Mcintosh Electrical Corporation
Snccesjora to Mclntwb Bttxtrj ft Opt. Co.
En.bli.hr J 1879
Euistb OSes and Strrlu Station
408 LnlBftoa *™, Naw York '
Mata Ofia and Factory: Mcintosh Bid.- . "**
223-233 N. California An, Chlcato, III- , "
Addrc:
Mentioning The American Physician Insures Prompt, Careful Service
454
Helpful Points
[Phila., Jane, 1922
Shows How to Get Better Results
That attack of neuralgia, neuritis, muscular or artic-
ular rheumatism, etc., can be relieved more easily and
quickly by the use of radiant light and heat applied by
means of the Thermo-Lite Therapeutic Lamp. Send
for interesting literature and learn how you can get
better results, gain patients and increase your repu-
tation. Address H. G. McFaddin & Co., 34 Warren
Street, New York.
A Complete Baby Food
Nestle's Milk Food produces a complete food,
presenting everything the infant needs to assure
normal growth. It is not a modifier; it is concen-
trated dry milk powder already modified with cereals
and sugar that only requires the addition of water
and boiling for one minute.
A liberal supply of samples for professional use
and copies of "The Mother Book" for distribution
to your patients, will be sent to American Physician
readers on request. Address: Nestle's Food Com-
pany, Nestle Building, New York, or 112 Market
Street, San Francisco.
Has Great Therapeutic Value
Dr. W. H. Morse writes : RHINOL has already won
its reputation as specific in diseases of the nasopharyn-
geal tract. The world war has occasioned a notable
addition to this reputation.
Soldiers who were gassed when in service have
almost invariably engaged — as the French phrase it — in
chronic rhinitis, with pharyngitis. Where this has en-
sued the affection has become remarkably stubborn and
persistent. The patient, complaining of the pulmonary
derangement, adds stress to the angina in the mucous
membrane of the nose and throat, "that suffocating
feeling:11 Examination shows an cedematous condition,
"an angry throat and nostrils." Not infrequently the
patient minimizes the chest disorder in favor of the
rhinitis. He speaks of it as "that sore breathing/' He
"wants to get rid of it, first of all."
The practitioner who is acquainted with RHINOL
has full evidence of the indication. Under these condi-
tions he realizes its great therapeutic value as, per-
haps, never before. The results from its exhibition are
uniformly satisfactory. Even before there has been a
repair of the chest lesion, he declares for improvement,
and when the rhinitis, which has become chronic, yields
to the RHINOL, his requisition is "for something that
will put the lungs in order with equal benefit."
It is not too much to say that wherever RHINOL
has been used in this description of rhinitis, the results
have been as satisfactory as they are in the acute rhi-
nitis which does not complicate any other affection of
the tract.
Comments on Santyl
From "Diagnosis and Treatment of Blenorrhagia in
General Practice," Prof. Mulzer, Munich. From Vox
Mcdica, No. 6, Dec, 1920. . . . When, during the
treatment of an anterior urethritis the process extendi
to the posterior urethra, the local treatment is immedi-
ately to be suspended, and remedies for internal use alone
are to be used. Whereas the use of these remedies is
(Helpful Points continued one leaf over.)
ANUSOL
(Tradt-Mtrk)
Hemorrhoidal
SUPPOSITORIES
They break the
"Vicious Circle"
in Hemorrhoids
L
Hemorrhoid sufferers are always inclined to become careless and dilatory
in their bowel movements, for fear of painful defecation.
And right there starts the "vicious circle"— constipation, local irritation,
aggravated Hemorrhoids, painful defecation, increased irregularity, and so
forth.
Anusol Suppositories remove the dreaded strain and the reassured patient
resumes his regular bowel function.
Then the excellent healing and tonic action of Anusol Suppositories can
set in and do its utmost without set-back-
And the utmost of Anusol Suppositories accomplishment is the utmost in
Hemorrhoidal therapy.
Ample Trial Quantify and Literature from
SCHERING & GLATZ, INC, ISO Maiden Lane, New York
You can buy with Confidence — See "Service Guarantee to Readers'* on page 468
J
The American Physician]
An Honest Market Place
455
"Massage alcohols" usually leave a heavy, unpleas-
ant odor, due to the denaturant used.
••ALKOLAVE S&D '— the quality rubbing alcohol
— leaves a refreshingly pleasant odor ; it is denatured
differently; by special process.
Use it clear or diluted; but only of course on
unbroken skin surfaces — never on mucosa and
never internally.
"Alkolave S&D"
in 4 os. and pts.
at jour druggist's
Sharp & Dohme
ChomisU since '60
To Reduce and Control Hypertension
The clinical significance of increased blood pressure is always that of a
danger signal. It should be interpreted carefully and treated efficiently.
Pulvoids Natrium Compound
{High Tension Dr. M. C. Thrush)
is a scientific, safe, reliable combination of proven agents. It produces
prompt action and its effects are prolonged. It does not disturb digestion
or renal function.
Composition
Potassium nitrate, sodium nitrite, sodium bicarbonate, nitroglycerin and
Crataegus oxyacantha (tonic for heart muscle and to prevent shock). Special
(green colored) sugar coating, to dissolve in intestinal tract, and avoid
gastric disturbance.
Booklet on High Blood Pressure: How to take, interpret and treat it sent free on request.
If you dispense ask for price list of Pulvoids, Wafoids, Vita- Yeast, Organic Products, etc
Special Offer to Physicians and Hospitals Only
200 Pulvoids for 91.00. One time only.
1,000 Pulvoids for $5.00. On 60 days' trial; money back if not satisfied.
Either mailed free when cash accompanies order or if sent C. O. D. mailing and collection charges added.
THE DRUG PRODUCTS CO., Inc., ISO Meadow St, Long Island City, N. Y.
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
Malnutrition
if produced by an obstruc-
tive sluggish intestine and
the gratifying results ob-
tained by using
Pluto Water
in these cases show it to be
the best agent obtainable in
disorders of this kind.
Many practitioners di-
rect convalescent patients to
the spring for rest and com-
plete treatment.
French Lick Springs Hold Co.
French Lick, lad.
in general useless in anterior urethritis, in the posterior
cases they may and should be used. Of the balsamics
/ employ exclusively Santyl, of which 20 to 25 drops,
or 2 capsules each containing 0.4 Gin., are given 4
times daily after meals.
Literature and samples will be sent gladly to Ameri-
can Physician readers, address: E. Bilhuber, Inc.,
45 John Street, New York.
Conclusions on Yeast Treatment
The conclusion of Dr. Philip B. Hawk and his asso-
ciates, on the yeast treatment in 17 cases of furunculosis
is: "In furunculosis, yeast is a remarkably efficacious
remedy. Its curative action in these cases is no doobt
aided by the leukocytosis which is developed."
The usual dosage in these cases was three cakes
(Fleischmann's yeast) a day — plain or suspended in
water, beef -tea or orange juice — generally before
meals. In some cases, because of the laxative action
of the yeast it was necessary to reduce the dosage.
For further information on Yeast, address: The
Fleischmann Company, Dept. S-6, 701 Washington
The Significance of High Blood Pressure
The doctor who appreciates the significance of high
blood pressure is always interested in anything in the
way of treatment that promises to bring about efficient
and at the same time safe reduction of the hypertension.
It is natural to depend very largely upon the use of the
nitrites to bring this about, but the opinion is steadily
growing that the continued use of nitroglycerin alone
is not to be commended.
Brunton, whose experience and reputation entitle him
(Helpful Points continued one leaf over.)
In Childhood
the benefits from wearing
O'SULLIVAN
RUBBER CO., Inc.,
New York
O'Sullivan's Heels
are recognized and appreciated by thoughtful physicians.
The light, springy step, the delightful resiliency, and the
avoidance of shock and jar, naturally mean much to the
active boy or girl.
Thus the child who wears O'Sullivan's Heels will be
happier, the structures of the feet will be strengthened, the
gait and carriage will be improved, and with elimination of
the continual jarring caused by hard leather heels there will
be a marked decrease of nervous irritation and tendency to
excessive fatigue, with their all too frequent depressive effect
on the whole body.
The sum total is more comfort, greater efficiency and a
real conservation of health.
Thus it is that O'Sullivan's Heels have come to fill a
definite place in the hygiene of childhood.
You can buy with Confidence— See "Service Guarantee to Readers" on page 468
The American Physician)
An Honest Market Place
457
Weeping eczema in a
child where nothing local
helps, suggests thyroid
origin. The thyroid is in-
timately connected with
the skin. Use Harrower's
Thyroid Function Test to
determine this apathy, then
use thyroid if indicated.
In girls inquire as to
menses. If irregular, and
especially if skin is worse
periodically, give Thyro-
Ovarian Co. (Harrower)
for thyroid and ovarian
dysfunction. Remember ali-
mentary canal and also
protein sensitization from
foods, etc.
Have You Made
Your Reservation?
for a copy of the new third edition of Harrower's
"Practical Organotherapy?"
The present edition contains most of the old fea-
tures and many new ones — fifty new chapters; larger
page ; larger type ; better in every way.
This New Book is Ready for Immediate Delivery
Send your order for a copy at once— enclose a dollar bill ;
and if this big, new, cloth bound, 416-page book does not "suit
you to a T' " your money will be promptly returned on request
The regular price of this book should be $4.50, but a dollar
represents the entire cost to you and the book will be sent on
approval if you prefer.
The Harrower Laboratory
Box 68, Glendale, Calif.
j
Creo-Tussin in Whooping Cough
IF YOU ONLY KNEW the excellent results physicians are getting from
the use of Creo-Tussin in whooping cough you would not be without it for,
as one physician stated, "good results are evident the first night.'
n
Physicians who are unfamiliar with Creo-Tussin are
requested to write us for sample and literature. Please
use attached coupon.
The Maltbie Chemical Company, Newark, New Jersey
Creo-Tussin
is a palatable solution of creosote,,
gelsemram, passiflora, yerba santa,
menthol and aromatic*. Conveniently ■
pat up in 2 ox. bottles with blank la- ■
Dels for directions, each bottle in!
plain carton. ■
Price— Dosen 2 os. $4.00, Pint, $2.40 1
r-----»-Cnt Here and Mail Today......
THE MALTBIE CHEMICAL CO, Newark, N. J.
Please mall sample Creo-TuMin U
A. P. 4 22
Mentioning The American Physician Insures Prompt, Careful Service
458
Helpful Points
[Plula., Jmi0922
"I Tried All
The Leading
"A fine strong girl born a
month ago, steadily lost ground,
in fact was rapidly falling away.
The Mother's Milk did not at all
agree or satisfy. I tried all the
leading foods and milk in var-
ious modified forms. But nothing
satisfied until I sent for a bottle
of Nestle's Milk Food, when, with
the first feeding, the little one
improved almost as if by magic.
The child is now living wholly
on Nestles Milk Food, and is
doing well."
(Physician's name and address
withheld for professional
reasons)
In emergency cases or for
routine use you may safely rely
upon Nestle's Milk Food as a
dependable nourishing food for
babies.
Nestle's is simply pure cow's
milk modified by the addition
of malt, cereals and sugar and
then reduced to powder form.
It is milk, free from pathogenic
bacteria, in a form which is
easily prepared and readily
digested.
Your name and address will
bring liberal samples.
Nestle's Food Company
Nestle Building
New York
112 Market Street
San Francisco
to be considered as an authority, recommends for the
treatment of hypertension a combination of the nitrite
of soda, the nitrate of potash and bicarbonate of soda.
This combination does its work very well, but accord-
ing to the extensive clinical experimentation carried on
by Thrush, of Philadelphia, nitroglycerin and Cratae-
gus oxycantha may be added to the above with decided
increase in therapeutic results when presented in proper
form. The blood pressure is promptly lowered without
irritation or shock and the effect of the combination
continues for a considerable period of time.
The formula suggested by Dr. Thrush has been placed
on the market under the name of Pulvoids Natrium
Comp., and has steadily grown in popularity and use
among progressive physicians.
Any physician who has not yet satisfied himself as to
the efficiency of this valuable combination in the treat-
ment of high blood pressure can easily convince him-
self by clinical test that the claims made for it are in
every way warranted.
Literature, price lists and Drug Products, a house
organ devoted to the products of the company will be
sent gratis to any physician on request. Address: The
Drug Products Company, Inc., 150 Meadow Street,
Long Island City, New York.
Keeps You Fresh on Anatomy
Your knowledge of anatomy cost you hundreds
of dollars and months of intensive study, and yet, con-
tinually, physicians say they forget much of it after
a few years of practice.
A Pilz Anatomical Manikin (life size, complete in
every part) is the equivalent of a human body to
dissect, always available and lacking: all unpleasant
features. It will keep your knowledge of anatomy, so
important an element of successful diagnosis and
treatment, always fresh and up to date. The prices
(Helpful Points continued one leaf over.)
MM
r tjYCOS
.\Nine Months
When Its Yours
~ ~/Jr $2*50 MoD,h|y Briigs U
Tks Bow lltt model rolotirstsd Blood
Ptomuts Apparatas. Dr. Rorera' 8phy
roMxnajMMMter ie vary aceorately
•nd resistersboth syotolieaad diutolk
where Is fB.06. We win send ft to yea on
rscetpt of only $2.60 sad. if mi tor tea dsye'
trial, yoo wish to keep It. simply psytfco
balaaeo— $S2J0— the tame ss root-la ah*
monthly payments of IS-SO each. Toa
oatar the cash pries (ao laterost— ao ea
sad Bars Bias fall months ta which to i
K pay for Itself.
Leather CaseandBookldFree
With srory Tyeosl is laslodsd Pros a ceaalae i
Too eaa pat your Ty cos into thlsesss sad earn
Ten Days9 Trial— Money Back
a***10*??; J^^^«^taoeoapoal*Jow-oaeIosefa»fei
first moan's rent sad wo will Immediately soad yoo thmtLtrammt
•S?*!?^*!?!** 2^7**2 P*/*"0 •*eh »oath until tho cash pries,
teadsys trial sad retara your money if yoo aro not satisfied. The
prlco for all cash with order is Josttbe mbm. W.60. ^^
■V. T.T^r J?*OM AKD MAIL COUPOH •«....
A. S. ALOE CO. Factory Dutrisaters. Wl OHrcSt.. St. Loafc. Us.
•m oatflt on t«n days' trial as par year offer. | ■erei Thai Uh Hill
» to remain In ^ootJlpaUlsYull. • "■"■ mm tm %n"
You can buy with Confidence— See "Service Guarantee to Readers" on page 468
The American Physii
An Honest Market Place
Indicated in adhesions
Adhesion* are most lifcely to occur in the
lower part of the colon. They are found
present in case* of extremely obstinate
constipation. A foremost roentgenologist
and alimentary sfiecialist states that in
these conditions the lubricating action of
liquid petrolatum is certainly indicated.
NUJOL is scientifically adapted
by both viscosity and spe-
cific gravity to the physiology of
the human intestines. In deter-
mining a viscosity best adapted
to general requirements, the
makers of Nujol tried consisten- AdWnuof Pewtccoloa
cies ranging from a water-like '" Cc""!it"Moa
fluid to a jelly. The viscosity of Nujol was fixed upon
after exhaustive clinical test and research and is in accord
with the highest medical opinion.
The unmatched resources of the manufac-
turers, the perfection of their technical
equipment and an expert personnel place
Nujol upon a basis of unique superiority.
Sample and authoritative literature deal-
ing with the general and special uses of
Nujol will be sent gratis upon request to
Nujol Laboratories, Standard Oil Co.
(New Jersey), 44 Beaver Street, New York.
Normal Colon
Nujol
REG. U.S. PAT. OFF.
A Lubricant; not a Laxative
Guaranteed by Standard Oil Co. (New Jersey)
Mentioning The American Physician Insures Prompt, Careful Service
460
Helpful Points
[Phila., June, 1922
£aJbova.toi»les Oln
The Ideal Mercury- Arsenic
Combination
Enesol
(Salicylarsinato of Mercury)
Loip Toxicity (70 times less than
biniodide of Hg.)
Painless injection, causes no local
irritation* Combined sterilizing and
specific action.
For intramuscular or intravenous
injection.
In ampoules of 2 mils (2cc) and
5 mils (Sec) of solution containing
the dose of 3 cgr per mil.
Dose — 2cc corresponding to 6cgr Enorsol
por day.
Saturation Dose 4 to 6cc every 2 or 3
days given by intramuscular injection.
2cc to lOcc every 2 or 3 days intra-
venously.
Write for samples, literature
and clinical reports
E. Fougera cV Co., American Agents
90-92 Beekman Street, New York City
^^^i8> PARIS, FINANCE ^^^^
are: $18.00 for female, with elaborate obstetrical sup-
plement; $15.00 for male, and $15 for sexless. And
for Dr. Minder's Manikin, female, $3.00; sexless, $2.50.
These are sent on receipt of New York check or
C. O. D., and through dealers, on money back
guarantee.
For free booklet, address : American Thermo-Ware
Co., 16-B Warren Street, New York City.
Effective Synthetic Compounds
In the treatment of neuritis, caused by toxins and
morbid states of the blood, found in the constitutional
state known as gouty, I have obtained ideal and gratify-
ing results from the use of pyrazophen. Without dis-
turbing the proper functioning of the human organism
there is obtained relief from pain, laxative action of
the bowels, diuretic action of the kidneys in conjunction
with the chemical reagent effects on the defects of
metabolism. The urine that had been turbid and
offensive in odor soon lost its turbidity and the odor
of putrefaction and became sterile.
— Dr. A. B. Lichtenwalnejl
Nasopharyngeal catarrh, aural catarrh, stiffness of
the joints and groups of muscles, cutaneous affections of
the eczematous type, acute and subacute rheumatism,
and that polyarthritis affecting the metacarpal and meta-
tarsal joints, and characterized by the development on
the dorsal surfaces of round, elevated, painful cyst-
like formations, which solidify and deform, are all re-
lieved by the use of befsal. — Dr. Henry Beates.
The price of this effective synthetic is $1.00 per
ounce. They may be ordered, or further information,
from Dr. S. Lewis Summers, Producer of Synthetic
Chemical Compounds, Fort Washington, Penna.
(Helpful Points continued one leaf over.)
CHLORYLEN
A New Treatment for Trigeminal Neuralgia
Chlorylen is used with marked success in the treatment of tri- facial neuralgia.
It has a specific action on the sensitive Trigeminus, gives immediate relief and the
pain disappears after a few treatments.
Chlbrylen is applied by inhalation. 20 to 30 drops are placed on cotton or
the handkerchief and inhaled through the nostrils, until the odor disappears. It
is a volatile liquid with a pleasing odor and is obtainable in bottles of 25 grams each.
NEUTRALON
A substitute for the Bismuth salts,
Sodium Bicarbonate, Silver Nitrate,
etc., in the treatment of Hyperchlor-
hydria, Hypersecretion, Ulcus Ven-
triculi, etc. A white, tasteless, odorless
powder; supplied in packages of 100
grams each. The dose is one teaspoon-
ful in a glass of water before food.
VALAMIN
A sedative and soporific for use in
the treatment of Neurasthenia, In-
somnia, Hysteria, Palpitation of the
Heart, etc. It is a Valerian and Amy-
lene combination, is easily absorbed
and acts promptly. Valamin is mar-
keted in packages containing 25 cap-
sules of 4 grains each. The dose is
one or two capsules after meals. In
nervous insomnia, two to four capsules
should be taken before retiring.
For further information and literature address:
KIRBACH, Inc., General Agents, 227-229 Fulton St.,
NEW YORK
You can buy with Confidence — See "Service Guarantee to Readers" on page 468
Tic American PhjiicUn]
The American Physician
A Stand-By in
Uterine Troubles
VIBURNO
repeat order* received from physi-
cian* and druggists.
Nervine-Tonic and Anticongest-
ive, with calmative and corrective
action on the bladder. Employed
with much satisfaction in ovarian
congestion and congestive dysmenor-
rhea; weak pregnancy and deficient
lactation; menopause and its phe-
nomena, including hallucinations, hot
flushes, etc, ; nervous and menstrual
derangements after "flu,*' and the
troubles of adolescent girls. Sterility
often responds after 2 or 3 bottles if
no lesion exists.
., VIBURNO
Mara ■
Pal up r
(njuKlnUd) t-U.
l. bottUs
SampU mi FormaU an Raooaal
THE VIBURNO COMPANY
116 MnkWn Lane, New York
Jr
%,
H(p.Ik]n»uf(ici<
TAUROCOL COMPOUND TABLETS
THE PAUL PLESSNER CO.
l^=
J*
Ditcrlyl Methykne-dualicyttc Acid. AN
UNQUESTIONABLE REMEDY FOR RHEUMATISM
Prim, 75 cwa per Ben.
IMbniyldiclIiylmethi'lcacdisilicylic Dip-
yruvic [CinchoninicJ Acid. AN EFFICI-
ENT AGENT FOR THE DESTRUCTION OF THE RHEUMATIC-
POISON AND A SOLVENT OF URATIC DEPOSITS.
Pile*. I1.M par Boi.
BEFSAL ;
iioooriiraiii
yScf Iodine, VALUABLE ALTERATIVE AND.
FSf'KClAIXY I'SKKl'L IS' INFLUENZA, PNEUMONIA, BRON-
CHITIS AND PULMONARY TUBERCULOSIS.
Price. (I.M par Box.
on the ipirocnctei oClypEiUi. AN^ALTlllA HVE OF* MARKED
VALUE. Prica. I1.M par Box.
PYR-AZO-PHEN 2g»~
Price. tl.M par Boi.
CHEMICALLY ANALO-
GOUS TO SALVARSAN. BUT CAPABLE OP ADMINISTRA-
TION VIA THE STOMACH. Prica. tl.M par Boa or M
DR. S. LEWIS SUMMERS
DOCTOR!
Do Yon Want
Results
tin
■Chronic
[Cases
F 1 SINUSTAT
Nn. 1 3WUSTAT l'itveoiin'in S*T
alioa, Neuntia,/
Rhn.mBli.ni, Lumb.ro.
Neuralgia, etc., by y
Tit Thla Thirty D
ya Free! Just / A. Co-
"e'cenl11!!! / Gantlamani
FREE! A Valuable
"hart / trial tlw Nu. 1
md BooJilel riving full
If- / SinueUt. If aati*-
Ultima Physical
Appliance Co. /
1M W. l*ka /wil
ln 60 day*; SS.00 in 3
month, and W.OO In 4
return It at tb* and of 30
CHICAGO, , (Slajnnd)
/Addren. ..
Mentioning The American Physician Innrct Prompt, Careful Service
Helpful Points
Prescribe
Marvel Whirling Spray
MARVEL COMPANY
II W. 4Sth Stmt Nb w York
Fatalities in I
More people die from pneumonia than any other
disease. Approximately 25 out of every 100 casej
end fatally.
Dr. Gustav Goldman has demonstrated that at
least twenty of these twenty-five deaths may be pre-
vented by employing bacterial vaccines.
Most physicians feel that it is unwise to delay and
chance a fatal termination. They use bacterial vac-
cines at once. And most clinicians have found that
the vaccines of the Bacteriological Laboratories of
G. H. Sherman, M.D., Detroit, Mich., are effective
and dependable.
An Effective Therapeutic Method
Intravenous medication has passed the experimental
stage — it has been found the effective therapentk
method in many conditions in the hands of countless
clinicians.
Endo Specialties for direct medication by the
intravenous method, made by the Intravenous Prod-
ucts Co. of America, Inc., 121 Madison Avenue, New
York, are prepared with the utmost care, skill and
acumen by experts. Formulae of these specialties,
reprints of interesting articles and price lists will
be sent gladly to American Physician readers on
Research Establishes Value of Petrolatum to
Overcome Stasis
The researches of men like Sir William Arbuthnot
Lane, of Guy's Hospital, London; Godfrey Taunton,
of Paisley Infirmary and Fever Hospital, Birming-
ham; J. H. Kellogg, of Battle Creek, and others,
(Helpful Points continued one leaf over.)
To ALLEVIATE PAIN, to PROMOTE DIURESIS
sad to PROTECT the membrane of the urethra, especially
THE POSTERIOR PORTION— these are the important
objects of the treatment of acute cases of Gonorrhea.
The entire urinary tract should be influenced by means
of proper internal medication. Local injections alone will
not be sufficient
This is the rationale of GONOSAN.
RIEDEL A CO., Inc.
104.114 South Fourth St. Brooklyn, N. Y.
LISTERS DIABETIC FLOUR
Strictly Starch-free. Produces Bread,
Muffins. Pastry that makes the
. bj^ distressing features
>fcTEs&
Litters prepared casein Diabetic Flour — self rising. A month's supply of 30 boxes $4.85
LISTER BROS. Inc., 405 Lexington Avenue, New York City
IA
You can buy with Confidence — See "Ser
The American Physician
A campaign of education — No. 5
Bacteria live in
Specialties for
Tooth Brushes
Hp ESTS »how that
1 a tooth brush con-
tain* millions of
bacteria a few hours
Tonsillitis
Benzomint
sfter using. These bac-
INTERNAL REMEDY
teria work their havoc
in the mouth unless
Compound of Sodium
preventative measures
are taken. Tooth paste
Benzoate with Alka-
to be thoroughly effi-
loids of Calisaya
cient must be antiseptic.
It must destroy harm-
A TIMErTESTED, highly
Z\ therapeutic formula which
has proved a veritable
ful bacteria both in the
mouth and on the
brush. The antiseptic
wonder worker in many thou-
qualities of
sands of cases t>f Tonsillitis.
Benzomint has pronounced ants-
Sfeo^^ZESSi'
septic and antipyretic properties.
Anti-Py-O
It soothe* instantly the intense
pain from swollen, inflamed
Dental Cream
gland*, and quickly counteract*
both local and systemic infection.
help to eliminate danger™
bacteria both on (be bruah
and in the mouth. In ipile
of ill strong antiseptic prop-
erties it is mild enough to
Glycodin
be wed on the most semi-
(GARGLE)
live tissue. Recommend it
to pattest! as n healer and
A N efficacious astringent
£-\ and antiseptic gargle of
" great value in the treat-
preventive of bleeding, re-
ceding gums, and pyorrhea
areolaris.
ment of Tonsillitis.
/ The Antidolor Mfg. Co.
/ ISO Mam St.
/ Spring-villa, N. Y.
Put, *l.O0i Fiva Pint*. $4-B0;
Cation, $0.00. Either preparation.
Moil iA« mifM tofloy
Sand lor samples and literature
AJsiT|i>oLOR MFC. CO.,
3J Main St., Springville, N. Y.
THROAT SPECIALTIES
On receipt of your professional card we will
■end you special sample tubee of Dr. R. B.
LABORATORIES
1 ^aatta'a ANTI-PY-O Dental Cream, including a
"nll-ataa tube for your personal use.
(MILBURN PHARMACAL CO., INC)
BALDWIN, L. 1. NEW YORK
McKasson A Rohblna
City , , ,. ■
Waolseale Distributor* '
New York City
Mentioning The American Phy
tician Insures Prompt, Careful Service
Helpful Points
[FhiU., June, l<
Amenorrhoea
Dysmenorrhoea
and other disturbances of the
menstrual function call for the
true active principle of Parsley:
APIOUNE
(Chapoteaut)
It Secures Results
by acting directly upon the uterine
nerve endings and producing ovarian
hyperemia, but without disturbing
gastric or renal functions.
Avoid impure or unreliable (ubitituta*.
Prescribe original vials of 24 capsules.
Laboratory of
Dr. Ph. Chapdie, New York-Paris
I'hyiiciani (ample and literature on r equal to
E. Fougera A Co., Inc., American Agent*
BO Babui Street, New York
Canada! Lraieni United, Montreal
Sal Hepatica
THE
STANDARD SALINE
LAXATIVE
Bristol-Myers Co.
NEW YORK
have shown increasingly the value of liquid petro-
latum for the elimination of alimentary toxins.
These poisons, which are big etiological factors
in some of the gravest diseases, are best combated
by such a liquid petrolatum as Nujol. Nujol, it is
found, absorbs and carries these poisons in solu-
tion and so eliminates them from the body. It
also exercises a lubricating and softening effect that
hastens evacuation and increases the number of
daily stools.
The company that manufactures Nujol possesses
an organization and equipment designed for the
manufacture of an unequaled product of this nature.
Its laboratories are models of cleanliness, airiness
and sanitation. Expert supervision guards every
step of production. Girls are clad in spotless white.
The home of Nujol has been aptly termed "the last
word in sanitary science."
Hulford to Distribute Hercurophen
It may interest our readers to know that the H. K.
Mulford Company have completed arrangements with
the Dermatological Research Institute of Philadelphia
to distribute Mercurophen, a superior mercurial germi-
Mercurophen was developed by Drs. Schamberg,
Kolmer and Raiziss, and introduced by them in 1917-
Clinical data and information will be furnished to
American Physician readers on application to the
Mulford Laboratories, Philadelphia, Pa.
(Our Advertising Standards one leaf over)
Woodlawn
Maternity Home
itrietly private and ethical Home Ken-
... unmarried girl* and women during pi
nancj and confinement with beat med
fij ■
MORPHINE
NEW HOME TREATMENT
—■■ieiil fat turn who dee», F—*«— Aian for fal hi
~" —••" SANITARIUf
You can buy with Confidence — See "Service Guarantee to Readers" on page 468
The American Physician]
An Honest Market Place
465
Success depends on Do rather than on Don't"
44
Not to me ALKALOL, for instance, when confronted with mucous membrane
irritation or inflammation, is a sin of omission that b apt to invite adverse
Because AUCALOL is almost a "specific" due first to its composition— it
contains physiologically needed salts.
Also, because its correct salinity and proper alkalinity enables it to reach
the cause of the morbid conditions.
Also, because ALKALOL being hypotonic, reverses the osmotic current and
feeds instead of exhausting the cells.
Add to these advantages its remarkable soothing and healing properties,
and the reasons appear why
ALKALOL IS THE IDEAL AGENT
for use in the eye, ear, nose, throat, bladder, vagina, urethra, rectum, on
the skin and internally as a mild yet active antacid.
Invest a cant! A postal request will bring
sample and literature
THE ALKALOL COMPANY
Taunton, Mass,
RHINOL
in All Affections of the Nose and Throat
March 15th, 1922.
Attention Dr. A. H. Werner, Pres.
RHINOL CO.. INC,
1416 Broadway,
New York City.
My DtAK Doctor:
I believe I hare an interesting report on the administration of Rhinol in a case of acute sinusitis, and
since I myself was the patient, I had the best opportunity of studying its effects in the most direct way.
During a heavy snowstorm on January 17, 1922, I contracted a severe "cold," and as doctors will do,
neglected it and attended to my duties for a week more, when an inflammation of both frontal sinuses and
both antrums forced me to give up. Prom my own experience I know now that this is one of the most
painful diseases in existence. A friend Rhinologist was consulted, and of course, he did what he could,
but I continued to suffer tortures of hell.
About a week later, through Dr. Graf, of New York, L heard of Rhinol, and ordered an outfit.
Well, Doctor, if Rhinol did nothing else but relieve a condition like mine, it would be one of the most
valuable additions to Materia Medica. But I am certain it cured me. Gradually the heavy pus diminished,
sad I at last ceased to suffer.
About a week after a radiograph taken by Dr. Teperson showed the left antrum still involved. Friend
Rhinologist advised operation and rinsing, but I was determined to keep on with Rhinol, since its application
had established free drainage and I was improving every day. About two weeks after there was no more
pus, and subjectively I felt perfectly well, and at the date of this writing continue to feel well. Another
radiograph will be taken soon, and I am positive it will reveal normal conditions.
I now employ Rhinol in my office and carry it with me on my daily visits, using it in every case of
Measles, Scarlet Fever, Tonsillitis, Rhinitis — and it has always given immediate relief, shortened the duration
ef illness, and probably prevented in several cases the usual severe complications.
I am grateful to Dr. Graf for having called my attention to Rhinol and congratulate you for having a
remedy which ranks most high among the pharmaceutical preparations at our command.
I cannot help feeling that if the medical profession would show something of the spirit attributed by
Caesar to the inhabitants of Gaul — novarum rerum cupidi — it would be better for them, as well as for their
patients. Very sincerely,
Signed, G. Thbodoi FiscHta, M.D.,
383 Clinton Street,
Brooklyn, N. Y.
Price Complete, $3.00 — Refilled Package*, $2.50
RHINOL COMPANY. Inc. 1416 Broadway. New York
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
IPhiU., June 1932
u.!tOUNEJr™ *• «"' ««-na oti hi
w tba markot In tbi* country. It baa
"""" ' *stai»lv*ri- adnrtaed. and
•taadUy and tnt
far Internal naa )
Wa again p
■ highly rafln__ .
Mineral Oil, with p
•T add lmpur
■ have saver boen mada
ahy.lcians hava baaa,
■ •tnglv proscribing It
operly adjuatad
Inw-
luJphar
g^sri?r?«srs?a?
©
OIL PRODUCTS CO., In*.
W UniMt Sahara, Naw Yerk, N. V.
THE STORM BINDER
TUli STORM BINDER ii adaptable to an}
case where an abdominal supporter is needed for
man woman or child.
THE STORM BINDER IS FOR GENERAL
SUPPORT IN Visceroptosis. Ob.
THE STORM BINDER IS
SUPPORT in hernia, floating ki<
OPERATIVE SUPP(
middle and lower abd
SPECIAL
R POST-
KATHER1NE L, STORM, M.D.
1701 Diamond StrMt
Thus* Advertising Pages art m
Honest Market-Puce
Our Advertising Standards
Advertisements must give honest service to out
readers and their patients is the basic principle for these
standards and for the conduct of The American
Physician's advertising pages.
Our attitude in applying these standards is not one
of narrow technicality but of practical service.
Advertisements of the following classes are not
acceptable for the pages of The American Physician:
Fraudulent pharmaceuticals; those making dishonest
Pharmaceuticals charging excessive price ; price not
warranted by content and by trade conditions.
Pharmaceuticals and other mixtures for internal use
and containing narcotics or other habit-inducing drugs
in quantities sufficient to promote their improper repeti-
tion on prescription (chloral-bearing proprietaries, etc.).
Potent pharmaceuticals which justly merit profes-
sional disapproval because of their lay advertising or
manifestly unethical exploitation.
Financial advertisements that claim returns not com-
patible with conservative investment. Only conserva-
tive investments are advertised.
Further
Advertising copy is subject to revision by the editorial
staff.
The American Physician agrees heartily with the
principles of the Council on Pharmacy and Chemistry
of the American Medical Association and we exclude
from our advertising pages such pharmaceutical prod-
ucts as they have definitely shown to be unworthy of
professional confidence and the manufacturers of which
have not removed the cause of objection; but we do
not accept such findings as are based on academic data
without due recognition of general clinical experience.
Concerning for mute. The American Physician is
urging pharmaceutical manufacturers to give full thera-
peutic data regarding formula?, stating quantitatively
active medicinal content, in order that physicians maj
intelligently prescribe. We do not accept advertising of
secret pharmaceuticals.
Bui We do not Decline
Advertising of original drugs, compounds or preparations imi-
tated in current editions of Ihe.U. S. Pharmacopoeia or Na™j]
that item to be honest and valuable, but which' have not been
reported upon by the Council on Pharmacy and Chemistry, or
You can buy with Confidence— See "Service Guarantee to Readers" on page 468
An Honest Market Place
™ (Neoarsphenamine~Metz)
| p is unsurpassed in reliability, trypanocidal e
»l J_ ciency and ease of administration.
LAB Neosalvarsan is manufactured by the proc
used in preparing the original Ehrlich prod
and offers the physician the ideal means
treating the luetic.
H-MIETZ LWOummes.Aa.
One-Titody-'foo Hudson Stmt, AfcMrt
NIQUE PO
7RY PRE
t trial in yoar
tt mrih,
% DoMt th
fee ted part
with a band
following cu
Lacerated
Barn*. S
Syphilitic I
fionilo/
ng Skin /.euro
VI QUE COMP
U 1
Mentioning Th* Amtriam Physician Inturtt Prompt, Cartful Strvkt
468
Helpful Points
New Prices on
Merz Santal Comp.
Capsules
DISPENSING PHYSICIANS CAN BUY
OF US DIRECT
10 Minim Elastic Capsules, box of 100
Alan boxes of 12 and box** of 24
5 Minim Perles bottle of 36
5 " " bottleof S00
6 " " bottleof 1000
Unsurpassed for happy effect in Urethritis,
Cystitis, Prostatic Troubles, difficult mic-
turition, etc.
PRICES AND SAMPLES UPON APPLICATION
Our Advertising Standard!
{Co*lin»ed ovtr frem prtitdii* paot]
ture and in such form as may parallel a prescription
qualified physician who is seeLing in Ihe proprietary
pharmacy in place of an extempore prescription.
Product* composed of minor botanic remedies
dosage, provided these drug* have a real place in mcatui ■■■«■«-
turc and are well defined in materia medira, since many ujou
sands of physicians esteem them despite pharmacologic dila
Minor antiseptics, soaps and toilet articles honestly advertised
ment; honestly advertised mineral waters and minor ptirnatitn,
food products, etc.
THE MERZ CAPSULE CO.
DETROIT, MICH.
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GOOD, OR HIS ADVERTISEMENT IS ELIMI-
NATED FROM THE AMERICAN PHYSICIANS
PAGES.
5 UuZom
1 §
S A physician gets do time to figure S
£ the cost of operating hit car, but £
5 if be is paying big repair bills, 5
t£ depend upon it poor lubricat- S
ing oil has something to do m
_ with it,
S Keep your car at your
S service by using EMCO
2 Automobile Oils, the
5 pure mineral oil, re-
S fined from famous
5 Bradford Crude
ANATOMY VIVIDLY PICTURED
is quickly learned and long remembered.
For reference. For demon*"
Depend upon the "Pius"
PILZ L1F&S1ZE MANIKIN
B ft. B la.
Female $!«.«
(Complete with obstetrical supplement!
Male *lS.fX> Sexle** *UM»
Dr. Minder's M»nlkin— ZO" x S"
Female *3.00 Sexle** ItW
All parts reproduced in layers to fold, flap over Bap.
Sent on receipt of K. Y. check or CO. D. Through
Write for frtt bookltti.
AMERICAN THERMO. WARE CO.
Ifl-B Wsjtsb Straat N— York CHy |
You can buy with Confidence' -See "Service Guarantee to Readers" Top of this page
An Honmt Mark* Plact
In Absr.ew, Felon, Carbuncle,
Arthritic Swellings, Orchitis and
Epididymitis, Burns, Sprains,
Bruises— -^n short, in all localized
inflammatory conditions,
PNEUMO-PHTHYS1NE is effect-
ive in that it lessens pain.
Reduces inflammation and swelling.
Counteracts the infection, and promotes healing.
Apply ■ thick layer to the affected part. Cover with four layeri of
gauze and then with a bandago. Tike application may be repeated
a* loan as drynei* of the paste indicate* that it* activ
have been absorbed.
l-Phthyaine Chemical Co-
Chicago, DL
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
NOTE — If you have Jnmt recently remitted and « US i.
ineloicd here, pleaea ignore it. With a lubBcriptlou lint m
large =• ouii it takes a few dayi for a subscription la pan
through, ba finally credited and the stencil transferred Iron
one classification to another.
WE ARE— A3 THE HEAD OF A MAIL* ORDER HOUSE ONCE SAID—
Always Receivin' Interestin' Tilings in the Mail
Now this month o
for the great American
r good friends wrote in, '
an." Whisper it! He r
4 with very great pleasure I send you the enclosed
« us when he says
The Great American Physician
Now that's fine and it's interest!
BUT the most interesting thing we can recci
— and a check. Yes, Brother, we want that check,
The envelope is right here. We are making
Here's hoping we hear from you, Brother,
id it makes us feci great.
can receive in the mail this month will be a word from you. Broth
fact we need it.
easy. YOU make it interesting.
( time. Thank you.
C. C. Tavlob.
DR. CRIBBLE'S SANITARIUM
irmrtly located at Lebanon. Tenn. — Established 18 Year*
For the humane treatment of
HUG, ALCOHOL AND TOBACCO ADDICTIONS
■r. Cribble's original method; cure* accomplished without pain or nervo'
Over 5000 cam successfully treated. For booklet and references addre
r. Power Gribble, 1519 McGavock Street, Nuhvitle, Tenn.
Pond's
I Extract
on to tret
the usual
orma of d
it mi
The
'*;::, 'r;.
n*the™s!mpn
Vattaek
-r
r™
and simile
POND'S EXTRACT CO., N™
Yoas akp
Lob
Ivy
Dermatitis I
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n phyud»n] An Honest Market Place
"SbO**^
STUDY and practical experience have
demonstrated that hydrogen peroxide
manifests its maximum efficiency,
only when it is free from those impurities
which interfere with the prompt and
unrestrained liberation of the pure
oxygen, on which its action depends,
Dioxogen
therefore, is universally recognized as the best
and most effective peroxide of hydrogen, not
alone because of its greater volume of available
oxygen, which far exceeds U. S. Phar. require-
merits, but particularly because of its excep-
tional freedom from residual substances
which would restrain in any way the free
release — and full effects — of this all-important
constituent.
The value of oxygen as a purifying and
antiseptic agent is too well established to
require extended comment; its influence on
disease germs, morbid processes, and its
stimulation of granulation and tissue repair
are so well understood, that further statement
is unnecessary.
In a word, Dioxogen offers a means whereby
a large amount of pure, unconcaminated
oxygen may be brought directly to the places
where it is required and in the active condi-
tion necessary to assure its highest potency.
lkland Chemical Co.
rthAvtenue JVw YOKK CITY
Mentioning The American Physician Insures Prompt, Careful Service
ENpOSAL
ENPO-SODIUM IODIDE
ENOOMETHYLENAMIN
It.gnmtfcu>*i3y/emi»rix
ENDOFERARSAN
'/TJ-7 aw> ArisiTC
ENDOOLQBIN
(Ch I am > 1 1. tt raw out *»>*<>i*)
Mamaag.'oii'a
ENDOCAODIN
(M.rcJOJ1,l
Calci'iB fod'dis 6*a?acet
Intravenous medication hu
long since passed the experi-
mental stage. The favorable
attestations of thousands of
reliable physicians are unani-
mous in their endorsements of
this method of remedial treat-
ment.
At the hands of our chem-
ists, specialists in research, our
products are prepared with the
utmost care, skill and acumen.
Their purity challenges com-
parison.
Formulae of our specialties,
reprints of interesting articles
and price lists cheerfully fur-
nished to physicians on re-
1 W tats git* termaoiafy-
GUIOLEUM
(fa- loco' UteOnfy) .
. GLYCO-ASEPTIC
<*£
Aw lftf,lvwllBt«*)l)
3KBM
Intravenous Products Co. of America, mc.
121 MadisonAvenue, ' NeWbrkCity
PurJ(fi
Safety
E£f/cien£p\i
The American Physician
luMttai Lab*n
loomftald, N. J.
Here's where genuine Atapkan im
manufactured by a special procemm
completely precluding the possibility
of unpleasant empyreumatic admix-
tures
Thia meant * still further im-
proved Atophan for your casea
of Rheumatism, Gout, Neural-
gia, Neuritis, Sciatica, Lumbago
and "Retention" Headaches.
Ample trial quantity and literature
from
Schering & Glatz, Inc.
150-152 Maiden Lane New York
AN IDEAL ARSENICAL
SODIUM DIARSENOL
SODIUM ARSPHENAMINE
Sodium Diarsenol marks a distinct advance in syphilology. It dissolves
very quickly in water, giving a solution ready for immediate injection. No
addition of sodium hydroxide is necessary. It has the therapeutic advantage
of arsphenamine with the solubility and convenience of neoarsphenamine,
and gives clinical results equal to or better than either of the two latter com-
pounds. Neutralization with alkali being obviated, there is no undue hand-
ling and consequent decomposition of the highly reactive solution.
SODIUM DIARSENOL has been accepted by the Council on Pharmacy and
Chemistry of the American Medical Association for inclusion in "New and Nun-
official Remedies."
5— i«Jm mmd Lifratmrm on wfast
DIARSENOL COMPANY, Inc.
BUFFALO BOSTON ATLANTA
You can buy with confidence— See "Service Guarantee to Readers' on page 542
The American Physician]
An Honest Market Place
475
WE BELIEVE
'T'HE Medical Profession will be pleased to know that for
the past nine months the Sherman ten mil. vial has been
filled to contain 1 2 Vi milliliters of vaccine.
In the future this package will be known as a 1 2/4 mil.
vial and will sell at $2.00, the price of the former 10 mil.
vial.
This is equivalent to a price of $ 1 .60 on a ten mil. basis
and is an increase of 25% in the quantity of vaccine.
Bacteriological Laboratories of
G. H. SHERMAN, M. D.
DETROIT, MICH.
The combination of tonics and stimulants ex-
plains the clinical results obtained in the
treatment of nervous disorders by the use of
FELLOWS' COMPOUND SYRUP
OF HYPOPHOSPHITES
"A true stabilizer of shaken nerves?9
It contains the ••mineral foods". Sodium, Potassium, Calcium, Manganese,
Iron and Phosphorous, and the stimulating agents, Quinine and Strychnine.
Samples and Literature sent upon request.
FELLOWS MEDICAL MANUFACTURING CO., Inc.
26
Street, New York, N. Y.
! VoL *7, No. 7, Published monthly— The Taylors; C. C. Taylor, Publisher; Mrs. J. J. Taylor, Ed. Mgr. Entered as
I s*cond-d+ss matter Feb. 13, 1896, at the post office at Philadelphia, Pa., under Act of March 3, 1879. The American
I Pkystdem, "Most Widely Circulated Medical Monthly," continuing the quarter century of distinctive service of
COPYRIGHT 1922, by The Taylors, Publishers, 4*0 Walnut St., Philadelphia, U. S. A. All rights reserved.
Medical Council:
The American Physician
Mulford
Pollen Extracts
mean more to the medical profession
than a mere seasonal remedy for Hay
Fever, to be obtained at a certain price.
They are the only pollen extracts, or so-
called antigens, which are standardized
according to protein nitrogen content
They include only the acetone-insoluble
portion of the pollen protein— the spe-
cific protein in refined form.
The salts, resins, sums, carbohydrates
and other extractives are eliminated,
and the resultant product is more stable,
and less subject to chemical changes.
It requires Mulford resources and
standards to prepare products of the
specificity, purity and desensitizing
value of Mulford Pollen Extracts.
For Diagnotil
Pollen Extract* In Iotn-
dennlc Bjrinra« and
Cntueou* Ontflu.
Pollen Extncta In Hjpo-
denulc SntnarnVtahi ut
Mulford HjDO-Unlti.
BEND FOB HEW LITEBATUBE
Mulford Company
Philadelphia
You can buy with confidence — See "Service Guarantee to Readers"
The American Physician]
An Honest Market Place 477
A Cough Sedative
and Antispasmodic
of Proven Value
When every other remedy fails,
try DIATUSSIN and benefit
through diminished individual
attention in all cases of per-
sistent cough; particularly
Literature ana Samples
whooping COUgh during pa- on request
roxysmal stage, when DIA-
TUSSIN administered regu-
larly will reduce expiratory
blasts and quickly terminate
the disease.
Ernst Bischoff Co., Inc., 85 Wert Broadway, New York |
- a
IniraHmUUUiHltRHUIIMIUWI^
Mentioning The American Physician Insures Prompt, Careful Service
478
Contents
Copyright, 19a, by Th* T&yhrs, AU rights rtstrvrt.
Editorials
The Present and the Future of Drug Therapy 469
Chlorophyll and the Vitamines 491
What Shall We Do in Cutaneous Anthrax? 492
Articles
Opportunity of the Family Physician Toward Insanity
of the Young.
By Bayard Holmes, M.D 493
Dr. Holmes says: "Whatever is to be done for the
twenty thousand and more youths who come down
with dementia praecox every year must be done before
commitment and before sanitarium segregation.
"The problem of dementia praecox is in the hands of
the family physician, where the problem of every other
disease which has been solved by our profession has
been safely placed."
Relation of the General Practitioner to Mental Disorders.
By Bamuel W. Hamilton, M.D 499
When power of fancy over reason becomes ungovernable
and apparently influences speech or action, the patient's
mind changes from normal to abnormal — he becomes
a menace to himself and others, as is verified in this,
Dr. Hamilton's classical paper.
The Diet In B right's Disease Complicated by Diabetes.
By Edward C. Bennett, M.D 501
Emergencies in Obstetrics.
By Charles Mazer, M.D.
502
An obstetrical emergency is like a smouldering fuse of
the danger-laden bomb — in either. Quick, daring, dex-
trous action is pressing, or the bomb explodes and the
patient dies. With this in mind, Dr. Mazer's paper,
short, clean-cut, comprehensive and practical, we believe
will be appreciated.
Blood Pressure— Needlessly Alarming Laymen.
By T. J. Bowles, M.D
.504
Treating Sequalae of Fractures by Physical Measures.
By William Martin, M.D 506
Dr. Martin, in his excellent paper on the use of electro-
mechanotherapy in the prevention of the diastroos after-
effects incident to improperly treated fractures, narrates
how a patient would meet his doctor in the street aad
silently and scornfully hold up his ankylosed arm— to
the natural displeasure of the physician in question.
It is to prevent such "monuments" that we recommend
the utilisation of the methods advocated In this well-
written paper.
Prolapse of the Rectum.
By Charles J. Drueck, M.D.
501
Few diseases are as annoying as is a rectal prolapse,
even if it is not, as such, fatal. Few diseases cause
as much discomfort, misery, and suffering as does this
distressing disorder. To render the victim respite,
relief, perhaps cure, we present this highly instructive
paper of Dr. Drueck. The proctologist, as well u
practitioner, will not, we vouch, be disappointed with it.
(Contents amtmmfd mm pagm 480)
HINOSOL
"A POWERFUL AlsrriSEFTIC, SOMEWHAT STRONGER IN
THIS RESPECT THAN MERCURIC CHLORIDE AND CONSID-
ERABLY STRONGER THAN PHENOL."
(COUNCIL ON PHARM. AND CHEM. A. M. A.)
AseptikonS" (su
VAGINAL \
ppositories/
producing complete antisepsis
But
Non-poisonous, Non-irritating and No injury to membranes
Indicated in cervicitis, leucorrhea,
specific and non-specific vulvo-vaginitis, in all cases
where complete vaginal antisepsis is desired.
PARMELE PHARMACAL CO., 47-49 WEST STREET, NEW YORK.
You can buy with confidence — See "Service Guarantee to Readers" on page 542
The American Physician]
An Honest Market Place
479
The effect of the yeast
treatment on uric acid
excretion
An interesting investigation of the effect of fresh yeast on uric acid
excretion in normal persons has been recently conducted and reported
upon. (See Journal of Laboratory and Clinical Medicine, May, 1922.)
THE yeast cakes were eaten before
meals by two men and two women
subjects. One ate 3 cakes a day for ten
days. Another ate 3 cakes for six days,
then 6 cakes for four days; the third ate 3
cakes for three days, 6 cakes for three days
and 9 cakes for four days; and the fourth
ate 3 cakes for three days, 6 cakes for three
days, 9 cakes for three days and 15 cakes
for one day.
The daily diet was similar to the con-
ventional "purine free" diet based on eggs,
milk and cheese except that it was found
desirable to include a vegetable salad in
the noon meal. The same food was eaten
every day. Approximately forty calories
per kilo were provided and the weight of
thesubjects renamed constant throughout.
The uric acid in the urine was deter-
mined by the colorimetric method of Folin
and Wu. Hydrogen ion concentration was
done by the colorimetric method using
methyl red and thymol blue as indicators.
Total nitrogen was determined by the
Kjeldahl method.
The experiment was divided into four
periods — a fore period when no yeast was
eaten — a yeast period — and two after-
periods when no yeast was eaten. "There
was no significant change m the values for
uric acid in any of the subjects through-
out the experiment," comments the sci-
entist.
This result seems remarkable when one
considers that for certain periods three of
the subjects ate twice the therapeutic
dose of yeast, two ate three times the dose
and one ate five times the dose.
The summary states that "there is no
evidence of an increase in uric acid excre-
tion following the ingestion of the recom-
mended therapeutic dose of live yeast."
The Fleischmann Company feel that
this investigation proves conclusively that
the ingestion of yeast does not increase
uric acid excretion, and that, therefore,
the advantages of yeast therapy are safely
open to the nephritic and to those suffering
from gout.
A New Authoritative Book
Send for the recently published brochure on
the manufacture, chemistry, physiology and
therapy of yeast. This book is distributed free
to physiological chemists, physicians and hos-
pitals. Address The Fleischmann Company,
Dept. S-7, 701 Washington St, New York
City.
Mentioning The American Physician Insures Prompt, Careful Service
J
The American Physician
3
to (M§
I 5
•S A physician get* no time to figure
£ the co»t of operating hit car, but
£ if he it paying b
|£ depend upon it
|B ing oil hat aomc
S withit.
New Prices on
Merz Santal Comp.
Capsules
DISPENSING PHYSICIANS CAN BUY
OF US DIRECT
10 Minim Elastic Capsules, box of 100
Alto boxes of 12 nd ban* of 24
S Minim Perle* bottle of 36
5 " " bottle of 500
5 " " bottle of 1000
Unsurpassed for happy effect in Urethritis,
Cystitis, Prostatic Troubles, difficult mic-
turition, etc.
PRICES AND SAMPLES UPON APPLICATION
THE MERZ CAPSULE CO.
DETROIT, MICH.
ConteTltS canflnotJJnm, page 478
Diet In Typhoid.
By L. R. Mark ley, M.D
Infection Through the Umbilicus.
By A. Mackensle Korbea, M.D
In this, the twenty-eighth clinic of Dr. Forbes' *
on Clinical Surgery. Ibe author says: "The prog
In these rages of septicemic arthritis in Infants Is
bad. The mortality In this condition la. at least, aev.
live per cent. This high mortality la doe Dot so i
'o the surgeon's Inability t" ' "' '"'
the lessened resist
e of t
trol the liuTectlOD a
Infan
Efficient Future of Medical Practice
II It DMlrablc to Standardise Therapeutical 513
Long Distance Weather Prognosticating 514
Confusing Terminology of Present Metric System, Sug-
gesting Adoption of Universal Terms.
By F. A. Graft', A.B., M.D
MS
Birth Injuries 91*
Arsphenamlne Treatment of Syphilis SSO
"Pernicious Anemia" and "Septic Anemia" StO
Epidemio (Lethargic) Encephalitis SH
Practice of Obstetric* an Art W4
Money Back Guarantee to Subecriben
Thi Amaius Physicias i> pablisbed for enm ud tub .
nrpose — to give the general practitioner the efficiently srscnai
rrrice really helpful in the problems of everyday practice, sua
i promote and protect the oppertuuitite and iuttrttti of I
mrroJ practitioner in tviry possible way; and, if ffcii awrt
<ril done, to be financially self-supporting and to ears s rasa
oin a oy o
mill*
IC1AK
is not givtng
him
lull
SUM
ore ("pressed down a*
refund, without q.acnk'v
bicriptian, even if be bu
Th« Akiiicjih Fhysiciah seeks only satisfied, interested
•den.
Sabacription Contmaane*
Practically ail of our subscribers, as a matter of eonTenieset,
.-:.. ...i. — i~^™ m h. i-nntinued. to avoid missing iskici <■«
and to be billed wben subacripOM ■
annoi eufply fiocl
leriod.™ " **
Where this is »
However, if for
ription bill, it will be discontinued (at once, of course)
no charge for the copies sent after expiration.
I Anisic*™ Physicias does net distribute tmmflt copies i
copies of any kind.
SubMcription Price
lr cents a copy current issue (bsck issues tl.00 s OJfy-
istues not available}; U.00 for One Year; $3.00 io. Tw
t ($1.50 a year); $5.00 for Four Years (I US s year)
(1D.00 for Ten Years (only $1.00 a year).
This is for Domestic postage— U. S. and possessions. Cats
feneo. Canada and Foreign, 50c additional each year.
Addme all communication! and make alt fundi payable H—
Tht American Pkjnatm,
4M Walnut Street, Philadelphia. V. S. A.
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481
Hay Fever Memoranda
Late Summer Type, Patients whose hay fever develops in
mid-August and continues until frost should be tested with pollens
of local importance — primacy being given to the long distance
wind pollinated plants, e.g., ragweed. However, where contact
is unavoidable, as on a farm, the short distance wind pollinated
plants, e.g., corn — and the insect pollinated plants, e.g., sun-
flower, which are also atmospheric— -cannot safely be ignored.
ARLCO-POLLEN EXTRACTS
For Cirtmtom Tests and Ti
and late spring; also summer and autumn.
Literature and Lut of Pollen* an RtqaaA
THE ARLINGTON CHEMICAL CO., Yonkcn, N. Y.
SUMMER DIGESTIVE DISORDERS
Are best controlled by the use of
(Alkaline Elixir Rhubarb
Compound with Pancreatin)
FORMULA
Each fluid ounce represents:
Rhubarb 20 gr.
Berberine (Alkaloid from
Golden Seal) 10 gr.
Sodium Bicarbonate. 10 gr.
Pancreatin Glycerol*. 8 min.
Cinnamon 10 gr.
Summer brings its burden of digestive
disorders, Diarrhoea, Dysentery, Indi-
gestion, Cramp Colic, Constipation,
Hyperacidity, etc. To meet these con-
ditions the physician must administer an
antacid, an astringent, a hepatic and
intestinal tonic, and precisely these qual-
ities are combined in the ingredients of
Alkarhein.
Sample bottle and interesting literature will be sent upon request
tmirni
M FOUNDED Itat
ERRELLomm"
A CIBOmUfll.ttSA
Mentioning The American Physician Insures Prompt, Careful Service
An Honest Market Place
AUTHORITATIVE EVIDENCE
55. Vol. 1 1, "Dueajet of Women. as
edited by H Marion-Sims, U D . tad
in Dr Simi' own word*, ii recorded
' i which he held
the "great tervicc" i
DYSMENORRHEA
. HOYDEN'S VIBURNUM COMPOUND '
it u effectual therapeutically to-day
u in Ihe day of Sinn, and will give
you the tame "great service" in treat-
ing your dyimenorrhea curs, at wax
rendered to Dr 5 bin.
Prexribe, ai recommended by Sim],
in teaspoonful dotes, "administered in
hot water'' every hour for three or
four noun. See thai the genuine
H V C » "
HEW YORK NMMUEUT.UL CO.
Bedford Spring!, Bedford, Mail
been pnwtn fc» ynrt of dinl
in ..hi. ■*•
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An Honest Market Place
LOESERS INTRAVENOUS SOLUTIONS
INTRAVENOUS INJECTION
IS A SERIOUS PROCEDURE
THAT REQUIRES
FIRST: Selection of Standardized Solution*,
from a Reliable Laboratory.
SECOND: Full Knowledge of the Content*
of the Solution.
Half secret compounds, unscientific gunshot combina-
tions, specialties and low-priced substitutes are out
of place in intravenous medication.
Loeser's Intravenous Solutions are not "cures" or
"specifics," but simple scientific solutions of U. S. P.
and standard remedies of established therapeutic
value.
The contents are plainly stated on the label, free
from ambiguity, mysticism and charlatanism. They
are standardized by chemical, physical and animal
tests.
Clinical Report*. Reprint*. Price Luti
and
"The Journal of Intravenou* Therapy"
mill be tent to any phytician
on reqaett
New York Intravenous Laboratory
100 WEST 21ST STREET
NEW YORK, N. Y.
Mentioning The American Physician Insures Prompt, Careful Service
484
The American Physician
[Phfla., July, 1922
ffi^ft?*o3^1 The Management of an Infant's Diet |fefeSgf?fe&1FS
^1
Diarrhea of Infants
Three recommendations are made —
Stop at once the giving of milk.
Thoroughly clean out the intestinal tract.
Give nourishment composed of food elements capable of being
absorbed with minimum digestive effort.
A diet that meets the condition is prepared as follows:
Mellin's Food • 4 level tablespoonfuls
Water (boiled, then cooled) . 16 fluidounces
Feed small amounts at frequent intervals.
It is further suggested : — As soon as the stools lessen in number
and improve in character, gradually build up the diet by substituting
one ounce of skimmed milk for one ounce of water until the amount
of skimmed milk is equal to the quantity of milk usually given for
the age of the infant; also that no milk fat be given until the baby
has completely recovered.
i
i
i
8*SE*S3^i Mellin's Food Compmy, Boston, IfoSnjjSgflBSggg
I
Not to Know Is No Excuse
THE USEFULNESS OF ALKALOL
is being constantly brought to the attention of the medical profes-
sion. To neglect to try ALKALOL is to deprive patients of a most
valuable and effective agent for comfort insurance.
DURING THE SUMMER MONTHS
ALKALOL should be in constant use, in the eye, nose and throat,
on the skin, upon mucous membranes of the genito-urinary tract —
in short, anywhere, and in any condition where a soothing, healing,
cleansing spray, douche, gargle, wet dressing, injection, irrigating
fluid, or internal antiseptic antacid is indicated.
ALKALOL Is Different
in Composition, Action and Effect
From Ordinary Agents
Send for REASON WHY literature and sample
The Alkalol Company Taunton, Mass.
You can buy with confidence — See "Service Guarantee to Readers" on page 542
The American Physician]
An Honest Market Place
485
INDIGESTION
'"THE alleviation of the symptoms of
A indigestion is best accomplished by
facilitating the reduction of the undi-
gested mass of food to the soluble and
more easily movable end products of
proteid and carbohydrate digestion.
Pepsin and Pancreadn will take care
of the proteins, and for the rapid lique-
faction and progressive digestion of the
starches TakavDiastase is to be preferred.
But the value of TakavDiastase even
in proteid indigestion must not be over*
looked. This diastadc ferment is bene*
fidal indirectly in cases of protein
indigestion by disposing of the starchy
elements of the food, thus rendering pro*
teins accessible to the action of hydro*
chloric add and the proteolytic enzymes.
The usual dose is 2 to 5 grains, taken
with meals. It may be advantageously
combined with other remedies as in the
following formula:
Est. Nude Vomicae, §r. hr.
Pancfeatini«
Taka-Dftaataae, aa 3 i.
B
M. et fiat in capeuks No.
Sig: One capaufc with meaie.
Or, if you prefer a liquid mixture:
B Tr. Nude Vomicae, 3 HI.
Liq. Pancreatine f las.
Liq. Taka-Dftaataae, q. a. 5 hr.
VLetaif: 3 tt with meala.
Patients who have intestinal indi-
gestion with accompanying fermentation
and hyperacidity can be given grati-
fying relief by the employment of Taka*
Diastase, either alone or in a combination
such as this:
9 Reeofd&i, 3L
Milk of Magneaia. P. D. &. Ok.
Liq. Taka-Dtaetaee, aa Shr.
M.atatgt 3ttt.Ld.ooehourp.c-
And if there is an associated atonic
condition, rapid improvement follows
if capsicum and cascara sagrada are
combined with the Taka-Diastase. For
example.
Puhr. Gapaftd, jr. x.
Ext. Caacatae Sag.* gr.
-- - sg.
B
M. at fiat in capeulaa No.
Sftgt One capaule t4.d. one hour p. c
The relief which follows the adminis-
tration of Taka-Diastase is quickly appar*
ent, and indeed is quite a reasonable
expectation when it is considered that
Taka-Diastase liquefies 300 times its
own weight of cooked starch in 10
minutes.
®
Taka*Diastase is the kind of remedy
you are called upon frequently to pre*
scribe; moreover, it is the kind of rem-
edy you can depend on to carry out
its therapeutic mission: the alleviation
of the symptoms of indigestion.
Parke, Davis & Company
Neu/ Literature Qladly Sent Physicians on Request :
Qland Therapy — Pertussis Vaccines — TakarDiastase — The 1922 Catalogue
Mentioning The American Physician Insures Prompt, Careful Service
486 7fte American Physician [pha»., j,d>, 1922"
In summer diarrhea, intestinal catarrhs, etc
c
Tannalbin
DOSEi Infantai 1 to B tralna mini limn a day la gnat. Cblldrwt 7H la 15 mbt,
Adults: Half • teniiKioiiFu] US lo 30 aralcm in pnwder or 5-gi«in Ubletl)
three to flva timei a da? at hourly Intarvala.
Supplied in Powder and 5 grain Tablets
MmplM apply to F. BDJHUBER, Inc, 2S W«t Brotdw.r, Nn York
¥rp A Onr/^TVT-Cj *# ^w P*"**^ active principles
I Jtir\0 1 V/INE and V1TAMINES OF Yeast
GIVEN IN PLACE OF YEAST FOR MEDICINAL PURPOSES
Keeps well Pleasant to take Reliable
Literature and Sample on request
MERCK & CO. 45 Park Place New York
In Childhood
the benefits from wearing
O'Sullivan's Heels
are recognized and appreciated by thoughtful physician*.
The light, springy step, the delightful resiliency, and the
avoidance of shock and jar, naturally mean much to the
active boy or girl.
Thus the child who wears O'Sullivan's Heels will be
happier, the structures of the feet will be strengthened, the
gait and carriage will be improved, and with elimination of
the continual jarring caused by hard leather heels there will
be a marked decrease of nervous irritation and tendency to
excessive fatigue, with their all too frequent depressive effect
on the whole body.
The sum total is more comfort, greater efficiency and a
O'SULLIVAN real conservation of health.
RUBBER CO., Inc., Thus it is that O'Sullivan's Heels have come to £11 a
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An Honest Market Place
"With this Treatment
I Seldom Write a Death Certificate
FOR
INFANTILE DIARRHEA"
THE BRITISH MEDICAL JOURNAL SAYS:
"All experience goes to show that Virol is a food of marked value
in a great variety of conditions in which adequate nutrition by
ordinary means is not easy to secure, including the general range
of diseases accompanied by wasting and summer diarrhea."
**l have had most excellent result* with Virol; in
fact, to my mind it is the only treatment for infantile
diarrhea — barley water and Virol, or rice water and
Virol. With this treatment f seldom write a death
certificate for infantile diarrhea.**
Extract from doctor's letter.
DIET IN INFANTILE DIARRHEA
To eacfa half-pint of rice or barley water add one-quarter tea*
spoonful of Virol. Give one or two ounces of this mixture every
two hours. In cases of great prostration add 10 to IS minims of
brandy. When the evacuations indicate that the infection is at an
end, sterilised milk can be cautiously added to the Virolised rice or
barley water, the milk being substituted for the rice or barley water,
dram for dram, until Virolised milk is the sole article of diet. As
the child improves the Virol can be gradually increased.
A brochure on the treatment of acute summer diarrhea
will be sent to any medical man on application,
VI OL
Vsed in more than 2,500 hospital* and infant clinics in Great Britain.
Sole Agents for U. S. A.
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Mentioning The American Physician Insures Prompt, Cartful Serviei
The American Physician
NEURASTHENIA
The tumultuous life entails its penalties — among them neu-
rasthenia.
The storm and stress of modern civilization exhaust the reserve
force of the organism just as the suffering and hardships of war
did. Organotherapy is effective in overcoming the nervous
exhaustion induced more subtly, but just as surely, by the high
speed conditions of the Twentieth Century.
Hormotone
tends to restore the per-
fect hormone balance es-
sential to the maintenance
of health and to the resto-
ration of it in a run down
condition.
In neurasthenic cases as-
sociated with a high blood
pressure use
Hormotone Without
Post-Pituitary
Dose of either prepara-
tion: One or two tablets
three times daily before
meals.
G. W. CARNRICK CO.
419 Canal Street New York, U. S. A.
You can buy with confidence — See "Service Guarantee to Readers" on page 5
The Am
encan
Phys
iaan
VmL 27
JvAy, 1922
Nm. 7
The Present and the Future
of
Drug Therapy
BASED ON A SURVEY undertaken on our
travels and visits to many clinics and private
offices, the opinions here expressed are sent in from
New York City, where our survey ended.
There is no doubt at all that modern pharmacologic
and other research has done two things: first, it has
scientifically demonstrated the validity of many
erstwhile empiric claims, as based on clinical obser-
vation, though there has been added a modification
in indication and technic of administration of many
drugs; second, it has thrown doubt upon the physio-
logic activity of other agents formerly of repute.
In and of itself pharmacology has done little of a
constructive character and has added very few drugs
to our armamentarium. Were Peruvian bark never
heard of and its merits never discovered before the
days of the pharmacologist, it is doubtful if the
pharmacologist would have been prompted to investi-
gate it, and even if he had done so it is not at all
likely that his researches would have even suggested
its action in the treatment of malaria. The same
may be said of mercury and many other drugs. But,
on the other hand, were digitalis first introduced
through pharmacologic research, it is quite probable
that its indications, as understood today, would have
been fairly well worked out.
Yet pharmacology has served wonderfully as a
control to clinical observation and has explained
why certain actions may be expected of a drug and
the limitations thereof. On the other hand, pharma-
cologic findings are never final, requiring clinical
controls on the basis of actual sickness, not the
reactions of healthy animals to the drug under study.
Both in so-called "regular" medicine and homeo-
pathy, the study of toxicology, whether accidental
poisoning or regularly conducted "provings," has
very marked clinical limitations when endeavoring
to ascertain from such a basis the indications of a
drug in the treatment of disease.
Competent pharmacologists are very modest in
their statements regarding the assumed lack of activity
of any drug, and the sweeping denunciations of
many drugs so current today are too much based on
negative testimony. Suppose we had only the phar-
macologic findings on chenopodium. We would re-
gard the drug as one apt to cause a fall in blood-
pressure, with decrease in vagus irritability and a
possible respiratory depression; but we would have
no information as to the value of oil of chenopodium
in the treatment of hookworm disease. Cod-liver oil
was, by some pharmacologists a few years ago, re-
garded as of no more medicinal value than other oils ;
but now we know of its fat-soluble vitamine con-
tent and the drug has returned to favor, even with
the research men. So, then, negative pharmacologic
findings regarding many drugs must be taken with
certain reserve.
Where It ike FharwmeeUgic Pretcriker?
Yes, the pharmacologic prescriber actually exists,
and if he is a good diagnostician he is the best
clinician in the field. There is no doubt whatever
that modern materia medica and therapeutics,
largely based, as it is, on pharmacologic findings
controlled by clinical observation at the bedside, con-
stitutes most wonderful advance over the old empir-
icism. The best instances we have seen of such
prescribing is in some of the Boston hospitals, and
we were much impressed with the results. But such
a basis for prescribing is woefully lacking in most
hospitals; and to this day we find in many hospitals
the old system of made-up dispensary mixtures, No.
27 being prescribed for this and No. 18 for that.
There are, it is true, many very able prescribers on
the staffs of certain hospitals, and these men interest
themselves in series of cases and publish findings in
the medical journals; yet the great volume of work
in these very hospitals makes it necessary to relegate
most of the routine to assistants, who are hard pushed
490
The Present and the Future of Drug Therapy
[The American Phyariaa
for time, the result being that the run of patients
get No. 27 or No. 18, or something equally on-
scientific. Look over the dispensary records of the
average large city hospital and the truth of the
above will be proved. In some of the smaller hos-
pitals conditions are better, notably in the smaller
cities.
To prescribe scientifically is just as big a job as
to make a scientific diagnosis; both take time and
careful study. The idea that any one can prescribe
properly in a minute after the diagnosis is made is
all nonsense. Despite a lot of talk of the great need
for socializing the profession and providing hospital
care for everybody, one fact stands out : that is, that
there is a snap-shotism permeating all such work
that, despite elaborate hospital equipment and uni-
formed nurses, etc, the human factor is neglected.
View the work in the average New York City or
Chicago dispensary and judge for yourself. In the
average of them we find no pretense of living up to
pharmacologic teachings in the hurly-burly work of
public ward and dispensary.
Take the young men coming out of our medical
schools and after a residence in hospital for a year
or two entering private practice, what of themf They
are full of the idea that only a dozen or so of drugs
are of any value. It is asserted that with such a
limited number of drugs to study they will fully
understand how to use them; but it is our experi-
ence that they do not understand them any better
than did medical graduates of thirty years ago, and
they have such limited knowledge of the underlying
principles of therapeutics that their usage of these
few drugs is so "standardized" that it constitutes
merely a form of modern empiricism. Tet these
young men of modern training, after they are out
in private practice for a year or two, often become
most capable prescribers, using many reliable drugs
on a pharmacologic basis. If the hospital-trained
young man has been in the private wards under the
direction of clinicians who devote adequate time and
attention to individual cases, he is fortunate, for then
he goes into practice for himself with tempered views
and a real knowledge of therapeutic technic.
It took years to train the practitioner actually to
use laboratory diagnostic resources, but hosts of them
are doing it today: now the effort is to get seasoned
practitioners of the old training to use drugs equally
as carefully and exactly as they use reagents and
microscope. They are coming to it, the result being
that the careful prescriber of drugs is the much-
maligned general practitioner who is neither social-
ized nor standardized, but who is practicing medicine
as it is taught and has a better mortality record than
his fellow in the hospital ward can show. Socializing
and standardizing medical practice positively does
not make for efficiency. Abolishing private practice
would set medicine back for years.
T1* BmmmmSid*
The Modern Hospital for January, 1922, editori-
ally comments on the great growth of dispensaries,
both free and paid, and advocating the greater ex-
tension of the latter type; yet it deplores the fact
that it is so often the case that the service is in-
efficient, due to certain human factors, such as
variability in capacity of the personnel, lack of a
feeling of personal interest and responsibility, the
scant attention commonly given to each patient be-
cause of the large number to be seen during the
hours devoted to the work, deferring work to a later
date or referring the patient to another physician,
the absence of follow-up of patients seen, and the
dissatisfied attitude of the patients themselves, who
are treated as so much material and who often have
to wait for hours before they receive actual atten-
tion. That magazine thinks the cure consists in
getting more money and paying salaries to the attend-
ing physicians. We seriously doubt it, for the con-
ditions are due to human factors that factory
methods in medical practice will not eliminate.
But we are talking now about the present of drug
therapy and how these factory methods of practicing
therapeutics debase its standing as an art and a
science; in fact, quite ignoring modern teaching in
pharmacology and therapeutics and substituting a
hasty, standardized empiricism in drug treatment
that largely negatives the value of the more careful
work commonly done in the diagnosis. The way
patients are recorded as to symptoms and other find-
ings, run through two or three laboratories, sub-
jected to other tests, etc., is admirable, but young
and clinically inexperienced physicians and lay
laboratory workers can do this work and present a
chart covering the whole findings. But when it
comes to the summation of all of this work, interpret-
ing these various findings, making additional inquiry
and physical examination suggested by the chart and
the appearance of the patient himself, and, most im-
portant of all, carefully outlining case-management
and drug treatment indicated, that requires at least
a half hour's careful and discriminating work on
each case by a seasoned clinician of tempered judg-
ment and exact knowledge of diagnostics, therapeu-
tics and pharmacology. The man who becomes
accustomed to the slipshod and hasty treatment so
commonly doled out in five minutes to the dispensary
case is ruined for private practice, where higher
treatment standards prevail, unless he gets firm
hold on himself and resolutely shakes himself loose
from factory methods and the modern idea of
standardizing everything but brains and hard work.
The Fwtmre W Dng Thermpy
Our survey has made us absolutely out of harmony
with a lot of modern propaganda, for we have seen
what its actual output is when tried out Drug
therapy is fast becoming scientific, but it is hard to
PfciU., July, 1922]
Chlorophyll an* the Vitamines
491
interest the modern man in it except when it is
speculative, such as much of endocrinology and
serology are thus far in their development Men who
would smile at speculative diagnostic measures will
swallow, hook, bait and sinker, a lot of speculative
drug therapy or psychoanalysis. And the funda-
mental reason why so many men are not interested
in drug therapy and pharmacology is, as they tacitly
recognize in their own hearts, that it is a branch of
medicine that requires brains to master and apply,
and, as well, a large amount of time for each patient.
The future of drug therapy is that of one important
part in ease-management — just as important as is
the technic of a surgical operation. After all of the
laboratory findings, the case-history, the reports of
the specialists, etc — after these are all in — then the
patient should finally go to the master specialist,
the therapeutist and case-management engineer. Call
him general practitioner if you will, and deride him
if you want to, the fact remains that what is neces-
sary in the healing art is a general commander-in-
chief to outline the plan of campaign; the rest of
the men are scouts, engineers and technicians. So
let the at-present "general practitioner" cheer up,
for his position is the key to the situation, and
among his ranks will arise the master specialists who
will control the actual erection of the medical edifice
of the future.
But this future of therapy will be many-sided;
drugs will constitute but a part of it — an important
and exactly defined part — and the man who becomes
master of case-management on such a basis will
attain to it only after very hard study. Yet he will
gain, by virtue of his position, a commanding influ-
ence equal to that of the skilled surgeon; and his
success in actually applying scientific methods to the
treatment of non-surgical cases will elevate the whole
field of therapeutics and general practice. — T. S. B.
Chlorophyll and the Vitamines
WHAT RELATIONSHIP exists between the
vitamines and chlorophyll f The fat-soluble
vitamines are, after all, mostly elaborated in the
economy of the animal feeding on chlorophyll-bear-
ing plants, and when the animal is out on green
range the milk and flesh carries more fat-soluble vita-
mine than when the animal is stall fed.
The green and red cells in plants (chloroplasts and
ehromoplasts), according to Oliver, in "The Natural
History of Plants," are protoplasmic, taking from
the air carbon dioxid, which goes through the stomata
of the leaves and in the cell sap it is reduced by the
action of sunlight and carbohydrates are formed. The
green chlorophyll bodies are the principal mechanism
of this synthesis. Furthermore, according to Mathews
(Physiological Chemistry), chlorophyll is a catalytic
agent and has to do with the production of sugar.
It is a strange fact that certain animals, the volvox,
for instance, possess chlorophyll just as do plants,
and can form starch. Light synthesis in animals has
never been adequately studied, and when it is so
studied it is probable that the vitamines will be better
understood, for vitamines seem to be stored-up sun-
shine in foods.
Chlorophyll, when broken up, yields, like hemo-
globin, pyrrhol derivatives; it appears to be related
more or less closely to the hematin of the hemoglobin,
hemophyrrol being identical with phytophyrrol.
Plant chromoproteins are conjugated proteins like
hemoglobin and are closely related to the chlorophyll.
Both hemoglobin and chlorophyll absorb light and
they possess many vital elements in common. It
seems a reasonable supposition that as water-soluble
vitamines are found in abundance in chlorophyll-
bearing plants, that is, those rich in chlorophyll, this
latter agent must have a bearing on the elaboration
of vitamines in the plant structure.
The ftmcAcei Appticdtim
Burgi, in the Correspondene-Blatt fur Schweieer
Aertz, contended that chlorophyll is an hematopoietic
substance, and Maillart, of Geneva, agreed with him,
citing the green-vegetable-eating Genevese as remark-
ably free from chlorosis and deficiency diseases.
Mark that these contentions of Burgi and Maillart
were made in 1915 and 1916, before vitamines were
known in any definite sense. We venture to refer to
them and to the researches of Oliver and Mathews
as justifying our raising of the question whether or
not vitamines are derived from chlorophyll.
We incline to the view that chlorophyll is, basically,
one of the most important substances in nature, ren-
dering possible the elaboration of unfit into fit sub-
stances for animal nutrition. That a plant dies when
its supply of chlorophyll is shut off is well known,
even as an animal dies when deprived of hemoglobin.
The importance of chlorophyll in the dietary of ani-
mals should be studied, for, as it appears to us, we
are studying end-products in vitamines, not funda-
mental factors.
492
Announcements
[The American Physician
If we are correct it would appear that, regardless
of the differences in fat-soluble and water-soluble
vitamines as we know them, the fat-soluble vitamines
may be elaborated in the animal system if the diet
contains an abundance of plants carrying water-
soluble vitamines and, as well, large supplies of
chlorophyll.
It all comes right back to nature — to sunshine, to
natural processes of growth, to normal diet and
healthy living. All modern science is proving that
health and longevity depend on obedience to natural
law, and that good therapeutics consists in finding
out what factors in life are necessary to build up a
natural resistance to disease. Sometimes the agency
that produces immunity comes out of a bottle, but
more frequently the chemist need not be called upon.
Nature is the greatest chemist, and the vitamines she
has placed in foods suffice for all of our needs. What
are vitamines f After all, we don't know. Perhaps
they are stored-up sunshine as derived from chlo-
rophyll, even as coal is said to be stored-up sunshine
as derived from carbonaceous plants:
Coming
What Shall We Do In Cutaneous Anthrax?
REGAN, in several recent articles, has called re-
newed attention to cutaneous anthrax, prompted
no doubt by a recrudescence of the disease in this
country since the war. Anthrax was at one time a
veritable scourge, but has been rather infrequently
observed in man in the United States, but physicians
should know how to meet the occasional case observed
here.
Regan contends that the ideal treatment should in-
volve little scarring, should be specific, should limit
the local lesion and never disseminate it locally or
into the circulation, should yield a low mortality rate,
should cause a minimum of pain, should be applicable
in all forms and be prompt in result.
The classical local treatment is condemned, since
it spreads the infection. Surgical treatment by in-
cising the local lesion is considered dangerous and
rarely necessary. The natural tendency of the dis-
ease is to remain local and we should do nothing to
disseminate it. The barrier zone established is the
best possible protection. It is now well proved that
anti-anthrax serum is effective in the greater pro-
portion of cases; it should be injected around the
lesion, and used subcutaneously, intramuscularly or
intravenously, as may be indicated by the severity of
the case — 50 c.c. at a dose for four doses in mild
cases, 100 c.c. in more severe cases, and the maximum
200 c.c. Be sure to use it before a septicemia has
begun*
Applied Therapeutics, by A. C. Morgan, M.D.
"Empiricism accomplished much at the hands of
our forebears, who were keen in observing the
physiologic effects of medicine upon individual pa-
tients. Later instruments of precision have con-
firmed the findings of those investigators and
definite results can now be looked for in the light
of scientific accuracy."
The Conduct of the Third Stage of Labor, by Samuel
F. Gordon, M.D.
"The dangers due to accidents occurring during
the interval between the birth of the child and
the birth of the after-birth exceed those to which
the parturient woman is subjected because of
accidents during the rest of labor." This state-
ment deftly summarizes the importance of the
subject and should be a warning to those who
wade the dangerous streams of obstetrical
medicine.
Medical Diathermy in Joint and Bone Lesions, by
Elnora Cuddeback Folkmar, M.D.
The importance of using heat as a therapeutic
agent has been recognized for centuries. Various
methods, local and general, of increasing bodily
heat have been devised, from counter-irritants,
hot poultices, hot-water bottles, hot baths of
the home; to fomentations, hot packs, hot-air
bake ovens, tango mud and hot spring baths of
sanitoria and health resorts. None of these con-
vective methods induce heat deep within the tis-
sues. They are successful only in so far as they
produced by reflex action an indirect slight dila-
tion of blood vessels and an increased metab-
olism.
Cancer of the Liver and Gail-Bladder, by Hyman I.
Goldstein, M.D.
Cancer of the liver and gall-bladder, perhaps
more than cancer anywhere else, is fatal. How-
ever, it is so easily confused with other disorders
of gastro-pyloric, duodenal hepatic or cholecystic
origin that a diagnosis without laparotomy is
extremely difficult, often impossible. The light,
then, on this troublesome, but important subject
shed by Dr. Goldstein in this excellent paper
•will prove of highly practical value.
Rheumatism; Arthritic Conditions and an Effective
Remedy, by Lambert Ott, M.D.
Rheumatism, a loose term, with a painful
pathology and empiric treatment is a reminis-
cence of ancient medicine which so far has suc-
cessfully resisted scientific analysis. Dr. Ott
believes that he has established the etiology and
found a specific for this class of morbidities.
If so, this paper carries a message of hope to
the medical profession and suffering patients.
Some Interesting Surgical Cases, by Irvin Hardy.
M.D.
Dr. Hardy presents a series of highly interest-
ing cases, which incidentally illustrate some of
the "shocking" circumstances under which some
of our surgeons are called upon to operate. It
also demonstrates the daring, and adaptation,
and efficiency, and excellent results our surgical
colleagues are securing under trying environ-
ments in the scattered portions of our vast
country.
The following papers
art contributed exclu-
sively to this journal.
Republication is per-
mitted if credited as
follows: AMERICAN
PHYSICIAN, Phila-
delphia.
Original Articles
SMtnm, ttt nuum, bvi UtftA wfcii ms( mkurt
We are not respon-
sible for the views ex-
pressed by contribu-
tors; but every effort
is made to eliminate
errors by careful edit-
ing, thus helping the
reader.
The Opportunity of the Family Physician
Toward
The Insanity of the Young
By Bayard Holmes, M. D.,#
Late Secretary (1891-96) and Professor of Surgery
in the College of Physicians and Surgeons
of Chicago (1891-1911).
Editor and Publisher of Dementia Praecox Studies
(1918—)
Dr. Holmes says: "Whatever is to be done
for the twenty thousand and more youths who
come down with dementia praecox every year
must be done before commitment and before
sanitarium segregation.
"The problem of dementia praecox is in
the hands of the family physician, where the
problem of every other disease which has
been solved by our profession has been safely
placed/' — Editors.
NO MEDICAL SUBJECT is in greater disfavor
in the public and professional mind than that
of insanity. No subject approaching equal importance
has received from the profession and the reading
public such scant attention. Tet one cannot take up
a daily paper without observing evidences of the
grave social disturbances of the disease, both in
the columns devoted to the records of crime and in
those describing family infelicities and educational
complications.
Perhaps no words in our language are subject to
such quibbling ambiguity as those applying to the
insane. No two persons give the same meaning and
color to these common terms. The psychiatrists
(soul-healers) and alienists (transferers of patients'
rights by legal process) have fixed terms which they
use without fixed meanings, because the meanings
change from time to time and even vary in describ-
ing different mental conditions.
•Prepared for the South Dakota State Medical Society.
May. 1922.
Take the following for examples: lunacy, madness,
psychosis, derangement, aberration, mania, frenzy,
delirium, paranoia, hysteria, monomania and mental
slant, and the adjectives, crazy, confused, irrational,
unreasonable, pigheaded, freakish, nutty, demoniac,
deluded and locoed.
These words are all used both in solemn earnest
and in careless derision. No two persons attach the
same significance to them or use them under the
same circumstances.
The first important matter to any open-minded
enquirer in connection with this subject is the neces-
sity of considering a man as an entity. The individ-
ual must not be anatomized into body, mind and
soul, or any such metaphysical pieces. He must be
looked upon as one and inseparable. Think of the
mind, the psyche, as the manifestation or excretion
of the brain, just as the bile is the excretion of the
liver. Avoid every sort of mysticism or vitalism,
and don't quibble of the imperfections of the fore-
going simile.
The second important matter is the separation of
insanity from irrationality. It is a fact that most
insane persons appear irrational, but many, if not
most, irrational persons, regardless of the degree of
their irrationality, are not insane and no one would
seriously accuse them of insanity. I despair of find-
ing an example that some one would not object to at
once, but take a group of people who now argue
that the earth is flat. They may be considered by
most of us as perversely irrational, but they cannot
therefore be adjudged insane.
An InimbHMj Insmme ferum Mmy Be Legicml mmd RM'umd
In many if not every particular an indubitably
insane person may be logical and rational and his
conduct may be on a very high plane of rectitude.
When the insane in a certain institution were crowded
and sleeping on the floor, with utterly inadequate
facilities for feeding, for toilets and for bathing, an>
494
Opportunity of Family Physician Toward Insanity of the Young — Holmes (The American Physician
insane engineer went to the superintendent and pro-
posed a new method of building which could be
utilized with patient labor and a minimum of outside
help. The superintendent was a practical man and
took readily to the lunatic's novel proposition. Be-
ginning in a small way and extending as rapidly as
possible, he and the lunatic constructed building
after building, greatly to the relief of the congestion
and to the burden on the public purse. Irrationality
and insanity are only incidentally associated. The
insane are sick and the sick deserve a physician.
Insanity is generally looked upon as a chronic if
not a permanent and irretrievable condition. This is
not an essential characteristic of insanity. An in-
sanity may be acute, temporary and transient and
leave no trace behind. The drinking of "moonshine"
frequently produces a temporary condition that is
truly an insanity, and it sometimes produces perma-
nent defect, Korsokov's psychosis. Poisoning with
belladonna, hashish, pulka and some minerals like lead
and antimony display symptoms inseparable from
those of insanity. Infectious and febrile diseases are
frequently charcterized by periods of temporary in-
sanity and even by permanent insane states. These
states are sometimes short and violent and are clin-
ically termed delirium, but they are also often enough
protracted and take on all the essential features of
an insanity. Local disease of the brain, tumors, ab-
scesses, diffuse infections, emboli, thrombi, and ana-
tomic defects produce the clinical pictures of in-
sanity, and patients with these conditions are fre-
quently committed to asylums by legal process and
their bodily sickness is first discovered at postmortem
autopsy.
Evtu Arnhmh B*com* It
Even animals, ordinarily considered without reason,
become insane. There was a widespread disease of
cattle and horses and even of wild animals noticed in
Mexico and the southwestern states, known to the
rangers as "loco." This term was derived, no doubt,
from the Spanish "locura," crazy; or "loco," mad,
crackbrained. It was believed to be due to eating a
weed called the loco-weed and homeopaths sought this
weed as a remedy. Large appropriations have been
made by some of the western states to exterminate this
weed. In India elephants become insane from certain
glandular infections on their foreheads, and it is
necessary to scrape and cauterize these places or kill
the animal. Hunters tell stories of insane wild beasts,
but these stories are largely discredited, because we
have no way of recognizing insanity in dead animals
(or dead men, either) by objective scientific tests.
The sleeping sickness is perhaps the only exception
to this generalization. The worm that causes sleep-
ing sickness in man is found in the animals, and it is
also found in the fly that carries the parasite from
animal to animal and from animal to man.
is Notlumg New t tfWcm
Insanity is nothing new or modern. It was de-
scribed in the Eber's Papyrus, a medical encyclopedia
of 110 pages written 2,500 years before Christ It
was often mentioned in the Hebrew Bible. In the
New Testament a crazy man was cured. The demons,
long considered the cause of mental aberration, were
driven out and went into a herd of swine. The crazed
animals ran down a steep place into the sea, and
were drowned. The keepers of the swine didn't like
the method of cure and begged the innovator to de-
part out of their country. The geographical distri-
bution of insanity is practically universal, and no
tribe, clan, race, nation or family has ever entirely
escaped it. While It appears to be more frequent in
some places than in others, no locality and no civil
or social condition is immune. The civilized and the
uncivilized, the black, the white, the red and the
yellow, present typical cases of each form of insanity.
The insane are statistically more common in New
York than in Alabama, but statistics are based on
reported, committed, custodial cases. There is no
significant difference in frequency that does not de-
pend on the attitude of the public to these unfortu-
nates. While the insane were looked upon as demons
and chained up and kept in Jails and poorhouses,
they had a short life and were fewer relative to the
living population; now that they receive better insti-
tutional care they live longer and seem therefore in
greater ratio to the sane population. In the State of
New York Pollack has found inexplicable differences
between the ratio of commitment of dementia praecox
patients in neighboring cities, and among populations
of different racial origins. Occupation or custom may
yet yield some explanation if the cause of dementia
praecox is ever discovered.
The very aged sometimes become insane and this
condition is usually a part of a general nutritional
decline, and a slow invasion with parasites.
The symptoms of the insanity depend not alone on
the cause (the cause of one insanity is definitely
known), but upon the patient's personality. The
personality changes with the age and education of the
patient, hence the symptoms of two different insani-
ties, that is, of Insanities with different causes, in
young patients, are apt to be similar in a larger
measure than when one patient is young and the
other old. Paresis in the adolescent resembles the
more common insanity of youth, dementia praecox,
and (but for the objective methods of diagnosis and
the favorable result of treatment) the former case
would pass for dementia praecox.
N* Epfamc* W Heredity
There has occasionally been noticed a tendency for
members of certain families to suffer of insanity.
This has led to the presumption that insanity is
hereditary- The same was said of tuberculosis be-
fore the cause of tuberculosis was discovered. Con-
Pbfla., July, 1922]
Opportunity of Family Physician Toward Insanity of the Young — Holmes
495
sumption was said "to run in the family" and many
old bachelors and old maids lived lonely lives be-
cause they feared if they married and had children,
these children would be scrofulous or consumptive.
We now know that tuberculosis of the lungs is no
more hereditary than are cooties or the itch. There
is no better evidence to-day that insanity is heredi-
tary than there was fifty years ago that tuberculosis
was hereditary* The one insanity for which we have
discovered the cause, namely, paresis, is certainly
not hereditary or transmissible, though a syphilitic
infection is contagious. It makes lots of difference to
the brothers and sisters of an insane youth when
their mating time comes whether the insanity is
hereditary or not. If the professional and public
opinion is toward the hereditary and familial origin
of insanity, some of the marriages will be interrupted
or after marriage some conception or pregnancy will
be interfered with. The physician, the alienist and
the psychiatrists are taking grave responsibilities
when they declare insanity hereditary and transmis-
sible, but they now assume that responsibility with
no more scientific basis than their grandfathers de-
clared tuberculosis hereditary and transmissible, and
ruthlessly performed abortions on this theory after
grave consultations.
So far as I know, insanity has not been produced
experimentally in men or animals, though some of
the Bymptoms of insanity appear in occupational
poisonings. Workers in lead and antimony, those
who use crude wood alcohol and benzol (benzine),
those subject to gases containing CO., have more or
less permanent abnormal psychoses and are occa-
sionally committed to insane asylums.
The idea that soldiers were scared crazy by the
explosion of great shells has been much exploited in
the dally press, now become a great medium of medi-
cal* education, and the assertion by autogenous up-
lifters that adolescent delinquents have been made
crazy by the abuses of the police and by the so-called
third degree of the prosecuting attorneys does not
seem to be well founded. If these shocks made men
and boys crazy, then there ought to have been many
more such persons made insane. It is more likely
that the few who became insane under such shock
were previously sick and about ready to go crazy
anyway, or in the case of the police atrocities upon
the young, the insanity of adolescence provoked the
delinquent action which aroused the furor of the
officer who brought the smoldering insanity into
flame.
There are several clinical forms of insanity, but it
is enough for our purpose to mention four of the
more common groups.
Anrcsif
1. Paresis, or the insanity of the syphilitic, com-
prises about ten or fifteen per cent of the commit-
ments to the state institutions. That is to say, of
the 90,000 commitments in the United States each
year, 9,000 to 12,000 are insane because syphilis has
attacked certain parts of the brain. These patients
live only a short time in custody, perhaps three years
on the average, so only 80,000 to 40,000 of the nearly
400,000 in the institutions for the insane of the
United States are paretics. Although the cause of
this disease is known and methods of diagnosis by
biochemical, coloidal, chemical and histopathologic
or cytologic tests are positive and Indisputable, little
progress has been made toward cure. This insanity
can, however, be prevented by preventing the spread
of syphilis and by adequate protracted treatment of
the infected. This is the only one of the insanities
which has submitted to mechanistic solution. It is
the only one that can be rationally treated. It is the
only one against which preventive measures can be
instituted.
2. The insanity of the aged, or senile dementia,
comprises about the same proportion of commitments
as paresis. The duration of the disease is consider-
ably longer in custody, so that the number of the
senile insane in our institutions is somewhat greater.
Much can be done and is done for their relief and
comfort, and much more should be done under proper
segregation and colonization. Not enough, however,
is known of the physical condition of the aged pa-
tients to provide any prophylaxis or prevention. The
first steps in research require a complete survey
of their physical condition, and their restoration as
far as possible to a non-parasitic (uninfected) normal
existence. The senile insane might well be cared
for in isolated wards, where attendants would be
prepared to cater to the infirmities or placed in colo-
nies like that of Gheel, where they would still havt
the stimulus of family surroundings and young life.
3. The manic-depressive group comprises the larg-
est proportion of admissions and the greatest variety
in regard to the symptoms of the disease. It presents
the most difficult group to manage, for it contains
a large proportion of the suicides, the assaultive and
the noisy patients. Many of these patients are in
a most acute and fulminating condition and they need
the most immediate and aggressive therapy. Tet this
group furnishes the largest per cent of recoveries.
Probably half of all the manic-depressives are dis-
charged quite recovered. Relapses are, however, fre-
quent. The etiology of this clinical group is still
unknown. The treatment is symptomatic, elimina-
tive and hydrotherapeutic, open air and out of doors.
Many respond promptly to the removal of foci of in-
fection in teeth, tonsils, gall bladder, appendix, kid-
neys, tubes, uterus, bladder or seminal vesicles. There
is no demonstrated histopathology of the cerebrum
or other parts of the brain in this condition. Mental
hygiene and psycho-analysis have not, however, sus-
tained themselves either in prevention or cure. It is
a fascinating field for biochemical research. It is
distinctly institutional.
496
Opportunity of Family Physician Toward Insanity of the Young — Holmes I The American Pfayama
DoMafifl Prmecix
4. Dementia praecox is the diagnosis of the group
that supplies the growing population of the asylums
for the insane, because the patients are young when
committed, and they live, even in the restraint of
custody, for sixteen years or more. Only twenty pei
cent of the total admissions belong to this group,
but Bixty-five per cent of the patient population are
dementia praecox. There are quite a number of
deaths among these patients during the first year
of the disease, but after that time they seem to live
in confinement until tuberculosis carries them off.
Fifty-two per cent of them die eventually of this
disease, and some psychiatrists believe there is a
causative relation between dementia praecox and tu-
berculosis. Thus it appears that dementia praecox
is the great problem of insanity and it is obvious
that it costs the state sixty per cent or more of the
annual output for the insane. The charities budget
in most northern states is one-third or more of the
total state expenditure. Tet no state has supported
any active research into cause, cure and prevention,
and no state board or national psychiatric society has
ever petitioned a legislature for such an undertaking.
This leads to the study of dementia praecox alone
and to a consideration of the obstacles to be over-
come before dementia praecox is as rare a condition
in our state hospitals as typhoid fever is in the civil
and military hospitals, where it once filled a major
portion of the beds. It is my firm conviction that
such an issue would follow adequate research. One
would say at once that a disease which costs the
state more than half its appropriations for the de-
pendents, delinquents and defectives must have been
pretty acutely and diligently investigated during the
last thirty years. Unfortunately such was not the
case.
While the State of New York, for example, with
nearly forty thousand insane, costing ten million a
year for custody alone, is building new institutions
at five million dollars each, that State is making no
effort at research and supports the psychiatric insti-
tute with less than fifty thousand dollars a year —
an institute the bulk of whose energies is expended
in staff training and routine service rather than in
research for prevention and cure.
There are men in high places who excuse this lack
of vigorous research into cause, cure and prevention
by asserting that aggressive attack on a practical
problem, however important, is a wasteful and ex-
travagant method, and that each practical problem
should await the steady advance of the frontier of
pure science by which advance its solution will be
automatically accomplished. What did these oppor-
tunists say about the conduct of affairs by the Coun-
cil of Defense in the late war in organizing the chem-
ists, physicists and other technologists of the United
States to discover and contrive poisonous gases and
new means of assault — that is, new means of de-
stroying people? The neglect of aggressive research
by the professional erudite and the professional keep-
ers of the insane has been again called by "A Re-
port on the future independence and progress of
American Medicine in the age of chemistry," a docu-
ment signed by nine of the most conspicuous chemists
of the United States. It was probably written by
Julius Stieglitz. This booklet should have the serious
consideration of every physician and educated man,
whether professional politician or industrial organ-
izer, in the United States. In spite of the years long
custom and present conduct of the official almoners
of the state and of the official directors of state edu-
cation, the committee above mentioned urges aggres-
sive, coordinated strategic attack of the problems of
disease, among which it especially mentions dementia
praecox.
When in 1907 I began the study of the literatim
of the insanity of youth, my astonishment at the
scanty records of physical and biochemical examina-
tions of patients was paralyzing. It was generally
asserted that no histopathologic changes in the brain
and other organs of the body of dementia praecox .
patients had been recognized. It was, however, noted
that the brain weight as compared with the cranial
capacity was increased, and that there was a rela-
tive hydrocephalus, especially that the left ventricle
was enlarged and the amount of cerebrospinal fluid
was increased. (Reichardt, Zeit, f. Psy. 75, p. 34-
103.)
In the following years the evidences of a pathologic
condition of the brain and other organs of the body
developed until we can now give a fair description
of its pathology and histopathology correlated to the
symptoms of the disease, (v. Southard, Gurd, Raw-
lingson, Mott, Husciani, v. Dementia Praecox Studies,
Vol. II to Vol. V.)
With diagnostic physical, chemical, thermal and
electric findings the literature was almost equally
silent in 1908.
The condition of the capillary circulation had been
noticed and this was generally attributed to the in-
activity and the catatonia of the patient The di-
lated pupil was noticed and occasional mention was
made of other pupillary abnormalities. Some Italians
had noticed the excessive low blood pressure of the
early cases, among youths where a low blood pres-
sure is to be expected. There was reported occasional
sudden death and even rupture of the heart without
any obvious external cause. These events sometimes
gave rise to confusing legal investigations, during
which the existence of myocarditis was brought out
There was just enough. clue in the literature to keep
the flair of research acute, the pursuit interesting
and to prevent utter discouragement when a lead
ended in a succession of negatives.
PhOa., July, 1922]
Opportunity of Family Physician Toward Insanity of the Toons — Holmes 497
Then in 1913 I fell upon the German translation
of A. Justachenko's summary of psychiatric research,
which I translated into English, hut was not able to
publish.* It arranged in a systematic manner the
physical, chemical, serological and biological findings
already discovered in the insane.
The efforts which I had made to arouse the state
psychologic institutes of Illinois, of Michigan and of
New Tork to undertake research on dementia praecox
had proved unavailing and it appeared impossible
to activate the only endowment that had ever been
made for research into the cause and possibility of
care and prevention of dementia praecox. (v. De-
mentia Praecox Studies, 1918, Apr. No.) Therefore,
I sought aid from the Commissioners of Cook County,
under the presidency of Peter Reinberg, and in Jan-
uary, 1917, they appropriated $7,000 and the service
of the Psychopathic and of Cook County Hospital for
serious research. With two paid men and several
volunteers and the hearty support and cooperation
of Dr. Adam Szwajkart, the head of the Psycho-
pathic Hospital, who never ceased in enthusiasm for
the laboratory, we established an exclusive research
laboratory seeking the condition, the cause and the
cure of dementia praecox. It was a great adventure •
and the laboratory ward of ten beds was always full
ot interesting cases. The friends of many other par
tients begged to have sons, brothers or husbands ad-
mitted for experimental study and treatment We
were greatly restricted by lack of funds for the
chemicals and apparatus as well as by the inherent
complexity of the problem. Most of the patients
were free, a few paid the hospital ten dollars a
week and fewer still paid one laboratory fee of fifty
dollars.
It is not possible in this short article to recount
the devious course of our single year of investiga-
tions. The war and other inimical influences brought
the appropriation to an untimely end. The amount
of new work done was, however, very considerable.
Some of these investigations on individual patients
have been recorded in full in "Dementia Praecox
Studies," in the "Alienist and Neurologist" and in
other medical journals. In the end we had evidence
satisfactory to ourselves for the construction of the
following working theory which can be grasped by
any sympathetic person of some experience with
disease and some knowledge of the insane.
Fricu
Dementia praecox is an intoxication af-
fecting the brain, the choroid plexus and other gland-
ular organs of the body, particularly the testicles in
males and the ovaries in females. The cerebral lesions
are in the nerve cells and are recognizable histologi-
cally only when the Irritation of the toxine has
been so protracted or so acute as to produce cellular
•A few copies were typewritten and made accessible in
large medical libraries.
destruction. The glandular involvement, especially
that of the generative portion of the sex glands, may
be due to the primary toxaemia or to the intoxication
which follows nature's effort to rid the body of the
broken down, nervous tissues. (Carlo Ceni.) The
fact of a toxaemia is demonstrated by clinical and
pharmachological evidence only. That is to say, the
toxine itself has not been chemically demonstrated
in the blood nor has its catabolized residue been
found in the urine. Adequate researches have not
yet been made in these directions. Clinically there
are indubitable evidences of a severe toxaemia. The
reaction time for sight, touch and hearing is length*
ened and abnormal pupillary and retinal findings are
prevalent (Blinn, Bumke.) Basal metabolism is
often enormously Increased, and the thyroid shows
very general hypertrophy, so much so that it has been
occasionally attacked by surgeons and has been looked
upon by some encrinologists as a possible primary
fault. Tachycardia is conspicuous on exertion, and
low blood pressure is the rule — low even for the
young. The skin shows a multitude of symptoms ot
toxaemia. The odor of the perspiration is conspicu-
ous and suggestive. The sebum is excessive espe-
cially above the collar and in the scalp. The beard
on the face of boys becomes patchy and the patches
are separated by sharp demarkations. There is pro-
nounced dermographia over most parts of the body,
often long lasting. The hair on the legs below the
knees seems to grow excessively. The nails, espe-
cially those of the thumbs and big toes, exhibit con-
temporaneous transverse grooves and ridges suggest-
ing periods of diminishing and increasing nutrition.
If the beard of such a patient is shaved at regular
intervals it will be found to have grown more rapidly
during some periods of improvement than during
other periods of decline. There also appears a char-
acteristic edema of the skin with cyanosis and in
severe cases even gangrene. (Morel, Dide.) This
is noticed most often upon the arms and legs, the
feet and hands, but it does occur on the face. Since
any and probably all the endocrine are affected by
the toxic element either to increase, diminish or per-
vert their functions, we observe skin symptoms which
may be attributed to each possibility — the skin of ex-
ophthalmic goiter or that of Addison's disease.
The interstitial portions of the sex glands are tard-
ily affected, if at all, as histologic studies have shown.
The shrinking of the testicle, which is generally less
than one half the normal weight, may destroy the
interstitial cells by sclerosis and pressure atrophy
alone.
K—i Chemistry
The histology of the blood marks the patients as
toxic and ranges them with Osier's disease. There is
a concentration of the blood, increased viscosity, and
great increase in the number of red corpuscles, 6,-
000,000 to 8,000,000 erythrocytes, with only 6,000 to
>
498 Opportunity of Family Physician Toward Insanity of the Young — Holmes (The American Phjncua
10,000 leucocytes. The number increases with exa-
cerbation of the disease and on the other hand when
sudden betterment appears the number of red cor-
puscles just as rapidly approaches normal. (Kahl-
meter, Lund vail.)
The blood chemistry of dementia praecox patients
has never been systematically carried out on an
adequate scale, coordinated with other examinations,
but enough has been done to excite the greatest in-
terest. Haemoglobin is increased and in a few cases
methaemoglobin or sulphhaemoglobin have been rec-
ognized. The defensive ferment reaction of Abder-
halden suggests catabolizing ferments for cerebral
tissue, the sex gland, the thyroid and often other
endocrine glands and organs. These reactions are not
to be considered as solitary diagnostic signs, but as
indicative of the diffuse action of the toxine. Thus,
the origin of the high haemoglobin Index, the poly-
cythaemia, the cyanosis, and the low blood pressure
appear consistent with a disturbance of the efficiency
of the circle of detoxicating endocrine glands, acted
upon by a particular sort of toxine not very unlike
the toxines that come from latent or occult infection
of teeth, tonsils and the closed cavities of the body.
(Cotton.)
The adrenalin reaction suggests the sort of toxic
substance with which the patient is overcome. When
0.5 cc. of 1-1000 solution (P. D. & Co.'s) adrenalin is
injected into the deltoid muscle of a dementia praecox
patient, the low blood pressure goes down still lower.
When a few (3-7) drops of the same solution is
dropped into the conjunctival sac of one eye of a
dementia praecox patient and the patient kept quiet
in the dark for half an hour or more, the pupil of
the treated eye will be found more dilated than that
of the untreated. This resembles the adrenalin re-
action of an animal or a man to whom a large dose
of ergot has been previously given, or to whom a
proportionate dose of histamin (beta iminazol ethy-
lamine) has been given.
A large proportion of dementia praecox patients,
regardless of the duration of sickness, give the clini-
cal symptoms of spasmophilia. The Trousseau, the
Chvostek, I and II, and the von Pirquet peroneal
are generally constant over long periods of observa-
tion (del Rio). No adequate estimations of the Ca
content of the blood in these patients has yet been
made.
If a barium meal is given dementia praecox pa-
tients, no retardation or evidence of motor inefficiency
is observed in the stomach or small intestine, though
a few cases show cardiospasm and pylorospasm.
Nearly every patient shows spasm of the ring of
Cannon. This ring is rarely observed in man. It is
about two or three inches to the left of the hepatic
flexure of the colon. The barium meal is observed
in dementia praecox patients to? remain in a liquid
state in the cecum for fifty-four to ninety-six or more
hours — in a few cases for weeks. During all this
time there are daily movements of the bowels. This
condition, cecal retardation, is a major symptom.
Now, with this outline, if a physician tries ration-
ally to regulate the condition by use of belladonna to
relieve the spasm, laxatives and purgatives to empty
the cecum, calcium and magnesium to diminish the
spasmophilia, he will produce little betterment,
though he will meet obvious indication.
Appemiecitotj, Ftthmtd hy DmSty /trig rfmt
Appendecostomy, however, has been very effective
when followed for months or years by daily irriga-
tions of the cecum and colon with ten quarts of
warm water at bed time. This operation was per-
fected for the treatment of amoebic dysentery and
can be done by any surgeon. Of course, all infected
teeth, tonsils or other foci of infection should be first
removed before appendecostomy is performed. The
appendix should be well healed before the irrigations
are begun.
Ten days or so after the operation the patient
should sit on the water closet stool. A pail holding
ten quarts of warm (110 degrees F.) water should
be hung three feet above the level of the stool and
connected by a small rubber tube to an inch and a
half of small catheter, just large enough to slip
through the appendix into the cecum. The water is
allowed to run into the cecum until it is full and
begins to give uneasiness. This is about 600 cc. as a
rule. The flow is stopped for a few moments and
shortly a squirting sound will be heard at the ring
of Cannon as the cecum empties into the transverse
colon. Then the flow is allowed to go on. The cecum
fills up again and empties more easily and quickly
into the transverse colon. Shortly the rectum is
emptied into the water closet bowl. This process goes
on for twenty minutes to half an hour when the last
discharges are relatively clean. Every night, four
and a half hours after the last meal of the day, this
process is repeated, and it should be followed up ai
long after it is begun, as the patient has been sick
before it is begun. In some instances improvement
appears almost at once, while in others absolutely no
change is noticed for months — In one patient only
after five months' faithful nightly irrigations. And
yet this patient has remained well and at work since
the summer of 1917. He was the second patient
treated, (v. Dementia Praecox Studies, vol. II, case
of Eldon Duggan.)
It is impossible with the present condition of our
ignorance of the disease to foretell which patients
are likely to recover or improve by this method of
treatment and which ones will fail to be benefited.
It certainly does not depend on the severity of symp-
toms or the duration of the disease. Patients sick
(Continued on page 518.)
Phila., July, 1922]
ReJmtioa of General Practitioner to Mental Disorders—Hamilton
499
The Relation of the General Practitioner
to
Mental Disorders
By Samuel W. Hamilton, M.D.,
Thirty-fourth and Pine Sts., Philadelphia.
I _
"AU power of fancy over reason is a de-
gree of insanity; but while this power is such
as we can control and repress, it is not visible
to others, nor considered as any depravation
of mental faculties; it is not pronounced
madness, but only when it becomes ungovern-
able and apparently influences speech or ac-
tion'* (Johnson: Basselas, Chap. XLIV.)
When power of fancy over reason be-
comes ungovernable and apparently influ-
ences speech or action, the patient's mind
changes from normal to abnormal — he be-
comes a menace to himself and others f as is
verified in this, Dr. Hamilton's classical
paper. — Editors.
THERE ARE TWO handicaps in handling men-
tal disease under which many of us labor in
general practice, both of which are regrettable, and
from one of which the next generation of medical
men should be freed. I refer to lack of time for long
sittings with our patients and to lack of competent
instruction about mental disorders in the medical
schools. To speak of the second first, I am sure that
many physicians have not cultivated an interest in
mental troubles because in medical schools they were
given only didactic instruction about such matters,
and never came in personal contact with the patients,
and furthermore acquired from older medical men the
feeling that mental disorders are obscure, have no
dose relation to normal mental life and cannot be
treated with any degree of satisfaction. This atti-
tude of mind would be sterile even if founded on fact.
Fortunately it is erroneous and many — by no means
all — of the medical students of today have more and
better teaching than we enjoyed.
The other handicap is that the general practi-
tioner has many and varied demands upon his time.
He is in no position to sit down for half an hour or
an hour to talk with a patient whose remarks may
be veiled by distrust, evasion and unintelligible sym-
bolism— and then repeat this on various occasions for
weeks. There are, of course, other obstacles to the
care of mental disorders by the general practitioner,
such as the perturbing effect of a mental patient on
the household, the need of very detailed care in many
cases and the inability of the ordinary family to look
after their sick relative by day and by night without
wearing themselves out and annoying the patient be-
yond the bounds of self-control.
Mental disorder is, of course, very frequent. It is
not a unitary disorder, but may be found as a symp-
tom of everything from cold in the head to tertiary
syphilis of the brain. Its treatment is sometimes
merely incidental to treatment of the general disease.
In other cases there seems to be no general disease and
the mental state, being purely a disturbed function of
the brain, must be treated so far as possible by bring-
ing to bear favorable influences on the mental proc-
esses. In still other cases, as general paralysis and
some senile disorders, the treatment is merely amelior-
ative and there is no more prospect of a favorable
outcome than there is from an inoperable cancer.
In what is said about the mentally disturbed in
their homes, I am not presuming to offer anything
but general advice. Those of you who have had
experience with such cases will perhaps hear cor-
roboration of measures that you have already used
successfully. Those who do not feel equipped to deal
with such matters will of course seek competent advice
from your consultants.
The Mhim
Concerning the deliria, not much need be said. Tou
are told by the nurse or relative that the patient seems
at times not to be himself. Tou notice his wandering
attention, his tendency to become detached from his
environment, to see and hear things that do not exist,
the mood usually somewhat depressed and a desire
at times to get out of bed and perform some errand
for which there is no need. I suppose that delirium
could be induced in any one of us by excessive heat
and deprivation of drink. At any rate no one seems
immune to delirium when seriously ill, and children
and some adults easily fall into it with even slight
illness. It demands constant watchfulness. In the
aggregate, many a case of typhoid fever or pneu-
monia has come to his death because of a wild act
committed in delirium, and families should always be
warned — as indeed they are — that such patients should
not be left alone no matter how quiet they may be
at the moment. Depending on the concomitant physi-
cal symptoms, one may or may not prescribe baths
or packs.
A medical friend and former assistant of mine
when ill recognized that he was becoming delirious,
and having observed the beneficial effect of the pro-
500
Relation of General Practitioner to Mental Disorders — Hamilton
[The American Phyadao
longed bath on restless patients, he gave the neces-
sary instructions to the household so that he himaftlf
could receive such a bath; he told me that he felt
calmer very soon after they had placed him in the tub.
Metdd DatmrbmKts m (ft* Agtd mmd ApwpUtAt
Mental disturbances are not infrequent among the
aged and in cases of apoplexy. Restless old people
are particularly trying in the ordinary household.
We repeatedly learn that the patient was managed
fairly well during the daytime, but at night he got up,
rambled around the house, was in danger of falling
downstairs, and disturbed everybody's sleep. The
family did not feel justified in locking him in his
room, not knowing what mischief he might get into
there, so, much against their wishes, they placed him
in an institution. Oftentimes the family are in posi-
tion either to engage an attendant for the nights or
perhaps one of their own members can change her
manner of life, sleep through the day and remain up
at night. Under such circumstances the care of these
patients may not be at all difficult With a light
burning in the room and someone at hand to talk
and to guide the patient if he must go to the toilet
or dissuade him from trying to go out of doors, he
will not be impossibly restless at night and will even
get a fair amount of sleep. Meanwhile the rest of
the family are not disturbed.
Gemerti f crofysu
General paralysis furnishes in metropolitan dis-
tricts a quarter of the male admissions, and eight to
twelve per cent, of the female admissions to the ordi-
nary hospitals for mental diseases. Like syphilis of
the skin, syphilis of the brain may simulate any other
disorder of that organ. But even when the mental
symptoms are at first obscure, physical signs and
serological findings in the blood and spinal fluid as a
rule make the diagnosis clear. We also know that a
large number of these cases never go to a hospital.
I once saw a farmer with general paralysis so ad-
vanced that his orientation was disturbed and he
could not control his sphincters, but nevertheless he
drove the milk wagon three miles every morning. It
had not occurred to the family that he was endan-
gering his own life and jeopardizing others. Prob-
ably the horse did most of the driving.
It would be impossible within a few minutes to
describe the various types of onset of general paraly-
sis, but when a middle-aged man is found losing
his ethical sense, acting otherwise queerly and show-
ing changes in pupillary and tendon reflexes, one
should at once seek all other necessary diagnostic
criteria, and then take steps to prevent the patient
from dissipating his property, disgracing his family
and endangering the welfare of the community. Not
long ago a prosperous barber with well-marked gen-
eral paralysis was so engaging in his conversation and
so pleasant in his manner that even his wife found it
difficult to think him on the road to mental deeay.
His plan for a trip to South America seemed to her
within the range of possibility, and only an extrava-
gant excursion to a seaside resort with an act of
unfaithfulness there convinced her that he was really
a sick man. Even then some of his relatives could
see nothing abnormal in his conduct on that occasion.
You recall that a general paralytic attempted the life
of Mayor Gaynor of New York and did seriously and
permanently impair his health by a shot through the
lung. In such cases hospital treatment may not be
necessary but it is usually advisable. In a hospital
many such patients quiet down and are able to go
home with a fair prospect of remaining there some
months with a degree of medical supervision.
AewUCm**
Every day cases of acute mental disorder come to
light. Without regard to the particular label that
one may affix, let us think of these as being excite-
ments which may lead to wild extravagance of con-
duct but whose termination may as well be in recov-
ery. Obviously they deserve the very best nursing.
The relatives are apt to keep such patients at home
just as long as possible and perhaps longer than the
welfare of the patient would justify. It may not be
true that all cases of mental disorder should be taken
forthwith to a hospital, but in many cases neglect is
fraught with grave consequences to the patient
Occasionally a well-developed case of excitement rims
its course in a week or two, but usually the duration
is much longer and early action should be taken to
assure the patient of the best care that the community
can give him. If you advise that the patient be
kept at home, you will, of course, make sure that he
is under constant observation day and night
I believe that useful lives are sometimes lost be-
cause the physician yields to the prejudices of the
family, agrees to treat the patient at home and gives
an inordinate amount of sedatives. Sedatives are ex-
tremely useful in the right place and quantity, but
are quite as dangerous as digitalis if abused.
Demnim Prmecmx
There is a large group of cases ordinarily called
dementia praecox, not a coherent group, but in a
general way embracing cases of loss of normal inter-
est with substitution of an imaginary world. Many
of these patients go years without entering a hos-
pital. Some are tramps; some are queer members
of families which are able to seclude them. In cer-
tain instances the family gives such patients as good
care as they could get elsewhere, but one should
always question seriously whether the flagging inter-
est could not be aroused in a hospital which has
special measures to bring to bear on its mental pa-
tients. To be sure, many such patients sink into
torpor in a hospital either because they are not
rightly handled or because no effort breaks through
Pbfla., July, 1922]
Relation of General Practitioner to Mental Disorder! — Hamilton
501
their wall of indifference, but one might expect and
I think sees better results in this direction in a hos-
pital than among eases which are kept at home with-
out the formulation of a definite program of treat-
ment.
Last we may speak of cases of depression. These
are found at all ages. The seriousness of mental de-
pression is often unrecognized by the relatives and
sometimes not even by the physician. The relatives
prescribe the theatre and the physician sometimes tries
to encourage the patient by telling him to forget it.
Well meaning efforts at producing a more cheerful
state of mind are foredoomed to failure. The fam-
ily does not and cannot be expected to appreciate the
dangers of suicide. It is seldom practicable in the
home to keep the patient under constant observation.
I recall the case of a wealthy manufacturer who took
a long trip or two, had plenty of medical attention
and almost every care that was conceivable. We
warned the family that suicide might be attempted
and that the patient must always be under observa-
tion and they thought that he was, but of course
in his grade of society it is customary to shut the
door of the bath-room when one goes in, and in this
case, as in many others, tragedy was consummated
in the bath-room. It is often difficult to predict an
attempt at self-destruction, but every depressed pa-
tient should be considered a potential suicide.
If you decide that the patient should go to the
hospital, how to proceed f Start by warning the fam-
ily against deception, misrepresentation and false-
hood. Few things are more pathetic than the plight
of the mentally afflicted, who in the hour of his great-
est need is deceived and lied to by those in whom
he should be able to trust implicitly. They excuse
themselves on the ground that they are making it
easy for the patient, but in fact they are trying only
to make it easy for themselves and at his expense.
If the patient can be persuaded to go to the Phila-
delphia General Hospital with his relatives or a
physician and sign an application for treatment, he
may be detained for three days, even against his will,
and during those three days, examination and commit-
ment may be secured. Many patients can easily be
persuaded to take this step, and when in the hospi-
tal will be contented to remain during any period
of observation that may be advised.
If the patient is recalcitrant and it is necessary
to secure his commitment to an institution, in Penn-
sylvania, two physicians who have been in practice
five years must see him and make a separate, per-
sonal examination and write out a certificate on
the form which can be obtained from the Department
of Public Health, City Hall, Philadelphia. Similar
provisions exist in other states. The form is simple
and can easily be filled out if the personal examina-
tion is made, but it is both outrageous and illegal to
commit a person as insane on the say-so of some-
one else. The certificate in Pennsylvania must be
made out within a week of the examination and
within two weeks of admission. When the certificate
is made out the physicians must go before a magis-
trate, sign the document in his presence and secure
his certificate to that effect The magistrate's certifi-
cate is already printed on the commitment form.
Armed with this document the relatives can insist
that the patient enter the hospital and the hospital
can insist on his remaining. A private ambulance or
a taxicab or even a trolley car may be sufficient
transportation.
Perhaps the patient has no interested friends and
the public authorities then must be appealed to to
secure his removal to the hospital. Unfortunately,
he may then become a charge of the police. A man
who breaks his leg on the street is bundled off to a
hospital whether he will or no and without interest-
ing the police in the matter, but the unfortunate
insane person does not in our city receive the same
consideration. Provision has, however, been made
so that the question of his removal is a medical
matter. Such eases, friendless or too poor for pri-
vate medical advisers, are to be reported to the dis-
trict physician, whose name can be learned at the
nearest police station. He sees the patient and on
his order the police patrol calls and removes the
patient.
With the patient in the Philadelphia General Hos-
pital you still have one function to perform. Try to
persuade the family to follow the advice of the phy-
sicians of the Psychopathic Department. Relatives
are prone to change their minds and want the pa-
tient out as soon as he is in. Sometimes they will
listen to you. Our colleagues in that department may
be depended on to act for the patient's welfare.
The Diet in Bright s Disease
Complicated by Diabetes
Editor The American Physician:
I am becoming increasingly fond of The Ameri-
can Physician. The article on Injuries of the El-
bow, by Forbes, was especially good and worth the
subscription price.
I wish some physician would write on this question :
How would you diet a case of diabetes mellitus com-
plicated with chronic Bright's disease t What is
good treatment in nephritis might be contraindicated
in diabetes. Is senile diabetes properly dieted by
allowing the ordinarily forbidden things in modera-
tion f
Edward C. Bennett, M.D.,
7801 Thirteenth Ave., Brooklyn, N. Y.
502
Emergencies in Obstetrics — Mazer
[The American Physician
Emergencies in Obstetrics
These cases require quick, daring, dextrous action
By Chas. Mazer, M.D.,
1626 Spruce Street, Philadelphia
Assistant Gynecologist to Mt. Sinai Hospital.
An obstetrical emergency is like a smoul-
dering fuse of the danger-laden bomb — in
either, quick, daring, dextrous action is
pressing, or the bomb explodes and the pa-
tient dies. With this in mind, Dr. Mazer's
paper, short, clean-cut, comprehensive and
practical, we believe will be appreciated, —
Editors.
THE MOST IMPORTANT emergencies in obstet-
rics are three: post-partum hemorrhage, rupture
of the uterus, and eclampsia.
P*$t-pmrtmm Hem*rrkmge
I have nothing original to suggest in the treatment
of post-partum hemorrhage. It is my intention to
emphasize the importance of being prepared to act
promptly and effectively when the contingency arises.
Obstetrics is still largely in the hands of the gen-
eral practitioner who, with few exceptions, under-
takes the delivery of his patient with nothing but
a few hemostats, a pair of scissors and some suture
material. It is to him I wish to carry the gospel
of preparedness, for his peace of mind and for the
safety of the woman whose life is entrusted to him.
Every physician knows that the most effective
method of promptly checking a severe post-partum
hemorrhage, following the delivery of the placenta,
is to tightly pack the uterine cavity and vagina with
sterile gauze. For this purpose he needs a tenaculum,
a pair of gloves, a uterine dressing-forceps, and a
five-yard package of gauze, all sterile and ready
for immediate use. It is also common knowledge
that, in case of severe hemorrhage before the third
stage of labor is completed, prompt delivery of the
placenta, either by Cred6 expression or intra-uterine
manipulation, is imperative as a preliminary to
packing.
Prcperedmu
Why do so many physicians completely fail to
avail themselves of the opportunity to save human
life and avoid prolonged morbidity t The answer to
this question is unpreparedness. He hesitates to
* Read before the Medical League, February 4, 1922.
invade the uterine cavity in a woman whose external
parts were not shaved and sterilized ; he hesitates to
invade the uterine cavity without sterile gloves and
sterile instruments. The fear of infection prompts
him to temporize with uncertain methods until the
loss of blood causes either death primarily or leaved
the woman in such a state of lowered resistance that
she falls a prey to even a mild infection. The best
trained physician, without the proper preparation to
meet such an emergency, is as powerless as a midwife.
No delivery should be undertaken without the as-
sistance of a person trained in aseptic obstetrics.
The character and uncertainty of obstetric work
on the one hand, and the prevalent scarcity of nurses
on the other hand, make it difficult to procure trained
assistance during delivery at the patient's home. To
solve this problem a number of physicians in Phila-
delphia have succeeded in training midwives as assist-
ants during deliveries. The advantages of having
the same nurse for every delivery is apparent. She
quickly learns your technique and follows it minutely.
Pitmtrm mmd Ftctp*
The busy physician resorts to the use of large
doses of pituitrin or to the application of high forceps
before the cervix is completely dilated, thus produc-
ing extensive cervical lacerations and consequent
hemorrhage. The injudicious use of pituitrin also
causes uterine inertia, which adds to the danger of
post-partum hemorrhage. The presence of an able
assistant whom he can leave with his patient during
the long and tedious hours of the first stage of labor
removes the temptation to terminate labor through
the use of pituitrin or the application of forceps
before the cervix is completely dilated and the pre-
senting part well engaged.
Ruptmre W tfc* Uterus
Rupture of the uterus gives rise to concealed hemor-
rhage. It should always be suspected when dealing
with a post-partum hemorrhage. The manual evacua-
tion of the uterine contents (blood dot or placental
tissue), which should precede the packing of the
uterus in post-partum hemorrhage, should also include
a careful examination of the uterine walls, less a
rupture remain undetected.
It is a safe rule to explore the uterine cavity with
the hand at the termination of every labor that has
necessitated intra-uterine manipulation. The objec-
tion to this procedure on the ground that it may result
in infection is overcome by the fact that the uterine
PhOa., July, 1922]
Emergencies in Obstetrics — Mazer
503
cavity has already been invaded. I believe that every
obstetrician of experience sees an occasional death
attributed to shock or hemorrhage which is really due
to a rupture of the uterus.
With the advent of pituitrin the frequency of this
accident has greatly increased. I refer to the in-
discriminate use of the drug which, in the hands of
the trained obstetrician, is an invaluable agent. The
rupture due to the abuse of pituitrin is usually a lat-
eral tear of the lower uterine segment, running up
from the cervix into the broad ligament with a re-
sulting hematoma.
Syphilitic women are especially prone to rupture
of the uterus, and the administration of pituitrin in
these cases should be avoided. Attempts at high for-
ceps delivery or version before complete dilatation
of the cervix are frequently the cause of this accident.
The lower uterine segment is thin and non-contrac-
tile. When, for any reason, the contractions of the
body of the uterus are not able to cause the descent
of the fetus, the distention and thinning out of the
lower uterine segment may become alarming, as evi-
denced by a very thick and very high contraction
ring and the appearance of a mass below the umbili-
cus that closely resembles an overdistended bladder.
The diagnosis of a ruptured uterus must be made
before the appearance of shock if the patient's life
is to be saved. The time consumed between the on-
set of shock and the placing of the patient on the
operating table is too long if the accident occurs out-
side of a well-equipped hospital.
The shock is not due to the rupture of an abdominal
viscus, but rather to the loss of blood that ensues,
hence there is an interval (occasionally of several
hours) during which the patient should be transferred
to a hospital for an abdominal section.
A sudden cessation of uterine contractions should
call for a careful abdominal and vaginal examination.
The presenting part, usually the head, recedes, the
hand introduced into the uterus may palpate the rent.
Abdominal palpation will usually reveal unmistak-
ably an altered condition in the abdominal cavity.
Unusual sensitiveness to the palpating fingers is fre-
quently present.
The FtXUmmg Tw Cms Mmy 1* iUmttrmtwe
Case 1. Mrs. B., aged 34, para IV., was known
to be a syphilitic She fell in labor at term. The
fetal head was partially engaged, the cervix not fully
dilated, the membrane ruptured. The uterine con-
tractions were weak and frequent. She was given
a half C.C. of obstetrical pituitrin, which was fol-
lowed by one fairly strong pain. The patient re-
mained perfectly comfortable, but vaginal examina-
tion disclosed that the presenting part receded. Fur-
ther investigation showed the fundus much above
the level it occupied previously. She had no ab-
dominal tenderness, her pulse was still very good.
The ambulance of the St. Agnes Hospital was hur-
riedly called, but when the patient reached the operat-
ing table she was in a moribund condition. While
Dr. J. C. Hirst operated on her, she was given
three thousand C.C. of salt solution intravenously.
The rent in the uterus was large enough to permit
the escape of the fetus into the abdominal cavity.
Seventeen days following the hysterectomy, the pa-
tient left the wards of the hospital in good condition.
Case 2. Mrs. D., aged 28, para VIII, was in labor
many hours with a breech presenting. The physi-
cian in attendance called for assistance. I found a
short and stout woman with a pendulous abdomen.
Uterine contractions were excessive. The uterine wall
was suspiciously thin. I made no vaginal examina-
tion, but began feverishly to prepare for the extrac-
tion of the fetus. Suddenly, the uterine contrac-
tions ceased. Vaginal examination failed to reveal
a presenting part in spite of the fact that the
physician in charge was able to diagnose a breech
presentation several hours preceding my examination.
The crest of the abdominal tumor was unmistakably
on a higher level. I hesitated to make an intra-
uterine exploration for fear of adding to the danger
of peritonitis. In view of the fact that the patient
was in good condition, my friend very reluctantly
consented to the removal of the woman to a hospital.
I met with greater opposition on the part of the
ambulance surgeon. When she arrived at the hos-
pital it was not before the lapse of several hours
when she was finally put on the operating table in a
condition of severe shock — the train of symptoms
they were waiting for to make the diagnosis certain.
She had a very prolonged and stormy convalescence.
One of the most dramatic emergencies in obstetrics
is undoubtedly eclampsia. We shall not enter into
a discussion of the source of the toxemia. Whether
it is of gastro-intestinal origin, the result of dis-
turbances in the glands of internal secretion, or of
fetal origin, is immaterial as far as the treatment of
the actual state of eclampsia is concerned.
The patient is suddenly seized with a convulsion,
the control of which is of prime importance. This
is best accomplished by the liberal use of morphine;
an initial dose of % gr. is given, repeated in %-gr.
doses every hour until convulsions have subsided or
at least diminished in frequency and severity.
The experience of the best minds in the profes-
sion is that the chances of the eclamptic patient are
improved by the emptying of the uterus, provided
this can be done without profound shock or grave
injury.
Post-partum eclampsia runs a much milder form
than eclampsia that begins before or during labor.
The loss of blood that accompanies the process of
delivery is perhaps the explanation. If the patient
504
Emergencies in Obetetries — Mazer
[The American Physician
is in the first stage of labor with an obliterated cervi-
cal canal or dilatable cervix, manual dilatation should
be employed and delivery accomplished by version
or forceps.
Ether, with an admixture of oxygen, should be
the anesthetic of choice, as it has been clearly shown
by competent investigators that chloroform produces
lesions of the liver and kidneys similar to those in
eclampsia.
Whatever the source of the toxemia, the liver is the
organ of importance in ridding the system of toxic
products.
As shown by Titus and Givens, the intravenous in-
jection of glucose serves rapidly to restore the de-
pleted and damaged liver cells. It is stored up as
glycogen, and the liver is thus fortified to cope with
the toxemia. Titus and Givens have reduced the mor-
tality of eclampsia through the use of glucose from
29 to 15 per cent.
If the blood pressure is above 160, 1 would precede
the intravenous therapy by the withdrawal of twelve *
ounces of blood.
The stomach should immediately be washed cop-
iously and 3 ozs. of castor oil and 4 mm. of croton
oil introduced through the stomach tube. Next is
the irrigation of the bowels with a warm solution
of sodium bicarbonate, and a hot, dry pack is given
every four hours.
What, in all probability, decided the issue between
life and death in a recent case of eclampsia I had
at the St. Agnes Hospital, was a lumbar puncture.
The cerebrospinal fluid was under such tension that
it spurted for several minutes in spite of the fact
that the patient was in the recumbent position. The
incessant convulsions ceased with the withdrawal of
a large quantity of cerebro-spinal fluid. It is my be-
lief that this measure deserves a wider application in
the treatment of eclampsia.
I do not agree with the advocates of immediate
Caesarian section in cases of eclampsia preceding
labor*. It seems more logical to suppress the convul-
sions, reduce the blood pressure, and establish an
active elimination before venturing on the hazardous
task of a Caesarian operation. The giving of large
quantities of water by mouth, or by hypodermiclysis,
is of utmost importance; also the utilization of the
oxygen tank during convulsions, and the open win-
dow between attacks, should not be forgotten. The
patient, however, should remain well covered, and
surrounded by hot-water bottles.
The presence of large quantities of urine in the
bladder, and even the absence of albumin and casts,
should not be taken as indicating a favorable out-
come.
The hepatic form of eclampsia is more severe and
renders a greater percentage of fatalities.
"Blood-Pressure
99
NEEDLESSLY ALARMING LAYMEN
Editor American Physician: —
Every cultured physician knows that, from the
hour of birth to the hour of death in old age, numer-
ous factors cause frequent variations in blood-pres-
sure and that these variations are purely physio-
logical, beneficent and conservative. Every tissue
of the body demands a constant supply of blood, and
death will be the result if this demand is not satisfied;
whenever from any cause the peripheral resistance
to the circulation is increased, it is absolutely neces-
sary that the blood-pressure should be increased to
overcome the resistance. This is the vis medicatrix
natura, and whoever interferes with this wise pro-
vision of nature is guilty of wrong practice. The
widespread craze over what laymen call "blood-pres-
sure" has terrorized thousands of men and women, and
made their lives miserable and wretched when told
that their blood pressure was too high, and that the
sword of Damocles was suspended over their heads
by a single thread and liable to break at any moment
Many thousands of healthy men and women have
fallen victims to this craze by the use of aconite and
veratrum and other heart depressants in combating
this conservative rise of blood-pressure, which nature
employs to overcome peripheral resistance to the
circulation. Every enlightened physician knows that
in every human being there is a perpetual conflict
between the animal and vegetative tissues of the body,
and that in old age sclerosis and degeneration are
inevitable. Certain diseases hasten the process of
retrograde metamorphosis, and with advancing age
the elastic arterial trio become rigid and offers
greater resistance to the circulation, and were it not
for increasing blood-pressure life would be im-
possible. Happily, the wise physician is now in
possession of the means to delay the progress of
sclerosis and, by his art and his science, he can assure
the old man and the old woman a complete cycle of
existence.
Let us hope that this destructive epidemic of mal-
practice, combating a wise provision of nature, will
soon subside.
T. J. Bowles, M.D.
310 E. Washington St., Muncie, Ind.
Ever since vaccination against smallpox had succeeded
in preventing the disease when properly and universally
used, there have been hopes among medical men that
similar methods of preventing other infectious diseases
might be found. Vaccination against typhoid fever is a
recent realization of the hope. We now appear about
to have a new demonstration of an efficient method of
vaccination against a very fatal disease, i. eM diphtheria.—
G. H. Weaver, M.D.
Phila., July, 1922]
Treating Sequelae of Fractures — Martin
505
Treating Sequelae of Fractures
h
Physical Measures
By William Martin, MJD.,
Maryland and Pacific Avenues, Atlantic City, N. J.
Late President of the American Electrotherapeutic
Association.
Dr. Martin, in this excellent paper on the
use of electro-mechanotherapy in the preven-
tion of the disastrous after-effects incident
to improperly treated fractures, narrates how
a patient would meet his doctor in the street
and silently and scornfully hold up his
ankylosed arm — to the natural displeasure of
the physician in question. It is to prevent
such "monuments" that we recommend the
utilization of the methods advocated in this
well-written paper. — Editors.
FROM TIME IMMEMORIAL fractures have been
the source of trouble, and no doubt will always
so remain unless some method of treatment and after
care can be devised that will be "fool-proof." It is
not a very rash statement to make that perhaps there
never has been nor ever will be a physician who has
not had or will not ever have trouble from this source.
There are so many good reasons why fractures may
cause both mental and physical stress, many of which
the physician has absolutely nothing to do with, and
are therefore entirely out of his control. There are
other sources that he does control, such as the use
of improper splints and the overlength of time of
retaining the splint in situ, as well as the improper
after-care subsequent to the removal of the splint.
Owing to the fact that bad results do follow one
cause or another, it would seem fitting that we con-
sider some method or methods of overcoming these,
both from the standpoint of the patient and physi-
cian, both of whom are rather solicitous, one from
the cosmetic and useful side and the other from
reputation and possible suit for damages.
Bmi Remits
Those of us who remember the younger Gross
(familiarly known as Sam) will perhaps recall his
statement in his lectures on fractures about his "monu-
ment." He told of one of his patients whose arm
he had set and by some inadvertence the result was
rather disastrous, so that whenever he met the pa-
tient on the street or elsewhere the patient simply
held up his arm to view without any words or look
of recognition. This was his "monument," and no
doubt many of us have such monuments to hand
down.
While the average physician of this day may make
less mistakes in fracture cases, at times in spite of
everything he may do he will have a "miss" or "slip
up," and a bad result be the outcome. How to best
get rid of this condition is a matter of judgment
and experience. Massage and passive motion have
been used for generations for this purpose and have
served fairly well in some cases, but if there is a
better way, why not use itt This brings us to the
point. It is not the purpose to consider all sequel©,
but those only that most frequently occur. Of these
stiffness, contractures and ankylosis are perhaps the
most common.
Stifacss mi Cmtrmctmm
Stiffness of the fingers and contractures of fingers
and wrists and the like are usually the result of a
too long application of splints without their removal,
at times, for massage and passive motion. Not only
do the phalangeal joints become contracted by liga-
mentous contracture, but the joints become ankylosed
after a time, thus offering greater difficulties to recov-
ery. In this condition the only remedy would seem
to be the use of some active mechanical measure.
This would suggest the use of the static wave cur-
rent and vibration, the two most active measures of
that type. It is usually found that the muscular
and ligamentous rigidity are not confined to the
fingers in the arm cases, but will extend and in-
volve pretty much all of the forearm, therefore the
treatment must include this as well.
Static Wave Cmrrtmt mi Vtkrdtmt—TcckMc
For the benefit of those who are not conversant
with the treatment, a short sketch of the method will
be given. The two .sliding poles of the static ma-
chine are pushed together before the machine is
started. The patient sits upon an insulated stand,
connected by wire attached to a metal electrode to
the positive pole of the machine, while the negative
is grounded. As the machine is started, the poles
are slowly and carefully separated. The spark jump-
ing across the gap thus produced gives the effect
of a back and forth surging or wave, the actual
effect being a contraction and relaxation of the
muscles and ligaments, the amount of this being ac-
cording to the width of the spark gap. When the
machine is run slowly, these contractions and relax-
ations are in consonance, and unless there is a sore
506
Treating Sequelae of Fractures — Martin
[The American Physician
nerve underneath the electrode there will be no pain.
That most of these cases do hurt under the treatment
is because there is some inflammatory condition pres-
ent, which keeps up the nerve sensitiveness. In the
event of such pain, the amount of current should be
gauged by the patient's tolerance. After the proper
time of this treatment is over, the part is thor-
oughly sparked by the use of what is called in-
direct sparks. In giving these, the machine is fixed
differently. The poles are drawn far apart, with
the negative, grounded. The positive is connected
to the platform by a metal rod, usually crook-shaped.
The patient seated or standing, the physician ap-
plies sparks from a sparking electrode which is
attached to a second ground chain, grounded sepa-
rately from the other ground chain. As the operator
approaches the part a spark jumps to it, causing
quick and active contractions. The effect of both
of these methods is to activate expression of the
exudate from the tissues, if this is soft, or to
break up adhesions, which are more or less organ-
ized. Naturally, when the latter condition is well
advanced, the results will be slow. Aside from this
mechanical action, we have some more or less active
hyperemia which is of value. This latter is not as
great as what can be produced by other methods
which will be mentioned later. Nerve-cell restoration
may be expected also as the result of this treat-
ment, through cell gymnastics, thus measurably pre-
venting atrophy.
SmtdUr J*i*U— Static Treatment PreceAeA by Heat
In case of the smaller joints such as those of the
fingers, we use less current and smaller sparks, and
these are directed by a special spark director, so that
they are applied just where they are needed. To go
into the exact technique of all of this treatment
would take up so much space that it may be best
to just touch upon it. It is considered good prac-
tice to precede this static treatment by the use of
heat. This is best given from a therapeutic lamp,
which may be from a fifty to a five-hundred candle-
power lamp properly hooded so that the rays will
be thrown in parallel and not in foci, as the latter
will burn. The part thus heated to a very active
hyperemia will respond much .better to the other
treatment. In passing, I will state that the usual
baking done so much in hospitals is a very poor
substitute for this, in fact it is of so little value
that it has been discarded in private practice. Perhaps
the time will come when hospitals will investigate
other methods.
AmkyloiU — Diathermy mi Vibration
Another method of heating the tissues through and
through is that by diathermy. This is particularly
applicable to those cases where there is ankylosis,
whether this be due to an infiltrate or exuberant
callus. In the latter case we must apply diathermy
of a greater amount of current and for a greater
length of time. Under proper technique this callus
will be absorbed. Diathermy followed by the static
wave current and sparks will take care of the ordinary
cases of stiffness and ankylosis. Many physicians
now know what diathermy is, who know nothing of
the other current applications. This has become
more or less fashionable of late, but that is nothing
against it, granting that it is used properly from all
standpoints. To apply this one must have some
knowledge of the physics of the current and have
the proper metal electrodes, as well as to use the
correct technique. The size of the electrodes must
be in proportion to the size of the part to be treated,
and these should be applied exactly opposite, so that
the current will flow evenly .through and not from
the lower corners or sides of the electrodes, thus over-
heating a part and not heating the rest, with danger
of a burn. Also one must bear in mind that the
skin is a poor conductor unless it is moist, so that
it is best to wet the skin or electrodes or both and ap-
ply them with some absorbent material, as a Turkish
towel, to take up the excess moisture that might
otherwise become steam and scald the parts. The
amount of current should never be excessive in
the average case, but generally is about 1000 am. for
electrodes 3x5.
Vibration may be used in selected eases instead
of the static wave, although it will not always act
as well. It is, however, an excellent adjunct, but
just as it is in all other matters, it must be done
correctly in order to secure the best results. Not
only correctly, but given from a vibrator that has
sufficient power to make an impression upon the
parts to be treated. There are many light vibrators
in the market that are used in beauty parlors for
skin massage, and that is all they are good for, and
they will have no value in such work as breaking
up ankylosed joints.
Abnormal SmteUimg •/ fume*
Continued abnormal swelling of the tissues may
be a sequela? of fractures, which may be due to cir-
culatory obstruction or it may be from an actual
infiltration of denser exudates. If the obstruction
of circulation is due to exuberant callus or from a
localized exudate, the treatment outlined above will
generally meet the occasion. If the callus is consid-
erable, it may take long seances of diathermy with a
fairly large amperage of current to absorb it This
may take a considerable period of time with daily
treatments, but it is well worth the effort. If the
tissues of the whole limb or a larger part of it are
infiltrated with exudate so that both motion and all
function are interfered with, it will be necessary to
thoroughly heat the tissues through, and then apply
the static wave current to the whole extent, and
give a current to tolerance, with daily treatments.
This will gradually express the exudate through the
natural channels and gradually restore the part to
PhiU., July, 1922]
Treating Sequelae of Fractures — Martin
507
usefulness. The softer or more recent the infiltrate,
the earlier the results will be secured, for a soft
exudate will be more readily removed than will an
organized one. When the nerve or nerves are caught
in either the exudate or the callus, pressure pain
will be the result. Here again the static wave cur-
rent comes into play with excellent results, except
when callus is the cause. Diathermy alone will meet
this condition.
Paralyses of fingers, arm or other part may result
from fractures from one cause or another, and these
conditions are not always easy of remedy, as they
are the result largely of long standing conditions.
If from pressure due to callus or any other form of
exudate, removal of this will necessarily have to
be the first step toward recovery. The paralysis may
be either a loss of motion or sensation, and some-
times will be of both. Following the removal of
the pressure, we must activate the muscular and
nerve cells as well as the circulation. Hyperemia
by either of the methods mentioned earlier in the
paper should be followed by the use of the constant
current applied by the modern method. The early
treatment was by the labile or stabile method of the
plain constant current, which was not always satis-
factory. Othero used it by the interrupted method,
which had advantages in stimulating the muscle action,
but it always was most unpleasant to the patient,
so that it was thrown to the discard by competent elec-
trotherapists who now use the sinusoidal type of
galvanic current. This gives the necessary muscular
exercise, at the same time activating the nerve cells,
and all without any unpleasant sensations. The
pads used in this method of treatment are of two
sizes usually, but not necessarily. The larger pad
is the indifferent and the smaller is the active one.
The large pad is usually applied upon the trunk near
the juncture of the limb or over the spine, so as
to include the nerve distribution, and the smaller one
may be applied by either being bound to the ex-
tremity of the limb as, for instance, the fingers or
toes, or it can be held by the operator and changed to
various areas from time to time. This method will
take in the whole length of the nerve distribution.
The current strength is usually small at first as in
all paralyses, and must be used with regularity and
patience.
Non-union of fractures is not the most common of
sequels, but it occurs often enough to be a matter
for grave consideration. Non-union may be the
result of various factors, all of which will be left
out of consideration here, but the line of treatment
will be similar in most cases.
The object to be gained is the throwing out of
callus, and this must be gained by an activation of
both the local circulation and the building up of the
general system. Defective metabolic processes may
be overcome by general measures, and the local con-
dition should be treated by moderate doses of dia-
thermy applied for moderate length of time at each
treatment. It will be remembered that for excessive
callus we use large doses of diathermy for their quick
results in resolving, while in non-union we must
stimulate the callus formation. This latter will re-
sult from gentle activation of moderate dosage, so
it will be well to bear this difference in mind. In
order that splints and dressings should not have
to be removed for daily treatments, metal splints may
be used that will obviate the necessity of their removal
more often than is properly necessary. The connec-
tions can be readily made to such splints and the
treatments given daily with ease.
There are many other complications and sequela
that might properly be considered in such a paper
as this, but as space must be thought of, such condi-
tions as sluggishly healing ulcerations which may
follow slow healing of compound fractures, and other
sequel® must be left for a subsequent paper.
In conclusion we may use the trite saying that
prevention is far better than cure. If all surgeons
or genera] practitioners would consider the possibil-
ity 'of the use of the static wave current for this
prevention of many of the sequelae, a great step for-
ward would be made. By this I mean that when the
usual time comes that massage and passive motion
are indicated, which is early, the wave current ap-
plied to the part in a proper manner would re-
lieve circulatory stasis, express the soft infiltrate
through the regular channels, and restore nerve cell
activity. This would do far more than can be pos-
sible under any other form of manipulation, and
without disturbance of the fragments, as it is passive
in a sense. It is the treatment par excellence.
A Case of Chorea and Erythremia
Lewis J. Pollock (J. A. M. A.), reports a case of chorea
in a woman thirty-eight years of age, with no history of
rheumatism, endocarditis, tonsillitis, or a former attack
of cholera.
The blood showed erythrocytes 8.100,000, leucocytes
8,500, and a hemoglobin of 115.
She was given roentgen rays at weekly intervals, and
at the end of a month was markedly improved. When
discharged, after a sojourn of about seven weeks in the
hospital, the red blood cells numbered 6,400,000.
Inasmuch as the erythremia nersisted after the chorei-
form movements disappeared, the supposition seems
warranted that the choreiform movements are not pro-
duced by any change in the blood but rather by a definite
pathological condition in the brain, such as hemorrhage
or thrombosis. The exact nature of such a lesion, the
writer believes, will remain conjectural until histological
study of such a case is made.
Prolapse of the Rectum — Drueck
[The American Flryiicuii
Prolapse of the Rectum
SURGERY OFFERS THE MEANS OF GIVING RESPITE, RELIEF AND POSSIBLE CURE
By Charles J. Drueck, M.D.,
30 N. Michigan Avenue, Chicago, Illinois
Professor of Rectal Diseases, Post-Graduate
Medical School and Hospital.
Few diseases are as annoying as is a rectal
prolapse even if it is not, as tuck, fatal. Few
diseases cause as much discomfort, misery,
suffering as does this distressing disorder.
To render the victim respite, relief, perhaps
cure, we present this highly instructive paper
of Dr. Drueck. The proctologist as well as
practitioner, wiU not, we vouch, be disap-
pointed with it. — Editors.
ANY PORTION of the bowel may invaginate into
or through a lower portion, and in the pelvic
bowel a complete prolapse may occur with or with-
out the procidentia appearing externally. When
the upper rectum or sigmoid intussuscepts, it may
include a fold of the peritoneum. A prolapse of that
part of the rectum above the pelvic floor may not pre-
sent at or protrude from the anus, and, if it does
not appear at the perineum, it can be recognized
only by digital or specular examination. This supra-
pelvic prolapse accounts for many cases of intesti-
nal stasis and of sigmoid accumulations.
Complete prolapse of the rectum is a far more
serious condition than the partial variety because of
the invalidism which it induces as well as the com-
plications which are ever present. (Figure 1.)
The true pelvic floor is a fixed structure, but
the fascial branches between these organs are sus-
pensory stays, allowing considerable play. It is these
rectal stays which offer the resistance during the
straining at stool which is necessary to prevent dis-
placement of the rectum. When these stays become
flabby from repeated or excessive stretching they
lose their contractile power and the organ they
support drops away. A lacerated perineum de-
stroys the fascia holding the rectum to the levator
ani, and the powerful intra rectal pressure soon
pushes the rectal wall into the vaginal outlet. The
protrusion in turn tends to further relax the musealo-
fibrous structures.
2. In other cases a defect in the pelvic fascia per-
mits a hernia of the pelvic bowel. This defect may
sometimes be developmental.
Two different types of pathologic change contribute
to produce procidentia.
1. Extreme mobility of the rectum and elongation
of its supports may be the result of imperfect
prenatal fixation or of traumatic conditions, either
of which permit of constant dragging on the rectal
attachments and supports. The intra-abdominal pres-
sure exerted at stool is applied to the recto-sacral
ligaments.
The uterus and rectum nave a common means of
suspension; therefore any cause bringing about the
fall of one endangers the flxidity of the other. Hys-
terectomy deprives the rectum of the anterior sup-
port afforded it normally by the uterus. The weak-
ening of the pelvic floor favors the prolapse of
both of these organs.
In early embryonic life the peritoneal pouch
reaches almost to the perineum. Later it recedes
higher, and if this process stops early the cul-de-ste
of Douglas will be deeper than is normal. If there
is also a developmental defect in the transversahs
fascia it requires but little increased intra-abdominal
pressure to drive the peritoneum as a wedge along
the prolongation of the transversalis fascia; the
incipient stage of prolapse.
Comci'a* Smrgtry
As this condition results from a failure of the
supporting structures of the rectum, no one technfo
will suit all cases, therefore a careful consideration
Pliila.. July. 1922]
Prolaps: of the Rectum — Druec';
of the factors causing the prolapse and the condi-
tions present in the case at hand is essential, together
with a knowledge of the pathologic changes in the
rectum, its supports and the surrounding tissues.
Because of the several factors contributing to the
prolapse and the extent to which it descends, a num-
ber of surgical procedures have been recommended
to restore the tonicity and fixity of the dislocated rec-
tum. The various "pesi«s" suspend or anchor the
gut from above, but do not correct the laxity or
redundancy of the pelvic fascia. Restoring the rec-
tal supports or supplying new ones will be wasted
energy unless the exciting cause is removed. In
women bearing children, repair of the perineum and
the levator ani muscle and the careful attention to
subinvolution of the uterus are necessary prophylactic
measures.
Ttdmc W Op*r.ri*a
The patient is "prepared for a laparotomy, placed
in the Trendelenburg position and the abdomen
opened by a liberal median incision extending from
the symphysis pubis to the umbilicus. The small in-
testines are banked out of the way and the uterus
pulled upward into the abdominal incision. A care-
ful examination is made of the position of the pelvic
viscera, the location of adhesions and the depth of
the peritoneal cul-de-sac, together with areas of loose
attachments. (Figure 2.) If small intestines are ad-
herent to the sac they are carefully separated and
plaeed back in the peritoneal cavity. Plastic work to
strengthen the pelvic floor by taking up a piece >E
the broad and round ligaments is done at this time;
it adds much to the security of the reposition of the
bowel.
The pelvic colon is now drawn up until the pro-
lapse is entirely reduced and held taut. Obliteration
of the Douglas pouch is now begun. Silk sutures are
passed circularly around the cul-de-sac, beginning at
its deepest point and continued up, each stitch being
placed at one-qoarter-inch intervals until the entire
pouch is obliterated. Usually six to eight sutures are
required. As the sutures approach the rectum the
serosa covering the anterior surface of the bowel
is included in the stitch. There is always danger of
damage to the ureters and the pelvic vessels at
this stage, and in placing these sutures caution must
be observed that these vessels are avoided.
As the prolapsed bowel is lifted into the pelvis it
will be found extremely long, relaxed and flabby
(atonic) with obliteration of its sacculations. The
longitudinal muscle-bands of the colon and sigmoid
are normally shorter than the bowel itself and the
contraction of these bands throws the large bowel
into sacculations. (Figure 3.)
Relaxation and flaccidity contribute to the disten-
tion and stretching as found in this atonic condition.
A re-establishment of these pouches enables the white
fibrous bands to contract and again provide their
supportive action. To this end the sigmoid is drawn
up until it is taut from below and the peritoneal coat
is abraded along the longitudinal bands by the oper-
ator's gauze eovered finger. A fine silk intestinal
suture is then inserted in the longitudinal muscle-
band, carried along within its fibers for one and one-
half inches and brought out. One-half inch farther
up the band the suture is reintroduced and another
inch and one-half is taken up. In this manner one
suture is continued along the whole length of the sig-
510
Diet in Typhoid— Markley
[The American Phytidu
moid to the sigmoido-rectal junction. The suture is
now carried back in the reverse direction on the
opposite border of the muscle-band. As this long
suture is tied, the muscle-band is shortened and the
normal sacculation of the bowel is restored.
A Her* T rMtncRt
The foot of the patient's bed is raised two feet and
so maintained for a week. The bowels are confined for
a week by regulating the diet and the use of Tine.
Opii deod., 10 minims each day. If the patient's
bowels should move before the eighth day she should
have a thorough irrigation with warm saline solution.
This operation is quite satisfactory where intussuscep-
tion occurs and when the prolapse can be completely
reduced and where, further provided, no neoplasm or
organic stricture is present.
Diet in Typhoid
Editor The American Physician: —
In your April Journal is a short and pointed
article by Dr. T. J. Stockard on the above subject.
I have, for 35 years, been feeding my typhoid
patients a liberal diet and have no regrets. I
honestly believe, in the years gone by, many typhoid
cases would have been saved on a more liberal diet.
In the spring of 1886 I located on the western
plains of Nebraska. During the following fall I
treated quite a number of typhoid cases, many of
them from 25 to 40 miles away. In one neighbor-
hood, 35 miles away, I had half a dozen cases. They
contracted the fever from spring water hauled 15
miles. I made them dig a well at once. On the up-
lands the water was very deep — 200 feet or more; on
the valleys about 50 feet. Practically all the cases
scattered over the great cattle ranges were caused
by drinking spring water hauled a long distance.
Possibly in some way the water became infected by
the range stock drinking at these springs.
There were no milk cows in the country; only con-
densed milk was available. I was at my wits' end
what to feed these patients. I finally hit on rice
custard made with condensed milk, the juice from
stewed dried prunes, milk toast, soft egg and corn
starch custards. I gave cold baths — the Brant treat-
ment. The way these people balked on cold baths
was a caution, but I stuck to my colors.
Wm It Rocky Momtdmm Fever?
The old cattle ranchers and cow punchers called
the fever Rocky Mountain fever. The old text-books
of the early 80's speak about Rocky Mountain fever
as peculiar to the eastern slopes of the Rockies. The
ranchers believed in sage tea, made from desert sage,
which grew all over the prairies. Owing to the high
altitude, practically all these patients perspired very
freely, and many had a high pulse-rate. One patient,
a local jeweler, began with a tremendously rapid
pulse. I ordered him to go to his people in eastern
Nebraska, where the elevation was less. He returned
later to thank me for my advice. The temperature
course, tympanites, dry brown tongue, often with
sordes, delirium, diarrhea and a few cases of hemor-
rhage, gave a typical typhoid picture. After treating
and closely observing many of these cases, I came to
the conclusion that Rocky Mountain fever was a
misnomer.
Early in 1887 or '88, I think it was, I wrote a
series of articles for the Medical World, describing
many of these cases. I especially called the atten-
tion of the profession to my plan of feeding, with
the good results I had. I also insisted that these
cases were typhoid and not Rocky Mountain fever.
A fire in the office of the Medical World at that time
destroyed my manuscript and many of the journals
containing my articles. However, quite a number
came before the public.
One year later a doctor at Boulder, Col., wrote an
article on Rocky Mountain fever, and proved that
this fever was really a true typhoid fever in every
respect, and proved his case with several autopsies.
I called the doctor's attention to my articles of a year
previous. I wrote short articles on typhoid feeding,
and spoke on the subject in medical society meetings
on several occasions, with little effect or attention.
About ten years ago a doctor in the East, connected
with some hospital, wrote an article on feeding
typhoid patients, telling us all about calories, etc,
and urging a more liberal diet. His article was ex-
tensively copied and commented upon as something
very new and up-to-date. Such is the way of the
world.
I seldom give my typhoid cases sweet milk, but I
do give them plenty of buttermilk, malted milk,
custards, milk toast with a soft egg, orange juice,
plenty of water and cold baths, and I have no regrets.
L. R. Marku&y, M.D.
Long Bldg., Bellingham, Wash.
Colloid Goiter
There is a syndrome often mistaken for hyperthy-
roidism. These patients present nervous manifestations,
with tremor, tachycardia, although of a different kind
encountered in hyperthyroidism. The thyroid gland is
generally enlarged, due to increased colloid content The
basal metabolic rate, however, is always normal The
importance of considering the latter group is that they
respond to medical treatment and surgery is contraindi-
cated.— -Charles F. Nassau in The Therapeutic Gasetti.
In people who die at seventy-five years of age the
chances are ninety in a hundred that they will die of
one of three causes — arterioclerosis, neplasm, terminal
infection.
Twenty ■ wghth
Infection Through the Umbilicus
Dr. Forbes says: "The prognosis in these
cases of septicemic arthritis in infants is very
bad. The mortality in this condition is, at
least, seventy-five per cent. This high mor-
tality is due not so much to the surgeon's in-
ability to control the infection as to the
lessened resistance of the infant." — Editors.
IN" THE MONTH of March four patients were ad-
mitted into the Children's Memorial Hospital suf-
fering from somewhat similar conditions.
IV First Cme M. L., 305/21, age six weeks, was
admitted into this Hospital because of swelling of
the left hand, left knee and right jaw.
The history stated that this child was a full term
baby, the delivery had been normal. The child had
never been nursed but, rather, nourished with artificial
food.
The child's mother contracted influenza the day
after her child was born. For this reason the child
was removed from her care. She did not see her baby
for ten days. When on the thirteenth day the mother
resumed control, she noticed that the child had pus
about the navel. She says that on the fourteenth day
she noticed that the child's right upper jaw, left hand,
and right knee were swollen. The history does not
state what was done for this child before her ad-
mission to this hospital.
When the child was admitted, examination demon-
strated an enlargement in front of the right ear in
the region of the parotid gland. There was no fluctu-
ation. The right knee was swollen and cedematous.
There were definite signs of fluid in the joint and
underneath the quadriceps tendon. There was no sign
of redness or acute inflammation.
The knee was aspirated and thick pus obtained.
Cultures taken showed a streptococcal infection. The
knee was opened both on the inner and outer side — the
pus was evacuated and drainage tubes inserted.
The temperature, which was high before, became
normal, and the child seemed to be getting along very
nicely.
I*t SmmT Cm— M. N., number 306/21, age three
months, was a well-nourished, healthy male, who was
brought to the Children's Memorial Hospital because
he had been suffering for a month, from pain with
swelling and redness of his right knee. No other
joints were affected. The mother gave a history of
hernial protrusion with infection about the child's
umbilicus.
At the time of admission examination demonstrated
redness of the skin, oedema of the subcutaneous tissues
and fluid in the right knee joint.
A diagnosis of infectious arthritis was made and
the knee joint was opened, a large quantity of pus
evacuated and a drainage tube inserted. Cultures
made from this pus showed a streptococcal infection.
Treatment was followed by great improvement. The
temperature became almost normal and remained so
for about ten days, when it rose to about 101 \ The
joints were now carefully examined and found to show
no signs of infection but a suppurative condition was
found in the middle ear. This was drained and the
child was removed to his home in spite of the protes-
tations of the hospital authorities.
TU Third Cm— D. D., number 322/21, three and a
half weeks old was brought to this hospital with the
following history: The mother was a primipara who
had had a miscarriage two and a half years before.
The child was not nursed but placed upon artificial
food. When the child was one week old it was noticed
that he seemed to be drowsy and he did not take his
food well. Soon he began to lose weight. Three
days before admission it was noticed that the child
was feverish and had a swelling on one side of his
neck extending under the lower jaw. The day before,
swelling of both the left and right foot had been
noticed. When the child was admitted his temperature
was 103°. A careful examination was made of the
swellings already described, fluctuation was detected
under the internal malleolus of the left ankle. This
fluctuating area was incised and about one dram of
creamy pus evacuated. Another abscess was found
on the dorsum of the left foot. This also was incised
and a small quantity of pus evacuated. Cultures
512
Infection Through the Umbilicus — Forbes
[The American Phjrsciaa
taken showed streptococcus. The temperature now
dropped to normal and in three weeks time the pa-
tient, who had evidently suffered from pyaemia, was
ready to be discharged from the hospital.
The Fomrtk Cwm the most interesting of all, Baby
P , number 341/21, aged eight days, was the
youngest of a family of three children. The delivery
appears to have been normal. The patient was
brought to this hospital because three days before, the
mother had noticed that# the child showed a marked
tendency to become intermittently rigid. During each
period of rigidity the child would become cyanosed,
his breathing labored, and a frothy white expectora-
tion would ooze from his mouth. There was a his-
tory of careless tying off and dressing the cord.
A diagnosis of tetanus neonatorum was made and
treatment was instituted. The patient died in six
days' time.
It has been noticed in the four patients whose his-
tories have been briefly studied that the cord or navel
was the sight of the original infection in each case and
that the etiological factors responsible for the lesion
were in three of them streptococcus and in the fourth
the micro-organism of tetanus.
In the majority of infants who suffer from septi-
cemia (in some cases shown as in arthritis), the
source of infection is either the cord or the respiratory
tract. If the primary infection is of the cord, the
streptococcus is usually found to be the reponsible
etiological factor. On the other hand, if the primary
lesion is of the respiratory tract, no matter how mild
this primary lesion may be, the organism responsible
for the lesions from which the patient suffers, is
most frequently the pneumococcus.
In our first case we note that there was an infection
of the parotid gland. This is occasionally seen as a
complication of septic arthritis of the new-born and
at times is seen as the only manifestation of infection
of umbilical origin.
It is interesting to note that an arthritis due to a
septicaemia whose primary source is in the cord ordi-
narily begins about the second or third week. The
joints which are most frequently affected are the knee,
the ankle and the hip, although the shoulder, the
elbow and the wrist may be affected.
Prognosis
The prognosis in these cases of septicemic arthritis
in infants is very bad. In the cases of streptococcal
infection reported two out of three have been saved,
but I think we should realize that this was more by
good luck than good management. The mortality in
this condition is, I should think, at least seventy-five
per cent. This high mortality is due not so much to
the surgeon's inability to control the infection as to
the lessened resistance of the infant. It is to be
remembered that the majority of these infants are suf-
fering from asthenia and that many of them are being
fed by mixtures of artificial milk, thus we cannot be
surprised that their resisting power is so low that they
die from exhaustion in spite of drainage and other
surgical procedures.
TttOHMM ffllMtol
Tetanus neonatorum is very rare but is a well-
recognized condition. It is supposed to be due in the
great majority of cases to an infection of the cord.
It is hard for one to appreciate how the cord becomes
infected with this anaerobic organism, but where in-
sufficient care has been taken in the dressings and
where the baby has lived in squalid surroundings, an
infection by this micro-organism is quite conceivable.
The symptons, of course, are characteristic, the clonic
spasm, the extraordinary wrinkled, whizzened appear-
ance which comes over the face when the patient is
suffering from such spasms, the respiratory disturb-
ances and the convulsive seizures.
You, who have been fortunate enough to have served
your country overseas, quite realize the difficulties,
the hopelessness of the treatment of tetanus. Yon
have all appreciated what the prophylactic treatment
of tetanus has meant in the saving of thousands, nay,
tens of thousands of wounded men, but few of you,
if any, will remember any patient who was saved after
the symptoms had once developed.
Some Causes and Some Results of Chronic
Intestinal Toxemia
Allan Eustis (N. O Med. and Surg. Jour,. Jan., 1922,)
states that on the basis of our knowledge of physiological
chemistry we arc justified in the belief that the substances
responsible for intestinal toxemia are am ins formed by
the putrefaction of several amino acids with loss of car-
bon dioxide; that these putrefactive basic amins have
definite physiological action; that they are normally
detoxicated by the liver; that when they are not
detox ica ted, they exert their specific, physiological action
on the individual. However, a diagnosis of chronic in-
testinal toxemia, only, is rarely justifiable, any more than
one of achylia gastrica, or tachycardia, unless the cause
of the same has been ascertained ; but on the other hand,
severe nephritis, a supposed diabetes or a case of sup-
posed hyperthyroidism, not to mention the large number
of neurasthenics, may have their origin in a chronic
intestinal toxemia.
A number of cases are cited which serve to bring out
the following points:
(1) Certain cases of intractable intestinal toxemia
may be due to intestinal stasis from an anatomical abnor-
mality, which can be relieved only by surgical measures.
(2) Some cases of chronic intestinal toxemia may
present symptoms of hyperthyroidism, which symptoms
are relieved by overcoming the intestinal toxemia..
(3) Intestinal toxemia may be the cause of an albu-
minuria and even of symptoms of uremia, relief of which
is complete after control of intestinal toxemia.
(4) Severe pyorrhea may be the cause of an intes-
tinal toxemia, and indirectly the predisposing cause of
asthmatic attacks.
efficient Organization of Medical Practice
THE GENERAL PRACTITIONER IS THE FUNDAMENTAL FACTOR IN EFFICIENT MEDICAL SERVICE
WhUe surgery, the specialties, hospitals, people are to be served, the primary im- ordinated in constructive co-operation with
institutional medicine, public health work, portance of the function of the General the essential service of the Family Physician,
industrial medicine, etc., have their definite Practioner must be recognised. Other divi- This is an integral purpose of The American
functions, if the best health interests of the sions of medical service must be properly co- Physician.
Is It Desirable to Standardize Therapeutics?
HOSPITALS are facing the question of stand-
ardization, and there is much difference in opin-
ion. Doubtless in some measure it is practicable to
standardize hospital equipment and certain technic;
there are, in fact, many advantages as relates to
factors capable of standardization. But it always
has been questionable to attempt to standardize the
therapeutics of a hospital by working out dispensary
formulae and numbering them, and it leads to machine
prescribing, which always is bad. The capable house
physician objects to such procedure; he wants to
learn how to practice medicine outside, and he knows
it is poor policy to carry into private practice a lot
of hand-me-downs used in. ward and dispensary work.
The visiting physician has learned certain therapeutic
tools, and when he finds he cannot use them in his
ward work because these drugs are not carried in the
drug room he is apt to say caustic things. The army
supply table is held up to him as precedent, and if
he served in the army he recalls how angry he was
sometimes over that hard-and-fast supply table and
how helpless he was in the face of army discipline,
he is apt to use some punctuated language to the
hospital superintendent.
Yet the advocates of standardization keep hammer-
ing away at it. Some of these men are laboratory
workers and they are used to the standardization so
necessary in that line of activity. Others are sur-
geons, who deal with antiseptic solutions, the giving
of intravenous medicaments, the meeting of shock,
post-operative hemorrhage, etc., where a certain stand-
ardization is desirable, especially when giving direc-
tions to nurses and internes over, the telephone. Some
are ex-army men, long drilled in to therapeutic stand-
ardization and who are lost without it. Yes, it is so
easy; one does not have to think, which some people
consider in bad form.
Tk Dion-is Pbu ike Remedy Equals X
F'md tfc Vaime W XT
The standardizes in therapeutics, who are strong
on diagnosis and weak on therapeutics, accept the
above proposition as gospel and believe that X has
"cure" as its value. Perhaps! Not always, however,
for the diagnosis must be correct to make it work,
and the diagnosis is very apt to be wrong; and X
means failure. The trouble with these men is this:
they are very sure they are imitating nature, and
they forget that nature refuses to imitate them. Let's
not be^ too sure about our "nature cures!" Nature
does not always work in partnership with man; she
never does unless man is going her way. How often
are we sure we are doing thatf
Laboratory findings are very good, but so are
the findings elicited by painstakingly going over the
patient himself, using the now too often neglected
resources of physical diagnosis. Recently we were
present at a consultation where three city specialists
and one country doctor were called. The three city
men were in entire agreement, based principally on
the elaborate laboratory findings, and their impatience
with the country physician who took fully thirty
minutes in carefully examining the patient was very
obvious. Yet, as the event proved, the country physi-
cian was right and he was retained on the case. He
had made laboratory tests himself, but he had also
very carefully observed the natural history of the
case and he studied the sick man, not the "case" of
alleged nephritis. The case was one of chronic aspirin
poisoning, not suspected by any of these men, but
finally determined by the country physician, who had
made the diagnosis of chronic poisoning and who set
out to find what was responsible for the condition.
The patient had long been taking a dozen doses of
aspirin every day, which was in excess of what the
newspaper advertisements recommended. Laymen
should not play with potent drugs.
Wark'mg Back to the Cams*
There are many cases where machine diagnosis fails
to work, as in the instance just cited. Doctor, did you
ever correct your diagnosis because the remedy used
failed to perform according to schedule t Of course
you have. Do you remember those cases of malaria
that failed to yield to quinine and that you finally
treated as typhoid 1 What about those "typical digi-
talis cases" in which digitalis failed, despite graphic
heart tracings and the existence of auricular fibrilla-
514
Is It Desirable to Standardize Therapeutics?
[The American Physician
tion, and that were really pernicious anemia well
under way to hopelessness until you woke up? What
about those pre-bacillary diagnoses of tuberculosis
that never did reach a bacillary stage, despite the
cock-sure t. b. expert, and that turned out to be half
a dozen different diseases of the malnutrition group?
Ton experimented quite a while with different reme-
dies until the time came that the blood counts cleared
up the situations. What about those diagnoses of
endocrine imbalance that turned out to be indicanuria,
masked diabetes or some focal infection? How may
we standardize the therapeutics of far from stand-
ardized diagnoses? Despite the vaunting of diag-
nosis, when it comes to obscure cases we are wrong
half the time — the best of us are.
It There Smck a TUmg m ike "CUuicd Cat^T
We often find the "classical case" in books, be the
case typhoid, pneumonia or what not; but we find a
terrible toll of unciassical cases in our practices, and
in which the "classical treatment" fails out badly.
What about standardization here? One man writes
in to The American Physician that he "cured" his
cases of "diphtheria" without employing diphtheria
antitoxin, and he believes he did; but the board of
health in his town reports an epidemic of aggravated
follicular tonsillitis. One can easily be wrong there
and be a good physician at that.
Another man considers measles as a very minor
affection requiring no medication, for he was never
through an epidemic of malignant measles with a
heavy mortality. Quite casual indeed is "malaria"
in the mind of the physician who never saw an estivo-
autumnal type of the disease or one with congestive
chill. Few of the cases he diagnoses as "malaria"
are in bed and, if he examined the blood smears he
would not find Plasmodia. And say, Doctor, what is
influenza and how do you differentiate mild from
severe cases? Are you ever sure of your diagnosis
of "influenza" in the absence of an epidemic marked
by a high mortality? What is "classical" rheumatism,
whatever that term means, for we confess we don't
know? Is exophthalmic goiter an endocrine, a cardiac
or a nervous disease? Describe a "classical" case and
outline a standardized treatment that really works.
When we standardize disease, the people who have
standardized diseases, and also standardize doctors
who have to treat these cases, then, after standard-
izing drugs and the making of them, we may ration-
ally talk about standardizing therapeutics, and not
until then. We all know that time is far off. —
T. S. B.
Long Distance
Weather Prognosticating
Some of the symptoms of gonorrheal rheumatism
are said to be relieved by intensive dosage with
sulphur, although the gonococci are not killed by it.
No man can with any certainty foretell the char-
acter of the weather for a week in advance, but the
following considerations, perhaps, may aid to some
extent in seasonal prognostication in the United
States.
If when the sun is south (November, December,
January and February) the prevailing low barom-
eters arise in the south, there is danger of cold
weather, with heavy precipitation along our two sea-
boards. If when the sun is north (May, June, July
and August) the prevailing low barometers arise in
the north, there is a likelihood of hot weather vitb
many thunderstorms. In a normal, or mean, season
the low barometers arise equally in the north imd
the south.
There is a certain norm in the temperature ot ihe
waters of the Atlantic and Pacific oceans adjacent to
our shores. If this norm is widely departed from,
in either ocean, there is a likelihood of a large num-
ber of storm periods, especially so if one ocean is
abnormally warm and the other abnormally cold.
If the thermometer ranges abnormally low during
the winter in Alaska and northwestern Canada, low
barometers occur in the extreme northwest of the
United States, with heavy precipitation on the Pacific
slope, but not necessarily low temperature. Such
storms spread east over the plateau region, but do
not influence very markedly the temperature of the
Atlantic slope. If, on the other hand, cold waves
center from Medicine Hat eastward in Canada, the
Mississippi valley and the East experience cold
weather, but the Pacific slope escapes. Cold waves
originating in southern Idaho and in Nevada, with a
north wind, may cause frost in California. Florida
is apt to have frost from movements of cold waves
south from the region of the Great Lakes or from
storms originating in southern Texas. These centers
of storm and cold weather may persist for long
periods and then markedly influence the weather in
low latitudes.
It is asserted by some persons that earthquakes and
volcanic eruptions in the southern hemisphere dis-
turb electrical conditions in the northern hemisphere
and thus cause stormy weather over long periods in
the latter hemisphere.
If the clouds persistently range high in spring
and fall, frosts are apt to occur.
Needless to say, the United States weather prog-
nosticators do not accept some of these statements;
but persons who study the weather maps often accept
(Continued on page 524.)
PhOa., July, 1922]
El Lingo Del Monde— Grafe
515
Confusing Terminology of the Present Metric System
Suggesting Adoption of Universal Terms
EL LINGO DEL MUNDO
By F. A. Grafe, A.B., M.D.
7 East McMillan St.,
Cincinnati, Ohio
MOST NATIONS, in the construction and im-
provement of their languages, have visited the
storehouses of ancient Greece and Rome, have bor-
rowed from their inexhaustible treasures enough to
supply their needs, have remodeled the supply in
conformity with their individual tastes, and have
appropriated it as their own.
If one rational universal modification had been
instituted, the present babel of languages would not
have descended to us, the tremendous wasted energy
in the acquisition and daily use of the different
languages might have been directed to more useful
achievements for the common good, more friendly
feelings might have supplanted the present ubiquitous
discontent and hatred. The horrors of a world war
might never have entered our peaceful homes; but
"what's done is done — would it were worthier." Let
us not grieve over what might have been, but rather
let ns direct our efforts toward establishing a better
era.
In the past various attempts have been made
toward the introduction of a world language. The
failures encountered have been due to the fact that
the languages had been constructed by lone indi-
viduals instead of by a combination of many indi-
viduals, for the working days in any one man's life
are too few to bring to a successful termination such
an herculean task, and, consequently, we are today
as far from having achieved success as were the
ancient Greeks who tried to unite their different
dialects into one Pan-Hellenic Attic language.
With the ever increasing facilities for international
communication, it becomes imperative to consider this
vast problem in a most serious state of mind. It is
not one man's problem; it is the foremost problem
of the universe, in which every individual and every
branch of society must take an active part. Thus,
and thus alone, may we hope to gain the desired
goal. It becomes the part of the financier and his
collaborators to introduce a monetary system which
may be accepted by all nations. It becomes the duty
of the legislators to make uniform general laws,
acceptable by all countries. It becomes our duty to
clarify and unify medical nomenclature, to introduce
simple terms for accepted standards, to remove the
old and obsolete, and bring order out of chaos.
This article has been written in the hope that it
will invite criticism and exchange of views. If you,
dear reader, have any suggestions to offer, kindly
address this journal or the writer; you may rely upon
my assurance that full consideration will be extended.
The world is on the qui vive; let us jointly have the
honor of driving the initial wedge.
Bcgimimg mkk Meiicd NtmturUtm*
If medical science evolves a language which is
acceptable by the entire medical world, other scientific
bodies will follow suit, and the dream of the ages
may be realized in our own time. Not only must
medical science blaze the way, but America — you and
I and all of us — must be the pathfinders.
To begin with, our means of comparing values
must be uniform. The metric system has been ac-
cepted as the best system, but there is a vast difference
between acceptance and use. Why do the English
people hesitate f To my mind appear two main
reasons: the change from a percentage system to a
per-mille system, and the confusing terminology. It
undoubtedly is unfortunate that the percentage
system was replaced by the per-mille system. It
takes one hundred units to make one dollar, the
picture we love so well ; now we are told that it takes
one thousand millimeters to make one meter and one
thousand milligrams to make one gram. We hesitate,
especially when the daily press quotes such painful
news that in Russia it takes ten thousand rubles to
see our Charlie Chaplin walk, or when you step on a
pair of first-class scales and are told that your weight
is sixty-eight thousand grams, when you full well
know that only yesterday another pair of equally
good scales quoted your weight as one hundred and
fifty pounds. There is, however, one ray of hope —
"things are not what they seem."
The confusing terminology : The baby has entirely
too many names, and the individual names consume
too many syllables. We are in the habit of using a
few chosen words, "the shorter the better" our motto.
The remedy: The length of the millimeter equals
the width of a line, which a normal eye may dis-
tinguish at the accepted optical distance of six
516
Best Current Medical Thought
[Phila., July, 1922
meters. "Lin," the first syllable of linea, would be a
rational and acceptable name for the unit we now call
millimeter. Its son, microlin, being the one thou-
sandth part of lin, it should replace the microscopic
unit micromillimeter, and meter should hold its same
old job. Gram, the unit of weight, is composed of
one thousand microgram; grama, its liquid equiva-
lent, replaces "cubic centimeter" and "milliliter," it,
too, is composed of one thousand units, each of which
is called micrograms, and each micrograms is the
liquid equivalent of microgram.
The Frenchman, originator of the system, placed
his little trademark in a conspicuous place by calling
the liquid quantity which equals one thousand grama
"liter," but when it came to the naming of the solid
equivalent of the liter, he was nonplussed and he
(To be concluded
called it kilogram, one thousand gram, borrowing the
Greek word "chilioi" for the purpose. The Latin
word "pondus" means a heavy weight, just suitable
here. Its first syllable, pond, should be employed.
If pond signifies one thousand gram, then ponda
signifies the liquid equivalent of pond. We repay
our debt to our sister republic and return to Fram-e
its "liter."
Our system, changed in name, but not in quantity:
meter — 1,000 lin.
lin — 1,000 microlin.
pond — 1,000 gram.
gram — 1,000 microgram.
ponda — 1,000 grama.
grama — 1,000 micrograms.
in next issue)
Best Current Medical 1 bought
Birth Injuries
Abstract of an address delivered before the Wayne
Junction Medical Society, April 25, 1922
By Alfred Gordon, M.D.
Injuries during the delivery or in the intra-uterine life
present several varieties. The central nervous system as
well as the periperal nerves may suffer considerable
damage. The most frequent occurrence of the first
group is meningeal hemorrhage. It may occur follow-
ing a laceration of the tentorium or a rupture of the pial
veins, a laceration of the superior longitudinal sinus or
of the lateral sinuses. The largest of the subarachnoid
veins, which are usually ruptured, are located along the
anterior and the posterior borders of the parietal bone,
which correspond to the lambdoid and coronary sutures.
The coronary suture corresponds to the Rolandie area
and, consequently, a hemorrhage at this level produces
motor symptoms, which is ordinarily the case. They
are hemiplegia, monoplegia, tremor, convulsions. If
convulsions do not disappear, eventually the following
conditions will be observed: arrested mental develop-
ment, Little's disease, disturbance of vision, ocular pal-
sies, deafness, disturbance of speech. It is, therefore,
evident that the recognition of meningeal hemorrhages
in newly born infants is a matter of great practical im-
portance.
The brain in all such cases presents very serious
changes. Foci of softening, retraction and depression
in the nervous tissue, adhesions and thickening of the
meninges, degeneration of cortical cells and of fibres —
all these pathological lesions are common findings. They
are the result of a meningo~encephalitis. Old lesions in
the vicinitv of the walls of the lateral ventricles may
lead to the formation of hydrocephalus, atrophy of the
brain, microgyria (diminution of the size of convolu-
tions), or else hypertrophy of brain tissue may be
encountered.
The causes of meningeal hemorrhages during birth
are, of course, traumata produced either by instruments
during delivery or else in protracted labor when forceps
is not applied promptly. Little lays special emphasis on
dystocia and especially on premature birth.
Sywtptotu
A. Infantile spastic hemiplegia may be noticed
at birth or only when the child makes the first at-
tempt to walk. Convulsions may appear early. While
the hemiplegia, in a general way, resembles that of
adults, it nevertheless presents some peculiarities,
namely: contractures with deformities; the flexion of
the hand and fingers and varus equinus are pronounced.
The striking feature is the atrophy of all the structures
of the affected side: skin, fat, connective tissue, muscu-
lature and bone; not only the limbs, but also the face
and thorax show diminution in size. Vasomotor dis-
turbances, as well as sensory, are present. The paralyzed
limbs are not infrequently affected with choreic or
athetosis movements.
Children born hemiplegic sometimes present other
defects, such as strabismus, hemianopsia, nystagmus,
deafness. Epilepsy is a frequent complication.
B. Spastic diplegia. Little's disease. When the seat
of the lession instead of being unilateral, is symmet-
rically distributed to the motor areas of both hemis-
pheres, the clinical manifestation will be a double
hemiplegia or diplegia. When the lesion affects only
both para-central lobules of. the motor area, the result
will be a paralysis of both lower extremities (para-
plegia). Little was the first to call attention (in 1862)
to premature labor as being the most frequent etiolog-
ical factor of spastic diplegia. Here a deficient
development of the pyramidal tract is the direct cause
of the malady. The pyramidal fibres become covered
with myelin only during the first few months after
normal birth and at seven months the pyramidal fibres
are absent in the spinal cord. There is, consequently,
no continuity between the cortex and oeripheral nerves
and the stimulation sent out from the cortex to *he
spinal centers is not properly transmitted. Hence the
rigidity of the muscles in the limbs.
The American Physician]
An Honest Market Place
517
Bowel Torpor in the Elderly
is usually the result of a progressive atony of the bowel, with a
gradual decrease of the natural mucus and other secretions.
The loss of moisture dries the feces and interferes with their
free and easy passage. Under such conditions
INTEROL
serves as a safe and
lowing its systematic
DIRECTIONS:
In treating the el*
derly, begin with a
tablespoonful morning
and night on an
empty stomach, in*
creasing or decreas-
ing as conditions re-
quire.
Sample and Interol
brochure on request.
efficient substitute for the physiologic secretions. Fol-
use, the bowel contents are kept soft, the intestinal
canal — especially the large intestine — is adequately
lubricated, and the feces are passed along and evacu-
ated in due time without straining, pain, or discomfort.
INTEROL thus constitutes an ideal medium for the
relief of bowel torpor in patients of advanced age.
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518
Best Current Medical Thought
[Phila., July, 1922
Besides premature labor (Little), intoxication of the
mother, with organic or inorganic elements, syphilis,
finally, trauma during labor (see above) — are all apt to
produce spastic paralysis in infants. The most frequent
form is Paraplegia which presents this characteristic
feature that when the child is standing the thighs are
in close contact with each other, while the legs are
separated. In walking, the legs have a tendency to
cross each other. When seated, the legs are extended.
In the diplegic form the face not infrequently partici-
pates in the general rigidity. When patient speaks, there
is a marked contortion of the muscles of the face. The
mentality is not infrequently involved and in such cases
epilepsy is frequently associated.
The prognosis, generally speaking, is unfavorable,
except in cases of a syphilitic character (as shown by
the Wassermann test).
The Opportunity) of the Family Physician Tolpard
Insanity of the Young — Holmes
(Continued from page 498)
Prevention is, of course, the most important ele-
ment. Prompt intervention in difficult labor and in
dystocia should always be borne in mind. Late for-
ceps application is to be avoided. Since meningeal
hemorrhage is a frequent etiological factor, early re-
moval of blood clots is urged.
Cushing has recorded satisfactory results (in 1905).
Gilles advises puncture of the anterior fontanelle.
Surgery directed toward the deformities and con-
tractures is apt to give favorable results. Tenotomy,
myotomy followed by application of plaster casts to the
limbs out in corrected positions has given favorable re-
sults in certain cases. Manipulations, exercises, massage,
warm baths — are ail good adjuvants in the post-operative
treatment.
Foerster has suggested, in 1909, resection of the pos-
terior spinal roots for relief of spasticity. Schwal and
Allison, in 1910, suggested "muscles group isolation,"
which consists of isolating the nerves distributed in the
affected muscles and injecting them with alcohol.
Finally, Stoffel, in 1911, advised exposing the nerve
trunks of the involved muscle and severing them. All
these special surgical procedures must be followed by
a course of massage and physiological exercises.
Injuries during birth may produce damage not only to
the central nervous system, but also to the peripheral
nerve trunks. The most frequent is the "obstetrical
palsy." It is almost always due to instrumental delivery
or difficult labor. The finger or tenaculu introduced to
facilitate the delivery, also the forceps may press directly
on the shoulder and the brachial plexus. In breech
presentation it is very frequent.
Sywtptoms
It is the "superior type" of paralysis of the brachial
plexus. The following muscles of the shoulder and
arm are involved; deltoid, biceps, brachial is anticus,
supinator longus and brevis, supra- and infraspinatus
and the clavicular end of the pectoralis major. These
muscles are controlled by that part of the brachial
plexus which takes its fibres from the 5th and 6th
cervical roots.
The disturbed function consists of an inability to flex,
supinate and abduct the arm. The latter is in a state of
extension. The forearm and hand are nronated. Atrophy
with partial or complete reactions of degeneration de-
velop rapidly. Sensations, as a rule, are not disturbed.
The treatment should consist, at first, of massage,
electricity and systematic exercises. Surgical interven-
tion may, in some cases, give satisfactory results.
for seven and for ten years have recovered, while
quite mild cases have failed to show benefit even
though sick only two years or even less. Nor do we
know just how the irrigation does its work.
We presume at present that the toxic agent is the
remnant of a histidin-like molecule (probably of a
polypeptid containing an imidazol radicle), left after
a colon bacillus has taken away the portion it can
consume. Ordinarily we think of the toxic sub-
stances produced by pathogenic bacteria as within
the body of the bacterium, an endotoxine, or as an
excretion of the microbe, an exotoxine; but in this
instance it seems that it is a toxic food remnant
after the bacterial repast — the poisonous residue of
the feast of our .messmates, the colon bacilli. In this
respect it resembles the etiology of no other common
disease. At first it seemed that this toxic residue
might be betaiminadzolethylamin, for it presents
some of the physiologic actions of that toxic amine,
and the biochemical paradigm of the production ot
this poison fits in with the retardation of the barium
meal in the cecum, but such a presumption provides
too much. This toxine is so poisonous that it kills in
a few moments after it is injected into animals and
before any neurologic changes have had time to ap-
pear. Research guided by clinical and especially by
favorable therapeutic experiments alone will answer
the many questions that have already come up. Until
researches are established on an adequate scale, and
the basis of the disease is completely elucidated, it is
the duty of the physician who first recognizes a case
of dementia praecox to institute detoxicating meas-
ures. The first of these is rest in bed in the outdoor
air, and sunshine, both day and night, i. e., the same
as in the ti tuberculous therapy of Rollier. The sec-
ond is the treatment of the spasmophilia by phos-
phorated cod liver oil and calcium lactate together
with calcium containing foods. The third is the re-
moval of foci of infection in nose, ears, throat, teeth
and natural cavities of the body, and early appende-
costomy and irrigation of the colon with large quan-
tities of warm water every night four hours after
last meal of the day.
This ProUem It m the BmmU W tk* Family Pkydam
Whatever is to be done for the twenty thousand
more youths who come down with dementia praeeox
every year must be done before commitment and
before sanitarium segregation. Not much assist-
ance can be expected from the professional psychi-
atrists as such authorities as Adolph Meyer, Peter-
sen and Church teach that the obvious physical
pathology observed in dementia praecox patients is
(continued one leaf over.)
The American Physician]
An Honest Market Place 519
Doctor:
Do your patients ever think of this:
It's not what they eat but what
they assimilate that counts
As every physician knows, digestion of food is essen-
tial in order to benefit by its nutritive qualities. More-
over, if in digestion food ferments or undergoes putrid
decomposition it may be an actual menace to health.
This is one reason why it is of advantage to have all
cereal foods thoroughly baked. Baking not only par-
tially digests cereal foods, thereby developing the partic-
ular flavor, but it establishes the physical condition that
avoids fermentation and promotes digestion, so that the
food is properly assimilated by the system to yield
strength and energy.
Grape-Nuts, the delicious cereal food made from
whole wheat flour and malted barley, is probably the
longest baked of all cereal foods. It is kept for twenty
hours in ovens heated to just the proper temperature
to develop the best condition of the cereal for digestion.
Grape-Nuts contains valuable mineral salts required
for nerve, tooth and bone structure. It is a good all-
round food that helps children to grow sturdy and
healthy, and there is nothing better for adults.
For breakfast or lunch the delight and appetite-
satisfaction in a dish of Grape-Nuts with milk or cream
is known practically throughout the civilized world.
You and your patients, can get Grape-Nuts anywhere
and everywhere ; in the most exclusive hotels and clubs ;
on dining cars; in modest lunch' rooms; and at the
largest and the smallest grocery stores.
Samples of Grape-Nuts, with full informa-
tion, for personal or clinical trial will be
sent upon request to any physician who
has not received them.
Postum Cereal Company, Inc.
Battle Creek, Michigan, U. S. A.
Mentioning The American Physician Insures Prompt, Careful Service
520
Best Current Medical Thought
[Phfla., July, 1922
due to mental states or unrelated accidents. If
the family physician treats his own dementia prae-
cox patients at the patients' home and the local cur-
ing hospital, on the Indications which I have tried my
best to present, many commitments will be saved and
the pessimistic and mystical attitude of profession
and public toward the adolescent insane will disap-
pear, research into cause, cure and prevention will
be established and this curse of youth will be as rare
in our state hospitals in another generation as typhoid
fever, which filled one-third the beds in the Cook
County Hospital when I was an interne there thirty
years ago, is rare in the great civil hospitals of the
United States to-day.
The problem of dementia praecoz is in the hands
of the family physician where the problem of every
other disease which has been solved by our profession
has been safely placed.
ArBphenamine Treatment of Syphilis
Dr. E. A. Fischkin, of Chicago, observes that phy-
sicians have unmistakably succeeded in curing syphilis
in the primary stage in a way that they have never done
before. This is made possible by salvarsan and mercury.
The author quotes several cases in which he has been
able to clear up primary cases without the appearance
of any secondaries.
Fischkin utilizes arsphenamine with mercury in the
primary and early secondary stages, and arsphenamine,
mercury and iodides in tertiary stages. For the mercu-
rials he uses calomelettes for inunction or bichloridol
collapsules for intramuscular injection. He says the
advantage of the latter is that they are less painful and
produce less infiltration.
As to the arsenicals, he favors neoarsphenamine and
silver arsphenamine and quotes a number of cases to
demonstrate the value of these forms of arsenic. He
believes that it requires from 25 to 30 injections in
favorable cases of secondary or latent svohilis to acquire
a negative Wassermann.
He warns that in no case does a negative Wassermann
indicate a lasting cure and that relapses may be ex-
pected.
In discussing silver arsphenamine, Fischkin finds that
it produces better results with a considerably smaller
amount of arsenic in comparison with those following
other products.
He concludes this interesting article by saying that
silver-salvarsan is parasitotropic in a greater degree
than the older preparations and is less organotropic. —
Am. Jour. Clin. Med.t April, 1922.
Pain occurs in most of the appendix attacks before
any other symptom develops, even the symptom of
rigidity, and this pain is usually felt first at the umbilicus,
later usually localizing in the right lower quadrant.
Therefore, pain here, as in many other abdominal lesions,
is not immediately associated with the visceral organs
involved, and it is also not uncommon to find both pain
and tenderness, and at times even rigidity, at points far
distant from the appendix — Dr. C. E. Tennant in Colo-
rado Medicine.
"Pernicious Anemia" and "Septic Anemia"
William Hunter (British Med. Jour.), from his ex-
tended experience in the study of the anemias, states
that the most important outcome of his studies may be
summed up in one sentence: The infective and clinical
features of severe anemias go deeper into their nature
and help far more in their diagnosis and treatment than
the various blood criteria so much before our notice in
dealing with anemias.
The percentages familiar to us in blood reports make
a deep impression on the eye and on the mind, but they
have the one great drawback that they always fail pre-
cisely in the borderland group of cases, in which the
clinical observer most needs their help, and they always
fail when the anemia is moderate in degree and when it
is particularly necessary to be sure of its character if
successful measures are to be taken in time to arrest
progress.
On the other hand, the outcome of the study of the
infective and clinical features presented by cases of
severe anemia has yielded the following information
briefly summarized:
(1) Two forms of severe anemia as to be recognized
The one is the great hemolytic disease sui generis, termed
idiopathic or pernicious anemia. The other is a very
common anemic condition — non-hemolytic in its nature-j-
which the writer has differentiated and termed "septic
anemia."
(2) The patient who presents the picture of des-
perate anemia, termed pernicious anemia, is really in
the grip of both the above forms of anemia, each of
them capable of killing him, and the combination abso-
lutely mortal. The chief one which gives his illness its
main characters, clinical features, and course is the
hemolytic disease; the other complicating one is the
non-hemolytic septic anemia.
(3) The outcome of this recognition and differentia-
tion is that the two anemias can be torn apart by re-
moving completely the septic anemia and its causes from
the pernicious anemia patient. On doing this, the great
hemolytic disease shows itself for the first time in its
true uncomplicated characters and course; and these
prove to be much milder in severity and with a much
better prognosis than were ever formerly presented.
(4) A further outcome of these studies has been to
reveal certain simple and easily recognizable diagnostic
features which enable pernicious anemia to be recog-
nized in its very earliest stages, even within a few weeks
of its first contraction, and on an average about two
years before it generally comes under treatment
(5) The infective and clinical features here referred
to, that help so much in the diagnosis and treatment of
both classes of anemia, are connected with observations,
not on the blood, but of lesions connected with the mouth.
These lesions are combined in the case of the pernicious
anemia patient, but are perfectly distinct from one
another, and have a totally different pathological and
etiological significance.
The infective lesions connected wtih the diagnosis of
pernicious anemia are the peculiar sore tongue which this
disease presents as one of its earliest features. The
lesions concerned with "septic anemia" are septic lesions
connected wtih chronic and overlooked dental and nasal
sepsis, especially the former, to which the author has
given the name "oral sepsis." When sepsis is removed
the powers of recovery from this hemolytic disease are
thereby increased.
The writer has had under his observation 150 cases
of pernicious anemia during the last twenty years, and
(continued one leaf over.)
The American Physician
Physicians are giving mora and more consideration
to bran. It may not only be prescribed for minor and
chronic constipation cases with confident expectations
of satisfying results, but its wonderful food properties
(as shown in the accompanying analysis) give it
double value to the patient,
Eellogg's Bran, cooked and krumbled, should not
be confused with common brans which become so irk-
some for the patient to eat Kellogg's Bran is delicious
not only in its krumbled crispness, but in its flavor,
which appeals to the most fastidious appetites. Eat
it as a cereal or sprinkled over cold or hot cereals or
in other cooked foods.
As you know, bran induces better peristaltic action
by adding indigestible residue in the bowel tract.
Eaten regularly each day — at least two tablespoon-
fuls; in chronic, old-age or bed-ridden cases with each
meal — the greatest relief may be anticipated. All
grocers sell Kellogg's Bran, cooked and krumbled.
We would very much appiecUte phyairiana Bending ut ■
request card for a large package of Kellogg'a Bran,
which'will be forwarded with our compliment*. We
dettre pnyriciani to penonally know the Table of
Kellogg 'a Bran, cooked and krumbled.
An Analgia of
K.Uogtf, BRAN
cooked and knunMsd
Aride from in
8.9
(per pound)
the original 'BRAS -cooked and krumbled
Mentioning The American Physician Insures Prompt, Careful Service
522
Best Current Medical Thought
[Phfla., July, 1922
finds that the dreadful, hopeless pictures which the dis-
ease formerly presented he no longer sees in patients in
whom he has been able to carry out the full measures
of anti-sepsis which he considers necessary, without
using any new methods of treatment other than this
antiseptic treatment against gastrointestinal sepsis, which
he recommended in 1890, and the measures of oral sepsis,
which he recommended in 1900. The name "glossitic
anemia" would best connote this great hemolytic disease,
help in its early diagnosis, and in its control.
Epidemic (Lethargic) Encephalitis
Report from the study and observations of several
doctors :
Morris Grossman (J. A. M. A,, April 1, 1922) reports
from a study of ninety-two cases from one to three
years after recovery that only ten of the ninety-two
patients examined in this series were free from symptoms
and showed no residual signs when observed from one to
three years after the acute illness. Fourteen others had
recovered, within this time, sufficiently to allow them to
return to their work. These patients, however, still
showed residual signs of their previous illness and com-
plained of various forms of psychic disturbances, such
as insomnia, irritability, poor memory, and fear neuroses.
Sixty-two patients showed a serious, more or less pro-
gressive involvement of the centralHervous system which
was evidenced by disturbances in the motor pyschic or
autonomic functions. Of these sixty-two patients, forty-
two showed a clinical syndrome which closely resembled
that seen in paralysis agitans. On account of the rapid
development of the syndrome, their emotional responses
were more active than those of the average patient with
paralysis agitans. They smiled more readily and seemed
to overcome their facial immobility more completely and
more easily. Their mental reactions were likewise more
prompt Almost 70 per cent, of these patients were
below thirty years of age. A strikingly large number
of them also showed pupillary changes and residual
signs pointing to cranial nerve involvement ; this is an
unusual finding in true paralysis agitans. Another out-
standing feature that was noted in the re-examination
of these patients was the strikingly large number who
showed increase in the activity of the abdominal reflexes.
Arthur J. Hall (The Lancet) states from his observa-
tions on thirty cases, eleven of which died (a mortality
just under 24 per cent.). There was nothing among
these cases that indicated direct or indirect infection.
It seems that epidemic encephalitis does not protect
against influenza or vice-versa.
With reference to the prognosis of the disease, Hall
feels that generalizations are not yet possible. He agrees
with Branwell that a steadily progressive stupor with a
rising temperature and loss of sphincter control is omi-
nous, though not necessarily fatal. During the progress
of a case it is often impossible to form an opinion as
to the prospect of recovery.
If one compares it with other acute specific infections,
it is apparent that the signs upon which we can usually
rely in them for prognosis are often not forthcoming
in cases of encephalitis. Patients with comparatively
(Best Current Medical Thought— Continued one
leaf over.)
qPiI. Cascara Compound — Robins a
fg± MILD, 1 GR.— STRONG, 4 GRS. f^
^^^ It is the failure of the secretory function of the bowel, together jg^
with a poor bile secretion, which, in nine cases out of ten, isfffw
©responsible for constipation. >d
Most cathartics altogether overlook this factor and address \S?
f^k themselves solely to a stimulation of the musculature. Some even /^
T&F inhibit intestinal secretion. The result is a rapid, unsatisfactory \Jp
ffo bowel movement, followed by paralytic reaction. /&
^jj^ Pil. Cascara Comp. (Robins) is a rational therapeutic formula, ^^
fA which promotes a natural flow of secretions, which is, in turn, the/|B
jS^ physiologic stimulant of peristalsis. Thus a normal evacuation is^BT
MA produced, without subsequent inhibition. f#0
^nw Samples and descriptive literature on request 2^
ttW A. H. ROBINS COMPANY Richmond, Virginia l8ft
You can buy with confidence— See "Service Guarantee to Readers" on page 542
The American Phyiici.n]
The American Physician
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Best Current Medical Thought
[Phita., J*, 1923
mild attacks recover, only to be seriously damaged for
very lone periods, even permanently. Others who haw
appeared in the early stages to be at death's door recover
quickly and completely, while still others whose illness
has seemed moderately severe for one or two weeks
suddenly ' become worse and die without any obvious
reason why they should.
George E. Price (I. A. M. A.) reports r
symptoms one and one-half years after recovery in this
case because it is the longest interval or remission so
far recorded, to his knowledge. The child made prac-
tically a complete recovery from the first attack, returning
to school. The question is raised as to whether the child
could have had a reinfection. The tendency of epidemic
encephalitis to relapse, and the absence of any data
regarding reinfection in the disease, point to a flaring
up of encapsulated foci, rather than a reinfection from
an outside source. The writer points out that the possi-
bility of a relapse in epidemic encephalitis after an in-
terval of a year or longer is of interest to life insurance
statisticians, who already- are chary of renewing health
policies to persons who have had encephalitis.
Long Distance Weather Prognosticating
(Continued from page 514)
i!
57' to 96" high. Consumes 3T5 watti
— 120 Tolls A. C. or D. C. Coven
square Inches 36" from reflector
Finish, Olive and Nickel Price coin
plete with stand 130.00 each.
Made of Aluminum, weight
._. .Finish, Black and Nickel,
Price complete without stand $1000
>eacb. Folding Stand only for No.
0045, (6.00 each.
i ef lighting itvica tine
statements not officially agreed to and base long dis-
tance prognostications on the factors noted above.
Since our great mountain ranges run, roughly,
from north to south, the weather is apt to be very
erratic, and the great continental bulk affects our
weather more than do the ocean areas, except on the
Pacific slope and along the Golf of Mexico. If our
mountain ranges ran east and west, the territory
south of them would all be semi-tropical.
The Practice of Obstetrics an Art
A. B. Somers' (Med. Herald) conclusions are:
First. — Childbirth, being a physiological process, can-
not be reduced to mathematical exactness.
Second. — A very large percentage of women have lo
be cared for and will be, by the average doctor and in
the average home, without trained attendants, and under
these conditions, nanipulations and operations are dan-
gerous.
Third. — The average doctor is inclined to adopt opera-
tive measures because the atmosphere of our medical
journals is full of it.
Fourth. — "When doctors disagree, who shall decide?"
We need a get-together measure on the part of radical
obstetricians.
Fifth.— It is not enough to say that the mortality and
morbidity rate is no greater under radical methods.
Modern science demands less mortality and morbidity,
and this we have not accomplished during the past twenty
Sixth. — We need more and better equipped maternities
for the care of all classes of obstetric cases.
Seventh. — We need more trained obstetricians, not
necessarily experts.
Eighth. — We need more prenatal teaching.
Ninth. — In brief, we need more practical good sense
and less haste in our obstetric practice.
n buy with confidence— See "Service Guarantee to Readers" on page 542
The American Physician]
An Honest Market Place 525
A New Salt of Marked Value in Gonorrhea
Zinc Borosalicylate (G«H»BOf) 2Zn.— NEISSER-SAN-KAHN—
by a fusing process in manufacture, the germicidal properties of the
drug are retained with elimination of its irritating properties.
KZ2SSZK-SfcX->ifrttK
( Zinc-Borosalicylate)
Has distinct advantages in treatment of urethral infections.
Definitely Germicidal Non-Toxic
Power of Deep Penetration into the Epithefiam
Does Not Stain Forms Stable Solution
The definite gonococcoddal strength of NEISSER-SAN-KAHN with its
freedom from irritation and other objectionable feature*— stamps this new agent
as an outstanding drug for use in genito-urinary diseases. One tablet in three
ounces of hot DISTILLED water injected at body temperature, three times
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Vaginal Suppositories NEISSER-SAN-KAHN— each containing 5 grains
N-S-K are stainless, non-irritating, definitely germicidal— EFFECTIVE. Supplied
in boxes of ten.
Procured on prescription (druggists not stocked being supplied through
the regular trade channels) or direct from our Laboratories.
Writs fsr Ummtore
YORK LABORATORIES COMPANY, Inc.
COURT AVE. AND JACKSON ST. YOJtK, PENNA.
ACTIVE CATHARTICS OR PURGATIVES THAT PRODUCE A WATERY
STOOL DO NOT GIVE GOOD RESULTS IN
Habitual Constipation
as the digestive secretions are carried off and a period of constipation follows
until the secretions again accumulate and the natural process of digestion and
assimilation is resumed.
A mild tonic laxative gives the best result and you can obtain this with Cascara
Comp. Tablets (KiHgore9s)9 as they stimulate the secretions, give an easy natural
movement without griping and do not become ineffective by continued use.
Dose: One or two tablets at night
Liberal Sample and Formula Sent to Physicians on Request
CHARLES KILLGORE
Manufacturing Chemist Established 1874
55 WEST THIRD ST., COR. WEST BROADWAY NEW YORK
Mentioning The American Physician Insures Prompt, Careful Service
'Book 'Re'btews
Practical Therapeutics
By Hobart Amory Hare, M.D., B.Sc, LL.D^ Professor
of Therapeutics in Jefferson Medical College and
Physician to Jefferson Hospital, Philadelphia.
Eighteenth edition, largely rewritten. Cloth, illus-
trated,, 1038 pages. Lea & Febiger, Philadelphia.
Price, $6.50.
This standard work has so long met the needs of the
practitioner that little comment is necessary. This care-
ful revision brings the work fully up to date. Hare has
always been a sensible writer, not so "critical as some
others, but dependable. This book shows his bent.
Refusing to delete drugs largely in use, or to refuse
comment on well-based proprietary preparation* of the
new-drugs class, he lists a large number of drugs and
preparations that do not meet with support in certain
circles. For the seasoned practitioner this is well
enough, but for the student the great wealth of matter
is confusing and hard to master. For the practitioner,
the book is of marked value.
Yet there are certain defects. The therapeutic uses
of many drugs discussed is too all-inclusive, extending
back too far into empiricism. One cannot help but note,
in the admirable Part IV on Diseases, the fact that many
drugs and hosts of "uses" discussed in Part II on Drugs,
are not even mentioned or are dismissed with a word.
Yet Dr. Hare has plenty of company in this genial
an it u He— one that it is about time to drop; it will be a
real advantage to clinical medicine. Also, or so it
appears to the reviewer, there is a paucity of waning
regarding heavy doses discussed, especially when de-
pressing drugs are under review. The experienced
practitioner has learned these points, but the student
has not.— T. S. B.
Medical Ophthalmology
By R. Foster Moore, O.B.E., M.A., F.R.C.S., Assistant
Ophthalmic Surgeon, St Bartholomew's Hospital;
Surgeon, Moor fields Eye Hospital, Cloth, splendidly
illustrated, 300 pages. P. BlakisWs Son & Co,
1012 Walnut St., Philadelphia. Price, $3.50.
Dr. Moore, while not producing a markedly original
treatise, has brought together under one cover a wealth
of data on ophthalmology in its relationship to systemic
disease. The work is well done and the general prac-
titioner of medicine will find in it much data bearing
on his work. The sections on visual defects1 due to
hemorrhage and neural lesions seem to us to be of
especial value.
(Book Reviews continued one leaf over J
I INTESTINAL INFECTIONS
CALCREOSE is an ideal intestinal antiseptic. It is useful
in cases of intestinal sepsis, either primary or secondary.
] CREOSOTE la one of the few drags which appear
] to have a Jut claim to be useful aa Intestinal
I antiseptic*, but it impair* the appetite and dis-
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] Price — Powder, lb.. $3.00. (Prepared by adding I lb. to I gallon of
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We believe that the hygroscopic properties of agar and the vitalizing
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Meniioning The American Physician Insures Prompt. Careful Service
528
Helpful Points
[PhUa., July, 1922
Harrower "Sanitablets"
The Harrower Pluriglandular Formulas are now sup-
plied as friable tablets. Each dose is individually
wrapped in paraffined paper—air-tight and moisture-
proof.
"Sanitablets" have the same formulas, list numbers
and prices as the corresponding Harrower capsules.
In asthenia, low blood-pressure, sub-oxidation, sub-
normal temperature and other conditions requiring
"adrenal support"— prescribe S. T. Adreno-Spermin Co.
(Harrower). The initials S. T. stand for "Sanitablet"
For further information address: The Harrower
Laboratory, Box 68, Glendale, Calif.
Post-Operative Constipation
Neglect of the bowels after operation is always apt
to give rise to serious consequences. In addition to
the depressing effect on the whole body, resulting
from the absorption of toxins from retained waste
products, the contents of the lower bowel become so
inspissated and dessicated that their ultimate evacua-
tion is accomplished by such mechanical difficulty
and severe straining that grave harm is often done,
particularly to the site of the wound.
Hernias are frequently produced, while hemorrhoids
are a common outcome. Other ill effects are prone
to follow; post-operative constipation and its persist-
ence often makes an operation a complete failure. For
obvious reasons, too great emphasis cannot be placed
on the importance of effective treatment. Cathar-
tics, enemata, etc., increase rather than reduce the
bowel condition and the surgeon is confronted by
the question of what to do to relieve the situation.
Clinical experience has shown that there is no
other measure so effective as a corrective of post-
operative constipation as a good, pure mineral oil
such as Interol. An excellent way of assuring maxi-
mum benefits from this product is to begin its use
one to three days following operation, giving two
drams every two hours until one to three days after
the oil has passed through the tract, whereupon it
is stopped and then resumed every three, then every
four hours; then when the patient's diet becomes
more liberal, thrice daily, in one to two-ounce doses,
gradually decreasing the quantity or the frequency,
as conditions indicate.
Thus employed, Interol softens the feces and lubri-
cates the canal, thus assuring easy bowel evacuation,
without straining and with gratifying avoidance of
the irritation and stimulation that usually accompany
the use of cathartics.
The more that Interol is used for preventing post-
operative constipation with its often serious conse-
quences, the more evident it becomes that it affords
uniformly effective results with complete freedom
from objectionable action or effects.
Sample and Interol brochure will be sent to
American Physician readers on request. Address:
Allied Drug and Chemical Corporation, 2413 Third
Avenue, New York City.
(Helpful Points continued one leaf over.)
ANUSOL
iTrodt-Mfk)
Hemorrhoidal
SUPPOSITORIES
They break the
"Vicious Circle"
in Hemorrhoids
Hemorrhoid sufferers are always inclined to become careless and dilatory
in their bowel movements, for fear of painful defecation.
And right there starts the "vicious circle**— constipation, local irritation,
aggravated Hemorrhoids, painful defecation, increased irregularity, and so
forth.
Anusol Suppositories remove the dreaded strain and the reassured patient
resumes his regular bowel function.
Then the excellent healing and tonic action of Anusol Suppositories can
set in and do its utmost without set-back*
And the utmost of Anusol Suppositories accomplishment is the utmost in
Hemorrhoidal therapy.
Ample Trial Quantity and Literature from
SCHERING & GLATZ, INC, 150 Maiden Lane, New York
You can buy with confidence — See "Service Guarantee to Readers" on page 542
An Honest Market Place
g(gcK*g)l
McK & R Compound Stearate of Zinc
for the Baby's Summer Comfort
jruptio
particularly trying on
babies- They develop
■ kin condition,
i and chafing! from
the acid perspiration stimu-
lated by the excessive heat
and humidity.
They are more liable to
"diaper rash" than in colder
weather as the akin surface
ia more susceptible to the
lary
and fecal discharg
greatly
ublea for your little patients,
Doctor, if only you will advise the
liberal use of McK & R Compound
Stearate of Zinc.
After the bath. Compound Stearate
of Zinc applied as a routine measure,
tends to overcome prickly heat, and
skin discomforts generally. A liberal
dusting with McK Ac Ft Com-
pound Stearate of Zinc
around the genitals and in
the tissue folds, will render
the local surfaces moisture-
proof, and prevent the irrita-
tion following acid d i s -
charges. Do not forget Com-
pound Stearate of Zinc as a
valuable aid in preventing
and overcoming sunburn, in
adults a. well as children.
If you're not already fa-
miliar with McK & R Com-
pound Stearate of Zinc, send
card for literature and samples of
this valuable product.
(f«7£>
I.K.B)
McKESSON & ROBBINS
INCORPORATED
Manufacturing Chanitb
91 Fulton Street, New York City
For the Doctor Who Wants Results
we supply a number of practical, ethical products such as
PULVOIDS NATRIUM COMP., which is rapidly becoming recog-
nized as the most reliable and effective combination for
reducing high blood pressure and maintaining normal tension.
Pulvoids Aurazyme
No. 41S
i conjunction with other indicated
leasures secure satisfactory results
> diabetes mellitus. A trial will
SalvaroU Suppositories
Rectal
require no technique and obtai
action and result* equal or superio
to arsphenamine intravenously ir
ENDOCRIN AND GONAD products, a complete line, at reasonable
price, and of premier quality.
Send for literature, case reports, price lists and our tittle periodical
"Drug Products," gratis to physicians
THE DRUG PRODUCTS CO., Inc.
> Meadow Street, Long Wand City, N. Y.
Mentioning The A:
Physician Insures Prompt, Careful Service
528
Helpful Points
[Phtta., July, 1922
Harrower "Sanitablets"
The Harrower Pluriglandular Formulas are now sup-
plied as friable tablets. Each dose is individually
wrapped in paraffined paper— air-tight and moisture-
proof.
"Sanitablets" have the same formulas, list numbers
and prices as the corresponding Harrower capsules.
In asthenia, low blood-pressure, sub-oxidation, sub-
normal temperature and other conditions requiring
"adrenal support"— prescribe S. T. Adreno-Spermin Co.
(Harrower). The initials S. T. stand for "Sanitablet"
For further information address: The Harrower
Laboratory, Box 68, Glendale, Calif.
Post-Operative Constipation
Neglect of the bowels after operation is always apt
to give rise to serious consequences. In addition to
the depressing effect on the whole body, resulting
from the absorption of toxins from retained waste
products, the contents of the lower bowel become so
inspissated and dessicated that their ultimate evacua-
tion is accomplished by such mechanical difficulty
and severe straining that grave harm is often done,
particularly to the site of the wound.
Hernias are frequently produced, while hemorrhoids
are a common outcome. Other ill effects are prone
to follow; post-operative constipation and its persist-
ence often makes an operation a complete failure. For
obvious reasons, too great emphasis cannot be placed
on the importance of effective treatment. Cathar-
tics, enemata, etc., increase rather than reduce the
bowel condition and the surgeon is confronted by
the question of what to do to relieve the situation.
Clinical experience has shown that there is no
other measure so effective as a corrective of post-
operative constipation as a good, pure mineral oil
such as Interol. An excellent way of assuring maxi-
mum benefits from this product is to begin its use
one to three days following operation, giving two
drams every two hours until one to three days after
the oil has passed through the tract, whereupon it
is stopped and then resumed every three, then every
four hours; then when the patient's diet becomes
more liberal, thrice daily, in one to two-ounce doses,
gradually decreasing the quantity or the frequency,
as conditions indicate.
Thus employed, Interol softens the feces and lubri-
cates the canal, thus assuring easy bowel evacuation,
without straining and with gratifying avoidance of
the irritation and stimulation that usually accompany
the use of cathartics.
The more that Interol is used for preventing post-
operative constipation with its often serious conse-
quences, the more evident it becomes that it affords
uniformly effective results with complete freedom
from objectionable action or effects.
Sample and Interol brochure will be sent to
American Physician readers on request. Address:
Allied Drug and Chemical Corporation, 2413 Third
Avenue, New York City.
(Helpful Points continued one leaf over.)
ANUSOL
iTrodt-M*rk)
Hemorrhoidal
SUPPOSITORIES
They break the
"Vicious Circle
9f
in Hemorrhoids
Hemorrhoid sufferers are always inclined to become careless and dilatory
in their bowel movements, for fear of painful defecation.
And right there starts the "vicious circle"— constipation, local irritation,
aggravated Hemorrhoids, painful defecation, increased irregularity, and so
forth.
Anusol Suppositories remove the dreaded strain and the reassured patient
resumes his regular bowel function.
Then the excellent healing and tonic action of Anusol Suppositories can
set in and do its utmost without set-back.
And the utmost of Anusol Suppositories accomplishment is the utmost in
Hemorrhoidal therapy.
Ample Trial Quantity and Literature from
SCHERING & GLATZ, INC, 150 Maiden Lane, New York
You can buy with confidence — See "Service Guarantee to Readers" on page 542
An Honest Market Place
ftffclUg)!
McK & R Compound Stearate of Zinc
for the Baby's Summer Comfort
THE a u miner leaion is
particularly trying on
babies. They develop
irritative * It i n condition,
eruption* and chafing* from
the acid perapiration stimu-
lated by the axceasive heat
and humidity.
They are mora liable to
"diaper rath" than in colder
weather — aa the akin surface
ia more susceptible to the
irritating effect* of urinary
and fecal discharge.
You greatly relieve all
theae trouble! for your little patient*.
Doctor, if only you will advise the
liberal uae of McK & R Compound
Stearate of Zinc.
After the bath. Compound Stearate
of Zinc applied a* a routine measure,
tenda to overcome prickly heat, and
■kin discomforts generally. A liberal
dusting with McK & R Com-
pound Stearate of Zinc
around the genital* and in
the tiiaue fold*, will render
the local surface* moisture-
proof, and prevent the irrita-
tion following acid d i • .
charge*. Do not forget Com-
pound Stearate of Zinc a* a
valuable aid in preventing
and overcoming sunburn, in
adult* a* welt a* children.
If you're not already fa-
miliar with McK & R Com-
pound Stearate of Zinc, tend
card for literature and sample* of
this valuable product.
I.K.g)
McKESSON & ROBBINS
INCORPORATED
Manufacturing Chtmitli
91 Fulton Street, New York City
(JwuE)
For the Doctor Who Wants Results
we supply a number of practical, ethical products such as
PULVOIDS NATRIUM COMP., which is rapidly becoming recog-
nized as the most reliable and effective combination for
reducing high blood pressure and maintaining normal tension.
SalvaroU Suppositories
Rectal
require no technique and obtai
action and reault* equal or (uperio
to arsphenamine intravenously ir
Pulvoids Aurazyme
No. 418
i conjunction with other indicated
i e inures secure satisfactory results
i diabetes mellitu*. A trial will
ENDOCRIN AND GONAD products, a complete line, si reasonable
price, and of premier quality.
Send for literature, case reports, price list* and our little periodical
"Drug Products," gratis to physicians
THE DRUG PRODUCTS CO., Inc.
150 Meadow Street, Long bland City, N. Y.
Mentioning The A;
i Insures Prompt, Careful Service
Helpful Points
Relieve Pain Effectively
Patn is a symptom that means more to the patient
than any other — every patient wants relief of pain.
Heat is undoubtedly one of our best means of reliev-
ing it — not covering up — but constructively relieving pain.
The particularly effective method for bodily application
of heat is by means of radiant light and heat made avail-
able by the Thermolite Light and Heat Applicator.
You will find many and varied uses for a Thermolite
in your practice. Physicians who have used this effective
means of applying radiant light and heat, would not be
without the Thermolite. You also will find it invaluable
as an aid in your practice.
Write for inceresting and instructive literature to
H. G. McFaddin & Co., 34 Warren Street, New York.
Libera] samples of Virol and interesting literature
will be mailed to physicians on request. Address: Gm.
C. Cook & Co., Inc., 59 Bank St., New York.
For Undernourished Infanta
Virol has solved that ever vexing question: what
nourishment to give the delicate undernourished infant
—for many physicians. Virol is composed of Red Mar-
row, extracted from ox rib and calves' bones by C. P.
of glycerine, refined marrow and beef fat, highly dias-
tasic malt extract, eggs, lemon syrup and soluble phos-
phates.
In serious cases of acute infantile diarrhea the addition
of Virol, under suitable conditions, enormously stimu-
lates the phagocytic powers of the white blood cells.
These sturdily attack the microbial invaders, and by
diminishing the intestinal flora cut off the production
of toxius at their source, with a consequent reduction
of the catarrhal condition of the mucous membrane.
As the glandular secretions become more normal they
again exercise their inhibitory effects upon the flora,
and digestion and assimilation are again established.
Summer Comfort for Babies
Summer is particularly hard on babies, as tvttv
physician knows. Irritating skin conditions are liable lo
develop, eruptions and chafings, diaper rash, prieklr
heat, etc.
You will greatly relieve all these troubles for your
little patients by advising the liberal use of McK & R
Compound Stearate of Zinc. A liberal dusting »itb
McK & R Compound Stearate of Zinc will go far
toward making a comfortable, therefore a health;, babj
during hot weather.
If you do not know this valuable product, send a tard
now for literature and samples. Address: McKesson k
Robbins, Inc., 81 Fulton Street, New York City.
A New Organic Mercurial
Mercury is one of the drugs that have survived mis'
understanding and abuse by the sheer force of inherent
therapeutic merit. For a time after saharsan was dis-
covered it looked as though the days of mercury u ■
antiluetic were over, but there has been much disillusion
on this point in recent years, and mercury is now ss
strongly entrenched in professional confidence- as it
ever was — more so, in fact, as a result of developments
in pharmaceutical manufacturing methods which hire
given us improved mercurial compounds.
The latest of these is Mercurosal, a Parke, Davis i
Co. product which is supplied in single intramuscular
and intravenous doses in glass tubes ready to be nude
(Helpful Points continued one leaf ovirj
This Doctor Relieved "Lordosis"
by UK of the Fhiln
Spinal Correction; a
wheel chair siid now runt and pliyi
ie records, showing splendid recover*
it hive been doomed lo a hopeless,
b helpless life as ■ hunchback or
d cripple. We want to co-operate
.f will eery doctor in the U. S. and
3 foreign countries who has anr
y casea under observation. Read
what this physician says of his
r Phils Burl Applfan
She it a very nervous, active child end
net stand on bar feet alone and had Is be
and play a like the rest of the children, and
llnly a great boon to suffering humanity."
DOCTOR ~jf^VHi-:&': 30 Day Trial
Appliance is made to sp.
ilter! under our absolute g
n or money refunded. It
:d for the bath, massage, rrfi
:ion. The price of the Fhilo B
the special course of exercise
improved cqndilioni is the spine straightens and co-operate with the' local physician, surgeon, or
the body assumes its normal condition and form. specialist in Orthopedic practice.
THE PH1LO BURT CO., 115-19 Odd Fellow- Temple, Jamestown, N. Y.
You can buy with confidence— See "Service Guarantee to Readers"
The American Phjmieiui]
An Honest Market Place
Tested Organotherapeutic Formulas in a
New and Better Package
THE HARROWER LABORATORY
Horn* OfttM Box 68, Gland*!., Calif omU
NEW YORK. 31 Park PUea " " " - - ■
CHICAGO, IM N. La Sail* 9*.
DENVER, 031 CMtral Savbtg* Buk Bla|
°'uri8landU-
SANITAB-
Mine for.
worm pfi-
batilutiun.
SANITAB-
countnt-
ak Blaf.
PORTLAND. ORE, MIT PHtvck Black
*
T HE older member* of
1 the Medical Profession
Pluto Water
excellent for the counter-
action of those drugs
which suppress secretions
and in prescribing this
valuable water in small
doses the action is to flush
the intestinal canal and
stimulate the liver to re-
move from the ducts the
accumulated secretions.
Many practitioners direct
convalescent patients to
the spring for rest and
complete treatment
French Lick Springs Hotel Co,
French Lick, lad.
Operative
Surgery
Special course in general
surgery, operative
technique and gynecologic
surgery given to physicians
of both sexes. Enrollment
limited to THREE.
First astisanbhip— No cadaver or dog -work
For particulars addreaa.
DR. MAX THOREK
AMERICAN HOSPITAL
Irvine Park BooUrard, CHICAGO
Long Diitaoc* Phoim
I-ika VUw 01 82-01 S3-01M-01M
Mentioning The American Physician Insures Prompt, Careful Service
532
Helpful Points
[Phila., July, 1922
up into aqueous solutions for injection.
Mercurosal is said to possess the unique distinction
I being absolutely bland in contact with the delicate
a* • • •• it**
"I Tried All
The Leading
MA fine strong girl born *
month ago, steadily lost ground,
in fact was rapidly falling away.
The Mother's Milk did not at all
agree or satisfy. I tried all the
leading foods and milk in var-
ious modified forms. But nothing
satisfied until I sent for a bottle
of Nestles Milk Food, when, with
the first feeding, the little one
improved almost as if by magic.
The child is now living wholly
on Nestles Milk Food, and b
doing well."
(Physician's name and address
withheld for professional
reasons)
In emergency cases or for
routine use you may safely rely
upon Nettle's Milk Food as a
dependable nourishing food for
babies.
Nestle's is simply pure cow's
milk modified by the addition
of malt, cereals and sugar and
then reduced to powder form.
It is milk, free from pathogenic
bacteria, in a form which is
easily prepared and readily
digested.
Tour name and address nmll
bring liberal samples.
Nestle's Food Company
Nettle Building
New York
112 Market Street
San Francisco
jviercurosai is saia to possess ine unique aisiincuon
of being absolutely bland in contact with the delicate
tissues of the venous walls ; and intramuscularly it is
said to cause very little pain.
Write to Parke, Davis & Co. for literature on Mer-
curosal.
Authoritative Evidence on Yeast
An investigation of the effect of fresh yeast on uric
acid excretion in normal persons has been recently
conducted and reported upon. ( See Jour. Laboratory and
Clinical Med., May, 1922). Although three of the sub-
jects ate twice the therapeutic dose of yeast, two ate
three times the dose, and one ate five times the dose,
the summary states that "there is no evidence of an
increase in uric acid excretion following the ingestion of
the recommended therapeutic dose of live yeast" It
seems therefore that the ingestion of yeast does not
increase uric acid excretion, and that, therefore, the
advantages of yeast therapy are safely open to the
nephritic and to those suffering from gout.
A new authoritative book on the manufacture, chem-
istry, physiology and therapy of yeast, in which you will
be interested will be sent to you free, address: The
Fleischmann Company, Dept S-7, Washington Street,
New York City.
Stabilizes "Shaken" Nerves
Nervous debility, nervous exhaustion and all as-
thenic affections of the nervous system, so prevalent
today, will respond to treatment which will replenish
the reduced mineral reserves of the system and supply
the necessary phosphorus to restore degenerated nerve
cells. This can be accomplished in. most cases by
Fellows' Syrup of the Hypophosphites.
Samples and literature will be sent on request to
American Physician readers. Address Fellows Medi-
cal Manufacturing Co., Inc., 26 Christopher Street,
New York.
Congestive Dysmenorrhea
Dr. F. H. Davenport, AB., M.D., Assistant in Gyne-
cology, Harvard Medical School, in his book on "Disease
of Women" and under the above caption refers to the
treatment of congestive dysmenorrhea and the use of
anodynes He says, "It is by all means wisdom to avoid
in these cases, if possible, all the use of stringer seda-
tives and anodynes."
In referring to the use of medication in these cases,
Dr. Davenport, in his most excellent work on "Non-
Surgical Gyecology," says: "Hayden-'s Viburnum Com-
pund has seemed to be the most effectual remedy of this
class, given in hourly teaspoon ful doses in hot water,
for five or six times."
That Hayden's Viburnum Compound is of inestimable
value in the treatment of dysmenorrhea is not only indi-
cated by its employment by gynecologists of today, but
in the past by no less an authority than J. Marion Sims,
who prescribed it and recommended its employment.
Hayden's Viburnum Compound is not a narcotic and
contains no habit- forming drugs. It is a product of
known composition and as a uterine sedative it holds
first place in the opinion of many physicians as not only
a dependable therapeutic product, but a remedy wihch is
safe to administer to their patients. Given in teaspoon-
ful doses, administered in hot water, it will prove most
effective. Samples on request New York Pharmaceu-
tical Co., Bedford Springs, Mass.
(Helpful Points continued one leaf over.)
You can buy with confidence— See "Service Guarantee to Readers" on page 542
The American Physician]
An Honest Market Place
533
A. Normal Ileocecal Vahre.
RtpwdwceJ/rom "Colon Hypcnt,uhJ> H. KcUogg, M. D.
B. Partially Incompetent
Ileocecal Valve.
C Wholly Incompetent
Ileocecal Valve*
The incompetent ileocecal valve
and Petrolatum Liquidum
A noted authority, whose observations have covered hundreds of
cases, states that aside from routine measures, the regular use of
liquid petrolatum is the most effective means of combating in*
competency of the ileocecal valve. Medicinal laxatives increase
the antiperistalsis by which the reflux from the colon into the small
intestine is increased* Liquid Petrolatum increases die motility of
die small intestine, but does not increase antiperistalsis*
To find a viscosity which would give Nujol its greatest
efficacy, its makers conducted exhaustive research and clin-
ical test. Consistencies were tried, ranging from a thin
fluid to a jelly. The viscosity finally adopted is the one
best suited to human requirements and is in accord with
the opinion of the highest medical authorities.
That the value of Nujol to the medical profession is
generally recognized is attested by its use by physicians
and in hospitals the world over. Sample and authoritative
literature dealing with the general and specific uses of
Nujol will be sent gratis.
Nuiol
nee. u». MTvOFF.
A Lubricant * not a Laxative
Guaranteed by Nujol
[, Standard Oil Co. (New J
Beaver Street, New York City
ersey)
Mentioning The American Physician Insures Prompt, Careful Service
534
Helpful Points
[Phaa., July. 1922
Agar Agar Effective in Constipation
Some cases of constipation are extremely difficult to
bring back to normal — all cases of constipation demand
attention. Mansfield Agar Agar Wafers— a drugless
laxative food— offer a reasonable and effective method
of treating most cases of constipation.
The hygroscopic properties of agar and the vitalizing
qualities of the entire wheat grain combined, have re-
sulted in a product of proven value in the treatment of
constipation due to intestinal atony. Test this out —
write for a package of the wafers — it will be sent free
to American Physician readers. Address : The Mans-
field Laboratories, Inc., 18 Chandler Street, Boston,
Mass.
Brings Prompt Relief
The summer season brings with it a number of
physical annoyances, not to say ailments, which react
most unfavorably upon the mental condition, and which
frequently send the sufferer to the physician in search
of relief.
A nasal mucous membrane that is at all sensitive
responds quickly to the irritation produced by dust, the
pollen of plants, and even those variations in tempera-
ture and atmospheric pressures that characterize the
heated term.
An agent, par excellence, which brings about prompt
relief and maintains constant comfort in such cases, is
Alkalol, what is true of the nose is also true of the
throat, in which Alkalol is equally effective. Irritations
and inflammations of the conjunctiva or inflamation of
the external auditory canal promptly yields to Alkalol.
A post card will bring samples and interesting litera-
ture to American Physician readers. Address: The
Alkalol Company, Taunton, Mass.
Assures Immediate Relief
To allay the itching, smarting and burning of the
heat rashes, there is no lotion more effective than Pond's
Extract, full strength or diluted with water equal parts.
It is cooling, soothing, and anti-pruritic, and the use
of Pond's Extract assures immediate relief in the treat-
ment of hives, sunburn, chafing, ivy-poisoning and simi-
lar conditions.
Tannalbin— Tablets
With the greatest prevalence of diarrhea and intestinal
catarrh in the warm season, it is timely to draw atten-
tion to the popular tannalbin tablets. They each contain
5 grains of Tannalbin and are especially suited for chil-
dren. Older children may chew them, while infants
may take them crushed in oatmeal gruel. If only half
the dose is desired they may be cut in two. Physicians
will be pleased to find that these tablets are a convenient
and rapidly acting remedy for intestinal catarrh espe-
cially in infants during the summer months. The drug
may also be obtained in powder form. Literature and
samples from E. Bilhuber, Inc., 25 West Broadway,
New York.
Reliable Effective Synthetics
Physicians are finding these two synthetics clinically
effective: Creasep and Iodomer, manufactured by Dr.
S. Lewis Summers, producer of synthetic chemical com-
pounds, Fort Washington, Pa.
Creasep — benzylidene-dibenzyl-diethyl methylene-diio-
do-diguaicol->— contains 25% of iodine in an unirritating
and assimilable form. It is a valuable alterative and
antiseptic, especially useful in influenza, pneumonia and
chronic bronchitis. The price is $1.00 per ounce.
(Continued one leaf over.)
CHLORYLEN
A New Treatment for Trigeminal Neuralgia
Chlorylen is used with marked success in the treatment of tri- facial neuralgia.
It has a specific action on the sensitive Trigeminus, gives immediate relief and the
pain disappears after a few treatments.
Chlorylen is applied by inhalation. 20 to 30 drops are placed on cotton or
the handkerchief and inhaled through the nostrils, until the odor disappears. It
is a volatile liquid with a pleasing odor and is obtainable in bottles of 25 grams each.
NEUTRALON
A substitute for the Bismuth salts,
Sodium Bicarbonate, Silver Nitrate,
etc., in the treatment of Hyperchlor-
hydria, Hypersecretion, Ulcus Ven-
triculi, etc. A white, tasteless, odorless
powder; supplied in packages of 100
grams each. The dose is one teaspoon-
f ul in a glass of water before food.
VALAMIN
A sedative and soporific for use in
the treatment of Neurasthenia, In-
somnia, Hysteria, Palpitation of the
Heart, etc. It is a Valerian and Amy-
lene combination, is easily absorbed
and acts promptly. Valamin is mar-
keted in packages containing 25 cap-
sules of 4 grains each. The dose is
one or two capsules after meals. In
nervous insomnia, two to four capsules
should be taken before retiring.
For further information and literature address:
KIRBACH, Inc., General Agents, 227-229 Fulton St.,
NEW YORK
You can buy with confidence — See "Service Guarantee to Readers'' on page 542
The Amr ricin Fhjiicuu]
The American Physician
Stomachic
Rebellion
is not in the clinical picture when you use
BENZYLETS.
That is an outstanding consistently constant
clinical fact when these gelatin globules each
carrying five minims of medicinally pure benzyl
benzoate are used. At your druggist's in 24 s.
BENZYLETS-
Sharp & Dohme
Mentioning The American Physician Insures Prompt, Careful Service
536
Helpful Points
[Pha»., joir, i«2
Iodomer is a synthetic which contains 25% mercury
and 29% iodine in organic combination. It reacts chemi-
cally on the spirochetes of syphilis and is used also in
place of the many inorganic compounds of iodine and
mercury. The price is $1.00 per ounce. Write to Dr.
Summers for supplies or further information.
Correction of Constipation and Autotoxemia
Besides lubricating the canal, Interol renders the feces
soft and plastic, thereby promoting their easy passage
and evacuation with gratifying freedom from discomfort
and distress. Interol is a pure mineral oil of the proper
density and viscosity to assure satisfactory lubrication of
the intestinal canal, and thus relieve and correct bowel
inactivity without the usual disagreeable effects of ca-
thartics as commonly employed. This pure, tasteless
and odorless mineral oil is notably free from the greasi-
ness common to such products. Interol will be found
effective in the correction of constipation with its attend-
ing autotoxemia conditions.
For sample and interesting brochure, address : Allied
Drug and Chemical Corporation, 2413 Third Avenue,
New York City.
Purity and Food Values of Green Olives
Recent newspaper stories have raised a question as to
the wholesomeness of olives. But it must be borne in
mind, when reading such reports, that green olives are
not to be confused with ripe olives; that Spanish green
olives differ radically from ripe olives in harvesting,
curing, packing, color and taste. No suggestion of
un wholesomeness has ever been connected with Spanish
green olives in newspaper reports or elsewhere. In fact,
they are pronounced a food of considerable importance
by the Department of Agriculture, and are known to
have a very high caloric value and contain in their oil
one of the three perfect fats.
Hot Weather Therapeutics
The house physician at a big summer resort hotel last
year bought gallon after gallon of Alkarhein, saying that
he found it of great value in the numerous cases of
gastric trouble among the guests.
Every physician has a great many patients who sdffer
from gastric disturbances in the summer time which will
be relieved promptly and permanently by Alkarhein, an
alkaline elixir of rhubarb and hydrastis. This prepara-
tion has grown steadily in popularity with practicing
physicians ever since its introduction many years ago, for
no other combination meets so effectively such a wide
variety of those complaints which are incident to the
summer season. If your druggist does not have Alkar-
hein tn stock — and most of the druggists do have it— he
can get it for you from the nearest legitimate jobber
The Wm. S. Merrell Company, Cincinnati, Ohio, who
make Alkarhein will be glad to send a free sample and
theraupeutic notes on its constitution and uses to Ameri-
can Physician readers, on request to them direct
The Original Russian Mineral Oil
Usoline was the first mineral oil put on the market
in this country. And while exaggerated claims bave
never been made for it — the many physicians who ha«
been employing this product have found it effective and
dependable in every way.
Usoline is a highly refined 100% imported Russian
mineral oil, with properly adjusted gravity and viscosity.
It contains no sulphur or acid impurities, no bloom or
fluorescence and no taste.
For clinical test, a 6-ounce bottle of Usoline will be
sent to American Physician readers free; write for it
Address : Oil Products Co., Inc., 50 Union Square, New
York, N. Y.
(Continued one leaf over.)
To ALLEVIATE PAIN, to PROMOTE DIURESIS
and to PROTECT die membrane of the urethra, efpecaally
THE POSTERIOR PORTION— these arc die important
objects of the treatment of acute cases of Gonorrhea.
The entire urinary tract should be influenced by means
of proper internal medication. Local injection* alone wfll
not be sufficient
This is the rationale of GONOSAN.
RIEDEL & CO., Inc.
104.1U South Fourth St. Brooklyn, N. T.
LISTERS DIABETIC FLOUR
^ Strictly Starch-free. Produces Bread.
■S «^_ Muffins. Pastry that makesthe
t\DtTES&
Listers prepared cast
LISTER BROS.
in Diabetic Flout — self rising. A month's supply of 30 boxes $4.85
Inc.* 405 Lexington Avenue* New York City
You can buy with confidence — See "Service Guarantee to Readers" on page 542
The American Physician
History of Dental Anaesthetics — No. 2
1846— "Letheon"
IN September. 1846. Dr. W. T. C
1 Morton, a former pupil of Dr. Horace
G. Weill in Dentiitry, went to a chemist
in Boston. Charles T. Jackson, to learn
how to make Nitroui Oxide Cai.
On the advice of Jackson, he purchased
imi Sulphuric Ether and on September
30th. IS46. tried it on a boy named Ebon
Frost. Following up the luccesa of thii
operation Morton and Jackson experi-
mented further with Ether, resulting in
their patenting the discovery of anaes-
thetic effects of Ether, the patents being
issued to Dr. Morton, who than called
his product "Letheon."
Anaesthesia is the name suggested by
Oliver Wendell Holmes to Dr. Morton, to
describe the condition produced by the
inhalation of Sulphuric Ether,
lis a far cry, indeed, from the anaes-
thesia as produced by this anaesthetic to
that as now induced, by the Conduction
method with
Antiseptic Local
The quality and d
.actor*"™ UsKry
IN BOTTLES
1 as. 2 as.
IN AMPULES
Cheek and Mail Thli Coupon No»t
THE ANTIDOLOR MFC CO.
33 Mala St., Sprinaville, N. Y.
Specialties for
Tonsillitis
Benzomint
Compound of Sodium
Beneoate with Alka-
loids of Calisaya
A TIME-TESTED, bight/
therapeutic formula which
has proved a rentable
wonder worker m many thou-
sand* of cases of Tonsillitis.
Benzomint hu pronounced anti-
septic gad antipyretic properties.
It soothes instantly the intense
pain from swollen, inflamed
glands, and quickly counteracts
both local and s;
Glycodin
(GARGLE)
AN efficacious
and antiseptic gargle of
great value in the treat-
ment of Tonsillitis.
THROAT SPECIALTIES
LABORATORIES
(MILBURN PHARMACAL CO.. INC)
BALDWIN. L. I. NEW YORK
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
[Phui.july. 1922
A Stand-By in
Uterine Troubles
VIBURNO
(BEACH)
The beat evidence of this is the
repeat orders received from physi-
cian* and druggists.
Nervine-Tonic and AnrJcongest-
ivc, with calmative and corrective
action on the bladder. Employed
with much satisfaction in ovarian
congestion and congestive dysmenor-
rhea: weak pregnancy and deficient
lactation; menopause and its phe-
nomena, including hallucinations, hot
flushes, etc.; nervous and menstrual
derangements after "flu," and the
troubles of adolescent girls. Sterility
often responds after 2 or 3 bottles if
no lesion exists.
UaUks «™iUr product., VIBURNO
la palatable and pUuut to taka.
" ■ ■ *i tXA
UtmJpl*
: hup. (-»
Pat up in 11 o
Samplt and" Female on Rnjattt
THE VIBURNO COMPANY
116 MaUaa Laaa, Ntw York
Sal Hepatica
THE
STANDARD SALINE
LAXATIVE
Bristol-Myers Co.
NEW YORK
Has Proven Its Value
As a cough sedative and antispasmodic, Diatussin has
proven its value in the hands of many clinicians.
When other measures fail you can reiy on Diatussin.
Try it and you will benefit through diminished individual
attention in all cases of persistent cough ; particularly
whooping cough during paroxysmal stage, when Dia-
tussin administered regularly will reduce expiratory
blasts and quickly terminate the disease.
Samples and literature will be sent gladly on request.
Address : Ernst Bischoff Co., Inc., 85 West Broadway,
New York.
Pollen Testa and Treatment for Hay Fever
Patients whose hay fever develops in mid-August and
continues until frost should be tested with pollens of
local importance — primacy being given to the long dis-
tance wind pollinated plants, e. g., ragweed. However.
where contact is unavoidable, as on a farm, the short
distance wind pollinated plants, e. g., corn — and the insect
pollinated plants, e. g., sunflower, which are also atmos-
pheric—cannot safely be ignored.
Arlco- Pollen Extracts for cutaneous tests and treatment
will be found reliable and effective. Literature and list
of pollens will be sent to American Physician readers
on request Address : The Arlington Chemical Co.,
Yonkers, N. Y.
(Our Advertising Standards. <
leaf •
it)
Woodlawn
Maternity Home
K itrictlj prince and etbioil Hone Rctrm
:or unmarried firla and women divinf f/rrt
lancy and confinement^ with beat medical
arc, nnrajoc and protection. A home f onnd
For the infant br adoption If daarred. All
publicity avoided. Prieea reasonable. Fui
Brticulara, prieea and terma, addreaa
OODLAWN, OWEGO, Ttof* Co, N. Y.
MORPHINE
NEW HOME TREATMENT
DR. QUAYLFS SANITARIUM
MADISON, OHIO
China; and cooling propertiea of
a it Invaluable for quick!/ allirine;
- -' --■■■--' J- u of aunburn.
I**. *& *h Probably no" remedy that can be employed will afford
■at Jl_ w? .•__ _ _■ ■«!> prompt and aatiafactory relief from thit con-
rnnn « rYrrsa*! <>ition. Th^ ,tindard «<»« 'of ham^di. » equ«jij
1 UilU OlJAUaClj effective for Prickly HM.Hivt,, Jvy Pou2m*f,
r of Inteeti, etc., and nmmer akin affee
reneral.
POND'S EXTRACT CO., Haw Yew 4CT bWM
=3
You can boy with confidence— See "Service Guarantee to Readers" on page 542
The Anericn pb,«cu>.] The American Physician
HAYFEVER
Rhinol for Hayfever and all affections
of the Nose and Throat.
HAYFEVER
Rhinol a reliable remedy.
Dr. A. Z. Hall, of Eaton, Colorado, says in a quite recent
letter:
"I believe that you have in Rhinol the moat
superior remedy on the market for Hayfever.
Please tend me 6 complete outfits C. O. D."
Use Rhinol one week before your attack and you will be
free from all trouble.
RHINOL CO., Inc., 1416 Broadway, New York City
Mentioning The American Physician Insures Prompt, Careful Service
540
Helpful Points
[Phila..July. I9>2
Amenorrhoea
Dysmenorrhoea
and other disturbances of the
menstrual function call for the
tme active principle of Parsley:
APIOLINE
(Chapoteaut)
it Secures Results
by acting directly upon the uterine
nerve endings and producing ovarian
hyperemia, but without disturbing
gastric or renal functions.
Avoid impure or unreliable substitute*.
Prescribe original vials of 24 capsules.
Laboratory of
Dr. Ph. Chapelle, New York-Paris
Physician*' sample and literature on request to
£. Fougera & Co., Inc., American Agents
SO Baakman Street, New York
Canada: Lyman* Limited, Montreal
*" aillj Diacetyl Metbyfene-diaaligrlic Add.
DY FOR RHEUMATISM.
UNQUESTIONABLE REME
Price, 75 cents per Box.
AN
BEFSAL
C»HmOu
DibenxyldM
yruvic (Cincl
ENT AGENT FOR THE DESTRUCTION OP THE Rl
POISON AND A SOLVENT OF URATIC DEPOSITS.
Price, $1.90 per Bos.
(TR E A. SEP Di*cct * BenwUdenedibensyldietbyl
^-*M' ^«s-^^ *W1-'1 MethylenediiodoaiRuaiacol. Contains
«% of Iodine. VALUABLE ALTERATIVE AND ANTISEPTIC.
^SPECIALLY USEFUL IN INFLUENZA, PNEUMONIA, BRON-
CHITIS AND PULMONARY TUBERCULOSIS.
Price, $1.60 per Box.
TOOOlVfER Mercury-DifododiaryL Holds
organic combination susceptible of circulating in fluids of body to react
on the spirochetes of syphilis. AN ALTERATIVE OF MARKED
VALUE. Price, $1.90 per Box.
PYR-AZO-PHEN 3mW
Benxol Methylene Disalicyik Didnchoninic Add. FOR NEURITIS
OF GOUTY ORIGIN AND FOR RHEUMATISM AND GOUT.
Price, $1.90 per Box.
ARS AMINE
AsCwHtfOOt
DIARYL-DIARSONATE.
CHEMICALLY ANALO-
GOUS TO SALVARSAN, BUT CAPABLE OP ADMINISTRA-
TION VIA THE STOMACH. Price, $1.90 per Box of 30
Capsules of 2)4 Grains Each.
DR. S. LEWIS SUMMERS
PrcftMr «f
Synthetic Organic Chemical Conpoudt
Fort Washington, Pi
These Advertising Pages are an
Honest Market -Place
Place When YmCmDedWkk
W< keUeee the r&Jti* or
■Mraf to pW msScol pwhsmem. W* sesk U mrtmsU
Our Advertising Standards
Advertisements must give honest service to our
readers and their patients is the basic principle for these
standards and for the conduct of The America*
Physician's advertising pages.
Our attitude in applying these standards is not one
of narrow technicality but of practical service.
Advertisements of the following classes are not
acceptable for the pages of The American Physician:
Fraudulent pharmaceuticals; those making dishonest
claims.
Pharmaceuticals charging excessive price; price not
warranted by content and by trade conditions.
Pharmaceuticals and other mixtures for internal use
and containing narcotics or other habit-inducing drugs
in quantities sufficient to promote their improper repeti-
tion on prescription (chloral-bearing proprietaries, etc.).
Potent pharmaceuticals which justly merit profes-
sional disapproval because of their lay advertising or
manifestly unethical exploitation.
Financial advertisements that claim returns not com-
patible with conservative investment Only conserva-
tive investments are advertised.
Further
Advertising copy is subject to revision by the editorial
staff. ,
The American Physician agrees heartily with tne
principles of the Council on Pharmacy and Chemistry
of the American Medical Association and we exclude
from our advertising pages such pharmaceutical prod-
ucts as they have definitely shown to be unworthy of
professional confidence and the manufacturers of which
have not removed the cause of objection; but we do
not accept such findings as are based on academic data
without due recognition of general clinical experience. m
Concerning formulae, The American Physioa* is
urging pharmaceutical manufacturers to give full thera-
peutic data regarding formulae, stating quantitatively
active medicinal content, in order that physicians may
intelligently prescribe. We do not accept advertising ot
secret pharmaceuticals.
But We do not Decline
Advertising of original drugs, compounds or P^^SE^
tated in current editions of the U. S. Pharmacopoeia or Nf**T
Formulary (except habit-inducing preparations) ; new Pf*J2"
that seem to be West and ▼«lu*hfe. W which have: «* **"
reported upon by the Council on Pharmacy and Chemistry, or
similar products whose manufacturers have not yet submittedjf
same to them for approval or rejection. We use our own )«r
ment in these cases, but will always consider proper c*nr»
against this class of remedies.
Preparations containing a limited number of drags m
{Continued one leaf over)
You can buy with Confidence— See "Service Guarantee to Readers" on page 542
An Honest Market Place
In Abscess, Felon, Carbuncle,
Arthritic Swellings, Orchitis and
Epididymitis, B u r n a , Sprains,
Bruises — in short, in all localized
inflammatory conditions,
PNEUMO-PHTHYSINE is effect-
ive in that it lessens pain.
Reduces inflammation and swelling.
Counteracts the infection, and promotes healing.
Apply a thick layer to the affected part. Cover with (our layer* of
^m game and then with a bandage. The application may he repeated
loon aa dryne** of the paate indicate* that it* active constituent*
ve been absorbed.
Pneumo-Phthysine Chemical Co.
Chicago, HI
Mentioning The Am
i Insures Prompt, Careful Service
Helpful Points
USOLINE w.» the fi,
■a the market Id thia
nag go rated claim a have
Id thia country." It Eat
idverttaed. and
We again preterit to you USOLINE a
a highly refined 100% Imported Ruaaln
Mineral Oil, with properly Hctluab
Ity and V
h properly adju.ted ■ rav-
T; containing no • uTphtir
ha conaeneue of opinion of eight load-
clinician! favored Imported Ru.etaa
(.ee A. M. A. Journal, Vol. 64. p.
OIL PRODUCTS CO., In*.
■0 Unloa Smart, New York, N. T.
Our Advertuing Standard*
{Cejiliiiiicrf aver from preceding page]
qoilifii d phyiician who ii iceiriilg in the proprietary form clonal
pharmacy in place of an extempore prescription.
dosage, provided these drn|a have a real place in medical ma-
l phyi
itieepticB, soaps and toilet articles honetuy adverti
■sicians and iavra.-n without false or frauduirat Ft
illy advertised mineral . "
Service Guarantee to Readers
IF YOU HAVE ANY UNSATISFACTORY
DEALING WITH AN ADVERTISER IN THE
AMERICAN PHYSICIAN, WRITE VS THE
PARTICULARS AT ONCE.
WE WILL IMMEDIATELY TAKE THE HAT-
TER UP WITH THE ADVERTISER AND SEE
THAT THE ADVERTISER EITHER MAKES
COOP, OR HIS ADVERTISEMENT IS ELIMI-
NATED FROM THE AMERICAN PHYSICIAN'S
PACES.
THE STORM BINDER
THE STORM BINDER is adapiable to any
case where an abdominal supporter is needed for
Tllf^ SJORMrBINDER IS FOR GENERAL
'deT'is FOR SPECIAL
KATHERINE L. STORM, M.D.
1701 Diamond Street Philadelphia
Write for Booklet
Marvel Whirling Spray
MARVEL COMPANY
25 W. 45th Street New York
You can buy with confidence— See "Service Guarantee to Readers" top of this page.
Ths Aniricu I'hyudul
An Honest Market Place
Mentioning The American Physician Insures Prompt, Careful Service
! The American Physktan I
ENDOSAL
ENDO-SODIUM IODIDE
ENDOMETHYLENAMtN
ENDOFERARSAN
ENDOOLQBIN
Matetag,'Bti/t
ENDOCAODIN ■
(Tubarculqs:*)
pecialties
for Direct Medication
Intravenous
Method
Intravenous medication has
long since passed the expen-
menial stage. The favorable
attestations of thousand* of
reliable physicians arc unani-
mous in their endorsements of
this method of remedial treat-
ment '
At the hands of our chem-
ists, specialists in research, our
products are prepared with the
utmost care, skill and acumen.
Their purity challenges com-
parison.
Formulae of our specialties,
reprints of interesting articles
and price lists cheerfully fur-
nished to physicians on re-
. .ENDOARSAN
ENPQMEK5AN
■Tilio fai/o~"tf trrptrtl/m it
guioleum
H%£S,%m;~ ,.0;/
(/or loci/ iAe a*4>) .
GLVCO- ASEPTIC
Intravenous Products Co. of America, mc. ,
121 Madison Avenufi^Ne-W^rkGity
Parity
Safety
Efficjengpii
Bird's tye View of Applied therapeutic!
(wf.567)
That Vexed Question of Diagnosis
(tart 5M)
Conduct of Third Stage of Labor
DANGER OF ACCIDENT GREATEST BETWEEN BIRTH OF CHILD AND PLACENTA
(page 565)
Rheumatism
A Mtnant of Hup*
AR THRTTK CONDITIONS AND AN EFFECTIVE REMEDY
(W575)
Full Contents on Page 550
A Constructive Market for Buyer and Seller
Rheumatism
Gout
Neuralgia
Neuritis
Sciatica
Lumbago
Migraine
What shall it profit \
the patients?
to have their sufferings relieved if it's done
by throwing into their moat vital body
machinery a monkey wrench-like colchicum,
the salicylates, heart-depressants, kidney-
irritants, intestine-disturbants.
Genuine ATOPHAN. devoid of all
these drawback*, ia manufactured at
our Bloomfi«ld, N. J., plant by a
ipecial proceu, precluding the po.ai-
bility of even tracea of unpleaaant
empyre lunatic admixture!.
Complimentary Trial Package and Information front
Schering & Glatz, Inc.
ISO Maiden Lone NEW YORK
AN IDEAL ARSENICAL
SODIUM DIARSENOL
SODIUM ARSPHENAMINE
Sodium Diarsenol marks a distinct advance in syphilology. It dissolves
very quickly in water, giving a solution ready for immediate injection. No
addition of sodium hydroxide is necessary. It has the therapeutic advantage
of arsphenamine with the solubility and convenience of neoarsphenamine,
and gives clinical results equal to or better than either of the two latter com-
pounds. Neutralization with alkali being obviated, there is no undue hand-
ling and consequent decomposition of the highly reactive solution.
SODIUM DIARSENOL has been accepted by the Council on Pharmacy and
Chemistry of the American Medical Association for inclusion in "New and Non-
official Remedies."
Manufactured by Diiiwiiol Laboratories Inc.,
DIARSENOL COMPANY, Inc.
BUFFALO BOSTON ATLANTA
You can buy with confidence — See "Service Guarantee to Readers" on page 614
1922]
The American Phpickm Advertising Service
547
WILLIAM SCHEPPEGRELL, A. M., M. D.
Says: —
President American Hayfever Prevention Association.
Chief of Hayfever Clinic, Charity Hospital, New Orleans,
"IF the patient applies for treatment during
* an attack of hayfever, the pollen extracts
are usually ineffective, and a vaccine should
be used, these being injected at intervals of
one or two days until the severity of the attack
subsides/"
The Vaccine used by Dr. Scheppegrell is practically iden-
tical with Sherman's No. 36 which is being extensively
used in the prophylaxis and treatment of Hayfever.
• From Dr. William Scheppegrell's new book on HayfeTer and Asthma
Lea 6 Febiger, Publishers
Bacteriological Laboratories of
G. H. SHERMAN, M.D.
DETROIT, MICH.
The combination of tonics and stimulants ex-
plains the clinical results obtained in the
treatment of nervous disorders by the use of
FELLOWS' COMPOUND SYRUP
OF HYPOPHOSPHITES
44 A true stabilizer of shaken nerves?9
K contains the "mineral foods", Sodium* Potassium. Calcium, Manganese
Iron and Phosphorous, and the stimulating agents, Quinine and Strychnine.
Samples and Literature sent upon request.
FELLOWS MEDICAL MANUFACTURING CO., he.
26 Chrfctopher Street, New York, N. Y.
Vol. 37, No. 8, Published monthly — The Taylors; C. C. Taylor, Publisher; Mrs. J. J. Taylor, Ed. Mgr. Entered as
second-class master Feb. i}, 1896, at the post office at Philadelphia, Pa., under Act of March 3, 1879. The American
Physician, "Most Widely Circulated Medical Monthly," continuing the quarter century of distinctive service of
COPYRIGHT 1922, by The Taylors, Publishers, 420 Walnut St., Philadelphia, U. S. A. All rights reserved.
548
A Constructive Market for Buyer and Seller
[Philadelphia
INDIGESTION
r I 'HE alleviation of the symptoms of
A indigestion is best accomplished by
facilitating the reduction of the undi-
gested mass of food to the soluble and
more easily movable end products of
proteid and carbohydrate digestion.
Pepsin and Pancreatin will take care
of the proteins, and for the rapid lique-
faction and progressive digestion of the
starches Taka-Diastase is to be preferred.
But the value of Taka-Diastase even
in proteid indigestion must not be over-
looked. This diastatic ferment is bene-
ficial indirectly in cases of protein
indigestion by disposing of the starchy
elements of the food, thus rendering pro-
teins accessible to the action of hydro-
chloric acid and the proteolytic enzymes.
The usual dose is 2 to 5 grains, taken
with meals. It may be advantageously
combined with other remedies as in the
following formula:
. B Ext. Nucia Vomicae, gr. iv.
Pancreatine
Taka-Diastase, am 3 i.
M. et fiat in capsulas No. xx.
Sig: One capsule with meals.
Or, if you prefer a liquid mixture:
B Tr. Nucia Vomicae, 3 Hi.
Liq. Pancreatine 1 iaa.
Liq. Taka-Diastase, q. a. 5 iv.
M. et sig: 3 U with meals.
Patients who have intestinal indi-
gestion with accompanying fermentation
and hyperacidity can be given grati-
fying relief by the employment of Taka-
Diastase, either alone or in a combination
such as this:
9 Resorcini, 3i.
Milk of Magnesia, P. D. & Ccv,
Liq. Taka-Diaataae, aa 3hr.
M.etaig: 3 ii t.i.d. one hour p. c.
And if there is an associated atonic
condition, rapid improvement follows
if capsicum and cascara sagrada are
combined with the Taka-Diastase. For
example.
B Pulv. Capsid, gr. x.
Ext. Cascarae Sag., gr. xx.
Taka-Diaataae, 3ii.
M. et fiat in capsulas No. xx.
Sig : One capsule t.i.d. one hour p. c
The relief which follows the adminis-
tration of Taka-Diastase is quickly appar-
ent, and indeed is quite a reasonable
expectation when it is considered that
Taka-Diastase liquefies 300 times its
own weight of cooked starch in 10
minutes.
Taka-Diastase is the kind of remedy
you are called upon frequently to pre-
scribe; moreover, it is the kind of rem-
edy you can depend on to carry out
its therapeutic mission: the alleviation
of the symptoms of indigestion.
Parke, Davis & Company
New Literature Qladly Sent Physicians on Request :
Qland Therapy — Pertussis Vaccines — Taka-Diastase — The 1922 Catalogue
You can buy with confidence — See "Service Guarantee to Readers" on page 614
August, 1922]
The American Physician Advertising Service
549
and Antispasmodic
of Proven Value
When every other remedy fails,
try D1ATUSSIN and benefit
through diminished individual
attention in all cases of per-
sistent cough ; particularly
whooping cough during pa-
roxysmal stage, when D1A-
TUSS1N administered regu-
larly will reduce expiratory
blasts and quickly terminate
the disease.
Literature and Samples
on request
Ernst Bischoff Co., Inc., 85 West Broadway, New York
Mentioning The American Physician Insures Prompt, Careful Service
550
Contents
Copyright, 19**, by Th§ TeyUrg. AU righto reurvtd.
Editorials
A Bird's Eye Vitw of Applltd Thtrapeutics.
By A. C. Morgan, M.D 661
"Empiricism accomplished much at the hands of oar
forbears, who were keen in observing the physiologic
effects of medicine upon individual patients. Later
instruments of precision have confirmed the findings of
those investigators and definite results can now be looked
for in the light of scientific accuracy."
Avoiding the Thtrapoutic Danger Lint 662
What Is Acute Indigestion and What 8hall Wt Do for
It? 663
Original Articles
The Conduct of the Third 8tage of Labor.
By Samuel F. Gordon, M.D 666
"The dangers due to accidents occurring during the
interval between the birth of the child and the birth of
the after- birth exceed those to which the parturient
woman is subjected, because of accidents during the
rest of labor." This statement deftly summarises the
Importance of the subject and should be a warning to
those who wade the dangerous streams of obstetrical
medicine.
Medical Diathermy in Joint and Bone Lesions.
By Blnora Cuddeback Folkmar, M.D., M.Pb., D.S.S..667
The importance of using heat as a therapeutic agent has
been recognised for centuries. Various methods, local
and general, of increasing bodily heat have been devised,
from counter irritants, hot poultices, hot-water bottles,
hot baths of the home; to fomentations, hot packs, hot-
(€ofita#ifs
air bake ovens, tango mud and hot-spring baths of
sanitoria and health resorts. None of these conTectire
methods induce beat deep within the tissues. They ire
successful only in so far as they produce by reflex
action an indirect slight dilation of blood vessels and
an increased metabolism.
Some Interesting 8urgical Cases.
By Irvin Hardy, M.D.* 571
Dr. Hardy presents a series of highly interesting cases,
which incidentally illustrate some of the "shocking"
circumstances ULder which some of our surgeons are
called upon to operate. It also demonstrates the daring,
adaptation, efficiency, and excellent results our surgical
colleagues are securing among trying environments In
the scattered portions of our vast country.
Rheumatism^and Arthritic Conditions, and An Effective
Remedy.
By Lambert Ott, M.D 573
Dr. Ott believes that he has established the etiology and
found a specific for this class of morbidities. If so,
this paper carries a message of hope to the medical pro-
fession and suffering patients.
Cancer of the Liver and Gall Bladder.
By Hyman I. Goldstein, M.D
.677
The Anti-malaria Campaign.
By W. H. Rand, M.D. ...
5t1
Malaria, a problem of ages, is still a problem of today.
We have discovered its etiology. We learned its mode
of prevention, control and cure, but we still have It sad
we have It because we fall to enforce the several factors
concerned In Its eradication, as we learn from Dr. Rand's
excellent paper.
on page 552)
Chinosol
"A POWERFUL ANTISEPTIC, SOMEWHAT STRONGER IN
THIS RESPECT THAN MERCURIC CHLORIDE AND CONSID-
ERABLY STRONGER THAN PHENOL."
(COUNCIL ON PHARM. AND CHEM. A. M. A.)
««
ASEPTIKONS (supVpAoGs,%Lr.es,
producing complete antisepsis
But
Non-poisonous, Non-irritating and No injury to membranes
Indicated in cervicitis, leucorrhea,
specific and non-specific vulvo-vaginitis, in all cases
where complete vaginal antisepsis is desired.
PARMELE PHARMACAL CO., 47-49 WEST STREET, NEW YORK.
You can buy with confidence — See "Service Guarantee to Readers" on page 614
August, 1922]
The American Physician Advertising Stroke
551
What
say about certain particular
properties of yeast
COMBATS INFECTION
CLEANS BOWELS
ACTS AS A LAXATIVE
INTESTINAL MOTILITY
A doctor of medicine and professor of
therapeutics at an American university y
writes : —
"Yeast has long been administered in infections,
and is frequently a very valuable treatment. It
cleans the tongue, causes movements of the bowels,
stimulates the production of white corpuscles, and
seems at times to combat streptococcic infections.
"One of the most useful laxatives is yeast * * *.
* * * It should be much more frequently given in
illness in which there is intestinal disturbance,
especially if it is associated with constipation/9
A physician in a large city makes the
following statement: —
"Vitamins are readily supplied to the body in
yeast9 and we sometimes advise patients to eat
one-half cake of yeast three times a day, the yeast
being stimulant in its nature to intestinal motility."
A fellow of the Royal College of
Physicians, London, says: —
"Yeast is a valuable source of this vitamin
(8-vitamin) and has the additional merits of being
comparatively rich in protein and of improving the
appetite. It may occasionally be substituted for
meat in the dietary with advantage."
Fleischmann's Yeast may be eaten plain, suspended
in water, milk, fruit-juices or any other liquid. It may
be spread on crackers or toast. From one to three cakes
a day has usually given excellent results.
Send for the new book on the chemistry,
physiology, and therapy of yeast. This book is
distributed free to physiological chemists, phy-
sicians and hospitals. Address
THE FLEISCHMANN COMPANY, Dept.S~8, 701 Washington Street, New York
RICH IN VITAMIN
VALUABLE PROTEIN
CONTENT
.h*.
Mentioning The American Physician Insures Prompt, Careful Service
A Camtruclioc Market for Buyer and Seller [Phibdeipiu.
Contents — ™.H™jyn™ pat. 550
Efficient Future of Medical Practice
That Vexed Question of Diagnosis HS
On the Management of the Chronic Nephritic EM
Physical Culture Propaganda S*T
Boot Current Medical Thought
The Origin of the Original Syndrome M>
Stricture of the Urethra In Women fa*
Curettage and the Treatment of Uterine Hemoirhag*..Sa
The Hysterical Nature of So-called Pernicious Vomiting
of Pregnancy 5*
Alimentary Infection* In Chronic Arthritle W>
Some Varietie* of Traumatic and Toxic Ulnar Neuritis.. H»
Boo
Hay Fever and Asthma *M
Mental Hospital Manual **
Benign Stupors 5M
Management of the Sick Infant 5M
The Life of Jacob Henle 5*4
Radium Therapy SM
New Prices on
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PRICES AND SAMPLES UPON APPLICATION
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can Physician is published for ont snd 9*h ***
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i or of *ny csmmtrcial iwttmt, bsTiof absolute]? ••
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subscriber, si any Sim*, feels tbst Tat Amvus
is not inring him /«i/ measure ("pressed don sad
'er") of such serrise. or i* dissatisfied for s«y mm,
write us we will cheirfnUy rtfaad, without nuetQoo.
he paid for the y«r» nbicriptie*. eren if he hM
silicut Physic i aw seeks enJy satisfied, interested
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"whe're this Is ».< the ^***^V^ |J ^SB*S%Cli
. """e'sired, '"if "tifics™n Is se^^PM™!™ receipT *
.ubscription hUl. it -01 be disconttrmed Cat Wg^of esnrss).,
Thi Amibicaw Physiciax does no* distributs ttmpli cosies at!
free copies of any kind.
Subscription Pricm
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la ior mini™.* postage — U. _ - — . —
Canada and Foreign. 50c additional each year.
it all ctmm**Uatimt end mmkt *Jt fundt paysWt *»—
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410 WoIk«i ftr«t, PWJaJrlf *w, t/- *- '*-
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August, 1922]
The American Physician Advertising Service
553
Hay Fever Memoranda
Late Summer Type. Patients whose hay fever develops in
mid-August and continues until frost should be tested with pollens
of local importance — primacy being given to the long distance
wind pollinated plants, e.g., ragweed. However, where contact
is unavoidable, as on a farm, the short distance wind pollinated
plants, e.g., corn — and the insect pollinated plants, e.g., sun-
flower, which are also atmospheric— cannot safely be ignored.
ARLCO-POLLEN EXTRACTS
For Cutaneous Tests and Treatment cover early
and late spring; also summer and autumn.
Literature and List of Pollens on Request
THE ARLINGTON CHEMICAL CO., Yonkm, N. Y.
SUMMER DIGESTIVE DISORDERS
Are best controlled by the use oi
(Alkaline Elixir Rhubarb
Compound with Pancreatin)
FORMULA
Each fluid ounce represents:
Rhubarb 20 gr.
Berberine (Alkaloid from
Golden Seal) 10 gr.
Sodium Bicarbonate. 10 gr.
Pancreatin Glycerole. 8 min.
Cinnamon 10 gr.
Summer brings its burden of digestive
disorders, Diarrhoea, Dysentery, Indi-
gestion, Cramp Colic, Constipation,
Hyperacidity, etc. To meet these con-
ditions the physician must administer an
antacid, an astringent, a hepatic and
intestinal tonic, and precisely these qual-
ities are combined in the ingredients of
Alkarheiw.
Sample bottle and interesting literature will be sent upon request.
M POUNDED IMS
ERRELl""""*
1 ~ cfcmnxn.usA
Mentioning The American Physician Insures Prompt, Careful Service
A Comtructioe Market for Bayer and Seller
= AUTHORITATIVE EVIDENCE!
Herewith is a photograph of Page
95. Vol. II, "Diseases of Women," as
edited by H. Mariai-Sims, M D , and
in Dr Sinu' own word*, is recorded
the high esteem in which he held
Haydm's Viburnum Compound and
the "great service" rendered in treating
DYSMENORRHEA
hytYDEN-S VIBURNUM COMPOUND'
u> as effectual therapeutically to-day
as in the day of Sims, and will give
you the same "great service" in treat-
ing your dysmenorrhea cases, ai was
rendered to Dr Sinu.
Prescribe, as recommended by Sims,
in teaspoon ful doses, "administered in
hot water" every hour for three or
four hours. See that the genuine
H V C and not a substitute is dii-
IEW YORK PHARMACEUTICAL CO.
Bedford Springs. Bedford, Haas.
i CMc s,h ,.i lus p.
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Simpln mad liKTiture on rtqunt.
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im elective, but tlie >k ol opium h ac< mS»it*tJ« itkM
■»cfer strict medial Oram." Ckloal and bnaiei at w-
hellebore (Me"nK tun ben t^MliwH Col-
cMnn. anitii ladm. ill la bet nr aadaUTa ud
laU-ipaimoaic la UK pbinucDsoila, lure bm t.[Joj«i
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August, 1922]
The American Physician Advertising Service
555
LOESERS INTRAVENOUS SOLUTIONS
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CONTROLLED BY
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Looter's Intravenous Solution
of
IRON and ARSENIC
A sterile, stable sefatJoa la henneticalhr sealed aoaeoluMe fl*»*
ampoules. Eacb ampoule contains 64 mJlllframs (1 fraJn) ef Iron
Cacadjrlate.
Permits the Intravenous Injection of a Hemotonic
of Established Therapeutic Value.
The Intravenous Injection overcomes every question
of absorption and warrants the expectation of
improved clinical results as compared with other
methods of administration.
READY — July Journal of Intravenous Therapy.
Special Anemia Number.
Abstracts and references from American and foreign Journals.
COPY ON REQUEST
New York Intravenous Laboratory
100 WEST 21ST STREET
NEW YORK, N. Y.
Producing Ethical Intravenous
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556
A Constructive Market for Buyer and Seller
[Philadelphia
The Management of an Infant's Diet |;
A Temporary Diet
<»c>V<» D.J<>D^<>
in
Summer Diarrhea
Mellin's Food .... 4 level tablespoonftds
Water (boiled, then cooled) . 16 fluidounces
To be given in small amounts at frequent intervals.
Each ounce of this mixture has a fuel value of 6.2
Calories and furnishes immediately available nutrition well
suited to spare the body-protein, to prevent a rapid loss
of weight, to resist the activity of putrefactive bacteria,
and to favor a retention of fluids and salts in the body
tissues.
♦^(L^xr^.e^
Mellin's Food Company, Boston, Mass. 1
«».i)r<OT<Or<
IPMIIIIIIIIIIIIIIIIIIIM
NOVARTAMIN
(Phenyl-Quinolin-Di-Carboxylic Acid)
In tablets.
Indications: Gout* Rheumatisms, Neuralgia,
Neuritis, etc., eliminating Uric Acid without
causing gastric disturbances. No disagreeable
taste.
Dose: One or two tablets three to four times
after meals dissolved in a little water followed
by a large glass of water.
NEUTRALON
(Synthetic Aluminum Silicate)
Indications: Hyperchlorhydria, Hypersecre-
tion, Ulcus Ventriculi and Duodeni.
A neutral and yet neutralizing substitute for
the Bismuth Salts, Sodium Bicarbonate and
Silver Compounds, etc. It reacts gradually
and its effect is more permanent than that of
the Alkalies and of Magnesia. A white, taste-
less, odorless powder.
The average dose is one teaspoonful in a glass
of water (preferably warm) a half hour before
food.
CHLORYLEN
( Trichlor Ethylene in its purest form)
Liquid in bottles of 25 grams each.
A new treatment for Facial Neuralgia.
Chlorylen is used with marked success in the
treatment of Facial Neuralgia. It has a spe-
cific action on the sensitive Trigeminus, gives
immediate relief and the pain disappears after
a few treatments.
Chlorylen is applied by inhalation. 20 to 30
drops are placed on cotton or the handkerchief
and inhaled through the nostrils until the
odor disappears.
VALAMIN
(Amylene-Hydrate Iso-Valeric-Elster)
In capsules.
A sedative and soporific, easily absorbed and
promptly acting.
Indications: Neurasthenia, Nervous Insomnia,
Hysteria, Palpitation of the Heart, etc.
Dose: As a Sedative one to two capsules, as
a Hypnotic two to four capsules followed by
a drink of water. In nervous insomnia two to
four capsules should be taken before retiring;.
For farther information and literature address:
Kirbach. Inc., General Agents, 227-229 Fulton St, N.Y.
InnnffliiM^
You can buy with confidence — See "Service Guarantee to Readers" on page 614
The American Physician Advertising Service
Mentioning The American Physician Insurer Prompt, Cartful Service
A CoruJrucfnJe Market for Bayer and Seller
In summer diarrhea, Intestinal catarrhs, etc
c
Tannalbin
Far Sale by LittTCitart and Sample* t
MERCK * CO.
Now York SlLouu
trn A OTP/""\lVT'sC 10 ^k6 P"1^*^ active principles
I H/\i3 A VyiNC and VITAMINES OF YEAST
GIVEN IN PLACE OF YEAST FOR MEDICINAL PURPOSES
Keeps well Pleasant to take Reliable
Literature and Sample on request
MERCK 8C CO. 45 Park Place New York
In Childhood
the benefits from wearing
O'Sullivan's Heels
are recognized and appreciated by thoughtful physicians.
The light, springy step, the delightful resiliency, and the
avoidance of shock and jar, naturally mean much to the
active boy or girl.
Thus the child who wears O'Sullivan's Heels will be
happier, the structures of the feet will be strengthened, the
gait and carriage will be improved, and with elimination of
the continual jarring caused by hard leather heels there will
be a marked decrease of nervous irritation and tendency to
excessive fatigue, with their all too frequent depressive effect
on the whole body.
The sum total is more comfort, greater efficiency and a
O'SULUVAN real conservation of health.
RUBBER CO., Inc., Thus it is that O'Sullrvan't Heels have come to fill a
New York definite place in the hygiene of childhood.
You can buy with confidence — See "Service Guarantee to Readers" on page 614
Animt, 1922]
The American Physician Advertising Service
559
"With this Treatment
I Seldom Write a Death Certificate
FOR
INFANTILE DIARRHEA"
THE BRITISH MEDICAL JOURNAL SAYS:
44 All experience goes to show that Virol is a food of marked value
in a great variety of conditions in which adequate nutrition by
ordinary means is not easy to secure, including the general range
of diseases accompanied by wasting and summer diarrhea."
"f have had most excellent results with Virol; in
fact, to my mind it is the only treatment for infantile
diarrhea— barley water and Virol, or rice water and
ViroL With this treatment I seldom write a death
certificate for infantile diarrhea."
Extract from doctor's letter.
DIET IN INFANTILE DIARRHEA
To each half -pint of rice or barley water add one-quarter tea-
spoonful of ViroL Give one or two ounces of this mixture every
two hours. In cases of great prostration add 10 to IS minims of
brandy. When the evacuations indicate that the infection is at an
end, sterilised milk can be cautiously added to the Virolised rice or
barley water, the milk being substituted for the rice or barley water,
dram for dram, until Virolised milk is the sole article of diet. As
the child improves the Virol can be gradually increased.
A brochure on the treatment of acute summer diarrhea
will be sent to any medical man on application.
Used in more than 2,500 hospitals and infant dimes in Great
Sole Agents for t/. S. A.
GEO. C. COOK & CO., Inc., 59 Bank Street, New York
Mentioning The American Physician Insures Prompt, Careful Service
A Constructive Market for Bayer and Seller
THE CRITICAL AGE
The menopause is not due simply to insufficiency of the genital
glands, but is the expression of an "endocrine crisis" complex,
varying in different persons, of which the said insufficiency of the
genital glands is the central factor, but, with it, other glandular
disturbances play an essential part. — Maranon.
The menopause, therefore,
is a functional plurigland-
ular derangement and is
best treated by plurigland-
ular therapy.
In hypotensive cases use
Hormotone
and in high blood pressure
cases
Hormotone Without
Poet-Pituitary
Dose: — One or two tab-
lets three times daily be-
fore meals.
G. W. CARNRICK CO.
419 Canal Street New York, U. S. A.
You can buy with confidence — See "Service Guarantee to Readers" on page 614
SPONTANEOUS EDITORIALS; An American Physician development of journalistic service; see footnote.
A Bird's Eye View
APPLIED THERAPEUTICS*
By A. C. Morgan, M.D.,
2018 Chestnut Street, Philadelphia, Pa.,
Associate Professor in Medicine in the Medico-Chi-
rurgical College, Graduate School, University
of Pennsylvania.
Empiricism Followed by Scientific Ob**rv*i*+
"Empiricism accomplished much at the
hands of our forbears who were keen in
observing the physiologic effects of medicine
upon individual patients. Later instruments
of precision have confirmed the findings of
those investigators and definite results can
now be looked for in the light of scientific
accuracy/'
)URING THE PAST DECADE the literature
has not shown much advanced work along the
e of Applied Therapeutics. Twenty-five years
> vegetable drugs were almost exclusively used,
n came a wave of therapeutic nihilism with, at
?sent, a renaissance, the tendency today being
ng the line of serums, vaccines, endocrines and
-siological chemistry.
)r. William C. Braisted, President of the Philadel-
a College of Pharmacy, recently made the state-
it that the commercial drug houses of the country
e practically a monopoly of the therapeutics of
iv. Empiricism accomplished much at the hands
rjuT forebears, who were keen in observing the
siologic effects of medicine upon individual pa-
ts- Later instruments of precision have confirmed
findings of those investigators and definite results
now be looked for in the light of scientific accu-
The end results of many scientific observations
?i<3e well with the findings of the*se original ob-
Polypharmacy is now less practiced and single
drugs are now universally used. The combination
of certain drugs which may act closely along similar
lines are often used with better effect than a larger
dose of the single drug.
A few years ago the Medical Review of Reviews
conducted a questionnaire to ascertain the five drugs
that are considered to be of greatest importance to
the physician, with the following result : Opium, mer-
cury, cinchona, digitalis and iodine, the list being
followed closely by arsenic and the salicylates.
The tendency today and, along the right line, is
to have fewer preparations of each drug, but to have
these preparations standardized so that they may be
used with the confidence of obtaining definite results.
Serums emi Vmc ernes
Serums and vaccines have an established place in
therapeutics, but their chief value is as prophylactics
and not as curatives; thus prophylactic injection of
anti-typhoid vaccine and anti-tetanic serum exert
their best effects when given as soon as suspicion of
contact arises. Conversely, we find that gonorrheal
vaccines and tuberculosis vaccines seem to act better
during the chronic stages of these affections. In-
fluenza vaccines are considered, by many, good pro-
phylactics but are of no avail after the symptoms
become pronounced; they would seem in some cases
to lessen the severity of or tendency to pneumonia
as a complication. The use of pneumonia vaccines
or bacterins has not yet reached the stage where we
can definitely say that they will uniformly yield
favorable results. Caution must be observed in any
case wherein the use of serum or vaccines is con-
templated by reason of the danger of anaphylaxis.
This is extremely important in individuals who have
or have had asthma, or in whose family this taint
exists. Adrenalin chloride in 10 or 30 drop doses
given deep into the skin, or, in extreme cases directly
SPONTANEOUS EDITORIALS contributions that have the natural
qualities of the editorial plus the
The editorial form has a journalis- Unfortunately, however, the edi- vigor of spontaneous expression; are
tic value all Us own — a quality of torial is subject to the limitation of in fact spontaneous editorials. It has
concisely illuminating a subject like being so largely occasional writing — occurred to us to give them a par-
a searchlight playing over a land- forced expression for the occasion. ticular attention they merit. — The
scape. Frequently we receive short pithy Publishers.
562
Therapeutic Danger Line
[Pha»ddphii
into the jugular vein, massaging the vein from above
downward, will sometimes overcome the violent col-
lapse and shock that accompany this dread condition.
Emiicrim Thermpy
Endocrine therapeutics is just now at its crest of
popularity, probably due to the pernicious advertis-
ing of commercial houses who are putting out enthu-
siastic, if not alwayB correct, reports of results ob-
tained. The pendulum will swing back in a little
time, after which endocrine therapeutics will find its
proper sphere.
Studies of animal extracts and organo-therapy have
been made for many years, but during the past two
or three decades there has been a steady advance in
our knowledge of these valuable means of thera-
peutics.
Venesection has long been a discarded procedure,
but it is again being used in properly selected cases.
Instead of resorting to the old method of cutting the
skin and incising the veins, this indication can in most
cases be met by insertion of a Wassermann needle in
a good-sized vein and the withdrawal of a sufficient
amount of blood, leaving the vein intact. This method
is more expeditious and is apparently safe. Lumbar
puncture is now the accepted procedure for anes-
thesia, diagnosis and relief of cerebral pressure, espe-
cially during convulsions, as in uremia, and also for
the introduction of antiluetic medication and the
meningococcus serum.
Gjamattict, Mechmmttkerepy, tad Rt*t Curt*
For many years the medical colleges of this country
have been lax in the proper balance of their curricula,
becoming top heavy with minor subjects, whose chairs
happened to be occupied by men of political, rather*
than of scientific attainments, at the expense of the
more practical subjects in whose training they were
remiss. Very little was said and still less done with
regard to the indications and application of massage,
gymnastics, mechanotherapy, rest cures and sena-
torial treatment, so that now when the young man
enters upon active practice he has no knowledge of
or preparation in these subjects. The crying need for
knowledge of this sort on the part of the physician
and the needs of the suffering public has given rise
to the birth of cults that raise a stench in the nostrils
of decency because of their false claims, excessive
fee charging, general sophistry, and cruel imposition
on the credulity of an ignorant public. The medical
profession has been remiss in its duty to the public
and the blame will continue to rest upon us, especially
the medical colleges, until these sins of omission have
been corrected.
•Read before the Lackawanna County, Pa., Medical
Society, April 18, 1922.
Avoiding the
Therapeutic Danger Line
PHILLIPS, in the Journal of the American Medi-
cal Association, April 22, 1922, warns against
the toxicity of phenobarbital (luminal), citing many
cases and quoting numerous authorities. Grinker
and many others have been strongly advocating its
use in the treatment of epilepsy and insomnia and
dosage has been run up to as much as 12 grains, 4%
grains frequently repeated being common practice.
Now, after numerous serious cases of poisoning have
been reported, Phillips contends that the single dose
should never exceed 1% grains and never more than
3 grains in twenty-four hours. These small doses
would probably be safe but they would not be effec-
tive.
This recalls to mind that, some time ago, the same
journal recommended 1% grains as the proper dose
of acetanilid. Doctor, do you remember the large
doses you used to givet In the influenza epidemic of
1889-'90 antifebrin was largely in vogue, and after
the epidemic was over and the physicians got to-
gether in medical society meetings to compare notes
it was agreed that we gave excessive doses. Yet mis
drug is acetanilid under a trade name, and we thought
it was perfectly safe. We know better now.
Barbital (veronal) is relatively much more safe,
for it is a diethyl, whereas in the case of luminal one
ethyl is replaced with phenyl; yet the dosage of 15
grains often recommended is excessive. Of late some
scamps have been selling it, mixed with milk sugar,
as "powdered whiskey" and such use, of course in
large doses, results in a twenty-four hour "jag" of
a stuporous nature that reminds one of the action
of the old "knock-out drops" made of chloraL The
recommended dosage of barbital is coming down,
down, down — just as in the case of heroin, which at
first was "harmless" and given in doses of one-sixth
of a grain, until we learned better.
Heinemann in The American Physician, April
1922, warned against the unwise and excessive use of
acetyl-salicylic acid (aspirin), and he is not alone in
his warning. We have ourselves seen seventeen cases
of aspirin poisoning, most of them from reckless
dosing.
Recall, if you will, the "1921 excitement," as benzyl
benzoate has been called, and the final conclusion that
to be effective it must be given in dosage that the
therapeutist feared to risk. At all events, it is
rapidly going out of use.
Aufwt.1922]
What Is Acute Indigestion?
563
LH U$ It SnmbU
There is no occasion to denounce all ooal-tar deriv-
esters and other new drugs, just because
they have been unwisely used and in excessive dosage.
It stands to reason that chemistry has much of value
to add to onr armamentarium. But we have to study
these drugs from many angles before we know in
just what indications and in what doses to give them.
Some of them appear later in modified form, safer
and more available, as is about to occur with benzyl
benzoate. Oar proper province is to avoid the thera-
peutic danger line.
Quinidin is the newest claimant for therapeutic
favor, the matter being discussed editorially in the
February issue of this journal. Now comes an
irtiele by Jackson, Friedlander and Lawrence, in the
(arch issue of the Journal of Laboratory and CUni-
al Medicine, and in which they claim there is noth-
ig unique in the action of this drug in auricular
brillation, several other drugs acting similarly by
rtue of their depressant action on the cardiac
oscle; and again the question of toxicity comes up
id warnings are issued.
What Is Acute Indigestion
and
Segard is out with still another warning against
ceding an epinephrin addiction in the treatment
asthma, for the imbalance is so variable in asthma,
I the balance between the vagus and the sympa-
tic so unstable, that, added to other factors, and
frequent toxic state, we must needs be careful
avoid any form of heavy dosing, more especially
made necessary by continued usage and a
•ance being established.
>th and others are complaining that neo-arsphena-
deteriorates and often becomes dangerous to life.
icty there have been several deaths reported from
muse. It is now urged that all preparations be
in refrigeration, such as is required for vaccines,
e dosage is, usually, 200 mg. per kilogram, and
sndency is to give repeated doses, some clini-
think we are overdosing with the modern arseni-
vhether deteriorated or not We have our own
ibont that, as was expressed in an editorial on
3 in the June issue.
ImUbSUb Dmn
i a favorite indoor sport to denounce our erst-
?£andard galenicals — the standbys of practice
years ago. We were in practice then and re-
r some overdosing, notably with pilocarpine;
ely did we have the serious results from over-
that are so common with the newer drugs.
handling very potent agents now; sometimes,
k> most too potent — for harm as well as good.
ixlci avoid the therapeutic danger line at all
t ^vas one of the aphorisms of Hippocrates to
'with our remedies and treatments. He
many ways. Let us emulate his example.
T. S. *.
What Shall We Do for It?
IN THE HURRY of a busy practice it is easy to
class many minor indigestions as "acute indi-
gestion," give a hypodermic of morphine and rush
off, returning next day to find the patient either
quite ill or unnecessarily narcotized. Such tactics are
poor policy. A genuine attack of acute indigestion
is a serious matter that frequently leads to a fatal
issue, while in minor indigestions morphine is about
the worst possible drug to administer.
Kemp said : "By many physicians the term 'acute
indigestion' is made applicable to, or synonymous
with, certain forms of gastralgia, toxic gastritis, acute
atony, acute dilatation of the stomach, or, lastly,
acute ectasia/' Morse, who favors accuracy, stresses
ectasia (acute dilatation) as the form of acute gas-
tritis to which the term "acute indigestion" should
be applied. Bassler, who runs strong on pathology,
divides and subdivides the various forms of acute
gastritis. He evidently does not like so nebulous a
term as "acute indigestion" and proceeds to out-
line several conditions so-called by hasty clinicians.
Personally, from considerable study of the con-
dition, and from "inside information" in our own
person, we agree with Morse and 1oy emphasis on
ectasia. Certainly all physicians see a class of
cases that are of severe type, come on suddenly,
reveal by percussion an acute dilatation of the
stomach, and that may be readily enough mistaken
for angina pectoris, perforation, intestinal obstruc-
tion, or peritonitis. While there is not the extreme
prostration and collapse noted in ptomaine poison-
ing, there is a degree of shock, extreme pain, vomit-
ing as a rule, tachycardia, subnormal temperature,
low blood-pressure, intense thirst and an entire ab-
sence of muscular rigidity.
When CmUed to m Cm*
Doctor, when you are called to a case of what
appears to be acute indigestion, don't make too
hasty a diagnosis or immediately mask the symptoms
with morphine. This drug may be indicated; if
it is indicated, give it, but not until after a diagnosis
has been made and, if a true acute indigestion, not
until after the stomach has been evacuated and an
enema has been administered.
Please bear in mind that we are not here consider-
ing ptomaine poisoning, the forms of acute gastritis
occurring in acute fevers or infectious diseases, the
heart-liver-kidLey symptom-complex kind, those due
to abdominal trauma, or even ordinary, every-day
indigestion due to flouting the "do nots" of ordinary
prudence; but these remarks bear wholly on the
kind of acute indigestion or gastric ectasia denned
564
[Philadelphia
by Morse. Certainly excesses in diet or drink, or
both, are responsible for many eases, in fact for
most of them; but an acute gastric ectasia is a far
more serious matter than is the ordinary indigestion
so frequently called "acute indigestion.,,
Bt Prompt
Morse says : "Unless recognized early, these cases
are bad, and present a formidable condition, the
death rate being very high. Our present knowledge
of the proper method of treatment should greatly
reduce the mortality."
Shattuck has given the principles of treatment
very clearly, as follows: 1, removal of cause of
symptoms; 2, rest and warmth for the patient; 3,
rest for the digestive tract; 4, symptomatic treatment.
Immediate evacuation of the stomach by a mustard*
emetic or, preferably, by lavage, washing out with
sodium bicarbonate solution, is the first thing to
do. Do not give depressing emetics. It is the worst
of policy to tie up the system with morphine, allow-
ing the slow method of intestinal elimination of the
offending matter to endanger the life of the patient.
If there is abdominal distention, which is common,
give an enema.
Now, having done these things, the patient will
be weak, but not in such extreme pain. The second
indication must now be met by covering him warmly
in bed, freely using the hot-water bags, and, if he
still suffers appreciably, giving one hypodermic dose
of morphine. The morphine may help to over-
come shock. Physicians should remember that shock
is not solely a surgical matter, *« a real shock is
more common than is commonly thought to be the
case in many non-surgical conditions. It is a wretched
thing to do to rush right off from a case of acute
indigestion and allow the patient to suffer hours
from shock, when the proper use of strychnine,
camphor, ether, whisky or other drug may be im-
peratively necessary.
Don't give purgatives at once; wait a few hours,
when calomel, followed by salines, is indicated.
Rest for the digestive tract must not be omitted.
Sometimes even water gives distress. Give ice. Some-
times one-drop doses of tincture iodine are useful,
but t^e extreme thirst and exhaustion are best met
by enemas of hot saline solution, or by hypodermocly-
sis. Symptomatic treatment must not be overdone.
Don't give a lot of bulky messes to these patients.
The so-called digestants will do no good. Give lit-
tle medicine, but do not allow a diarrhoea to exhaust
the patient. The principal thing is proper dieting.
A SerioM$ Matter
Let emphasis be placed on two facts: First, most
cases of so-called acute indigestion are nothing of
the sort described here; second, a real cause of acute
gastric ectasia is almost as serions an emergency
in the medical field as is appendicitis in surgical
practice.
Coming
Diphtheria: Control and Prevention —
by Dwight M. Lewis, M.D.
A preventable death not prevented is a stigma on
civilization in general and medicine in particular.
To correlate internal and prophylactic medicine,
to harmonize epidemic experiences and standing
facts, read Dr. Lewis's paper. You will find it
sensible, instructive and practical.
The Problem of "Nervous Indigestion"—-
by Geo. M. Niles, Ph.G., M.D.
The problems of "nervous indigestion" are nu-
merous and difficult, chiefly so because of the
organic and neurotic elements combined. Unless
the gastro-enterologist supplements his medica-
tion with common-sense psychology he is doomed
to positive failure. The factors here involved
have been happily solved by Dr. Niles in this
delightful paper. He truly succeeded, to use his
expression, in playing a poor hand remarkably
well.
Analgesia and Sleep, Without Narcosis—
by M. R. Dinkelspiel, M.D.
The narcotic and habit-forming properties of
opium and its educts have undoubtedly been the
primary cause for stimulating investigations in
the search for a less objectionable substitute.
While many substitutes have been and are being
tried out, and each has its individual value, none
of them has attained that minimum of risk which
is the ultimate goal.
The indomitable spirit of intensive chemical
investigation, which has resulted in a rapid succes-
sion of comparatively recent therapeutic achieve-
ments in the field of syphilis, leprosy, local
anesthesia, hookworm infestation, and other con-
ditions, will no doubt do much in the future to
meet this and the other problems which still con-
front our profession.
Varicose Veins — by A. Wiese Hammer, M.D.
The best results from operative measures are to
be found in cases in which statis is well marked
and the trunks of the veins are prominent
In deciding for or against operation, the dictum
of Mayo is applicable: "An elastic bandage is
applied from the foot to above the knee. If this
bandage can be worn with comfort, an operation
should give relief." Discomfort will show the
superficial vessels are necessary to the circu-
lation.
The Diagnosis of Typhoid Fever —
by Bruce Snow, M.D.
The paper of Dr. Snow comprises several inter-
esting features — it reviews typhoid fever vividly;
it presents some original angles together with a
splendid resume* on the standard laboratory
aspects of this undeniably important disease, a
disease which, in spite of its constantly reduced
prevalence, is still intermittently pandemic en-
demic, and epidemic, practically throughout the
world
Can Obstetrical Conditions Be Improved in Rural
Communities? — bv Mayer Shoyer. M.D.
The country practitioner is forced hv conditions
to be a really resourceful obstetrician. In the
cities, where hospitals and specialists abound, the
general practitioner usually attends so few obstet-
rical cases that he never becomes really skilled.
Advertising Standards — "A Scrric« •! Trrtk. frta C*vr to C*r«r"— pagt 612
The following papers
are contributed exclu-
sively to this journal.
Republication is per-
mitted if credited as
follows: AMERICAN
PHYSICIAN, Phila-
delphia,
Original Articles
Subnets, Ike whams, ton ftMtst win most mimti
We are not respon-
sible for the views ex-
pressed by contribu-
tors; but every effort
is made to eliminate
errors by careful edit-
ing, thus helping the
reader.
The Conduct of the Third Stage of Labor
By Samuel F. Gordon, M.D.,
1326 Rockland Street, Philadelphia, Pa.,
Demonstrator of Obstetrics, Medical School of Temple
University, Philadelphia, Pa.
Dangers Third Stage of Lobar
"The dangers due to accidents occurring
during the interval between the birth of the
child and the birth of the after-birth exceed
those to which the parturient woman is sub-
jected because of accidents during the rest
of labor." This statement deftly summarizes
the importance of the subject and should be
a warning to those who wade the dangerous
streams of obstetrical medicine. — Editors.
THE DANGERS DUE to accidents occurring
during the interval between the birth of the
child and the birth of the after-birth exceed those to
which the parturient woman is subjected because of
accidents during the rest of labor. The immediate
dangers of post-partum hemorrhage are evident to all,
but there is also an increased liability to infection
when the resistance of the patient has been lowered
by excessive bleeding. Toxemia, hemorrhage, and
even infection may depend upon the incomplete ex-
pulsion of the placenta.
It is my purpose to consider how the third stage of
labor may be guided, or aided, should assistance be
needed, and to report some abnormalities met during
the past three years in private practice.
Mechanism of Placental Separation
It is interesting to note that there has been little
real observation of the mechanism of the separation
of the after-birth. The mechanisms of Schultze and
Duncan described in the text-books are based on the
position of the placenta as found in the lower seg-
ment of the uterus and when discharged from the
vagina. It is taught that the placenta is separated
by the repeated contraction and retraction of the
uterus, with diminution of the placental site, five to
thirty minutes being required for the separation. It
may separate at the periphery especially at the lower
edge, or at the centre with the formation of a retro-
placental clot.
Franz, in 1916, investigated the method of placental
separation and expulsion by manual examination of
the interior of the uterus immediately after the birth
of the child. Our clinical observations support his
views, and we believe the Roentgen-ray studies of
Weibel and Warnekros support them. Franz found :
As a rule, the entire maternal surface of the pla-
centa is separated at the same time by one uterine
contraction; birth of the body and extremities by a
uterine contraction is accompanied by complete sepa-
ration of the placenta, otherwise several contractions
are necessary; complete separation with formation of
a retroplacental clot is the rule; partial separation
makes necessary several contractions to complete the
detachment; attempts at expression of an incom-
pletely detached placenta increase blood loss, while
early expression decreases blood loss when the pla-
centa is completely detached.
Our clinical experience at the Samaritan Hospital,
in the service of Dr. J. O. Arnold, with the use of
pituitrin administered intramuscularly immediately
after the birth of the child's head, corroborates the
observations of Franz. Ryder, and mere recently
Brodhead and Langrock, show the lessened blood loss
when pituitrin is used at the beginning of the third
stage of labor. The latter mention the occurrence
of hour-glass contraction in a number of their cases.
This has not been noticed in this clinic since we began
giving it intramuscularly before the birth cf the body.
Attempts to express the placenta before the rise of
the uterus indicating the passage of placenta into the
lower uterine segment are, we believe, the cause of
this anomaly.
The views of Franz have been questioned by Frankl
and Hiess, who stress the importance of retropla-
cental hemorrhage in the separation of the placenta.
The reported success of Gabaston's method of causing
566
Conduct of the Third Stage of Labor — Gordon
[Philadelphia
artificial detachment of the placenta, would support
their contention. Gabaston, in cases of adherent pla-
centa, injects at least five hundred c.c. of salt solution
into the umbilical vein. This swells the villi, ruptur-
ing some, and causes a retroplacental hydroma. At
the Samaritan Hospital we have not found use for
this method, and, in the author's cases where manual
extraction was necessary, it could not have been em-
ployed.
Comdmct of the Third Stage
The preparation for the third stage of labor begins
at the onset of labor. Indeed, it requires not only
that the patient be carried through her labor with
greatest conservation of her physical and mental
energy, but that she be brought up to her confine-
ment in the best condition possible, so that she will
be as fully prepared for the stress and strain she
must undergo.
We conduct the third stage of labor in the follow-
ing manner: As the head of the child is born, 1 c.c.
of obstetric pituitrin is injected intramuscularly into
the outer side of the thigh. It acts quickly and, after
forceps operations, prevents delay in the delivery of
the shoulders by overcoming the sluggish condition
of the uterine musculature often present when an
anesthetic has been used. We also believe that it
aids complete separation of the placenta and its
rapid expulsion into the lower uterine segment or
vagina.
After the child is born, a clean towel is placed
beneath the patient. The patient should now be on
her back. A sterile basin, pushed against the peri-
neum, collects all the blood lost, and receives the
placenta and membranes as they are expelled. An
assistant meanwhile has followed the uterus with a
hand lightly laid on the fundus.
If there is no hemorrhage, or undue relaxation of
the uterus, nothing is done until there is evidence
that the placenta has passed into the lower uterine
segment. Should the uterus balloon up, gentle rub-
bing of the uterine body is done, the uterus being
held by the hand with the thumb in front and the
four fingers behind. It is necessary to warn against
rough manipulations of the uterus. Abnormal separa-
tion of the placenta, shock and increased bleeding are
caused in this way.
Efforts to complete the delivery of the after-birth
before it has been expelled from the fundus are
avoided. We wait for the rise of the fundus, and
note its change in shape from a globular mass to one
flattened from front to back, and that it is smaller
and harder.
At this time, in normal cases, the woman is asked
to bear down. I have found Baer's suggestion to
grasp the recti and draw them together during a
pain, while the woman bears down, useful at this
time. More often the patient, if a primipara, is
under the anesthetic. In these cases and where the
above method fails, we practice early expression of
the placenta. The uterus, for this purpose, must
be firmly contracted. It is grasped in the hand
with the thumb in front and the fingers behind,
without squeezing, and is pressed down in the direc-
tion of the birth canal. The fundus is used only
to press against the placenta lying in the lower
uterus and vagina.
As the placenta emerges from the vagina it is
allowed to drop into the basin, dragging the mem-
branes after it. If there is any adhesion of the
membranes they are grasped close to the vulva with
a hemostat and removed as carefully as possible.
Ergot is now given in 1 c.c. dose of a sterile
solution, by intramascular injection.
Unless the woman bleeds there is no danger in
leaving the secundines in the uterus for a day or
more. This is rarely practicable, and, in the pa-
tient's home, dangerous without constant attend-
ance. Our practice is to try simple expression sev-
eral times, during an hour or more, before attempt-
ing a Crede, which differs from a simple expression
in that the uterus is squeezed forcibly by the hand
as it is pushed in the direction of the inlet Our
experience is that attempts to do a Crede without
anesthesia sometimes cause great shock to the patient,
and when done to stop bleeding, due to a partially
detached placenta, often increases the hemorrhage.
If there is excessive bleeding and the placenta is
not readily expelled there should be no hesitation in
entering the uterus with the hand and manually re-
. moving the placenta. The author in his work keeps
ready additional sterile gloves to be used for this
purpose should it become necessary.
One should be familiar with the various anomalies
of the placenta and the methods of examining that
organ for defects. Now is the time best suited to
remove any fragment of placenta that may be
retained.
Abnormalitiet in the Delivery of the PimcenU
Abnormalities in the separation of the placenta
may be due to faulty uterine contractions, either
n. tural or due to the accoucher's manipulations. In-
carceration behind an abnormal contraction ring, x
behind a prematurely closed cervix are examples of
this. Inflammatory changes in the decidaa may
cause adhesion of placenta or membranes. Penetra-
tion of the deeper uterine wall by placental or
chorionic villi ; abnormalities of the uterine wall, such
as fibroids; peculiarities of placental formation and
implanatiori, such as placenta circum valla ta and mem-
branacea; and accessory placentae are among the
causes of abnormalities in the delivery of the secun-
dines. It must be remembered that true adhesion is
rare. The placenta that is slow in being delivered
is usually merely retained in the lower uterine segment.
(Continued on page 584)
August, 1922]
Medical Diathermy in Joint and Bone Leaiona— Folkmar
567
Medical Diathermy in Joint and Bone Lesions
By Elnora Cuddeback Folkmar, M.D.,
M.Ph., D.S.S.,
1730 Eye St., N. W., Washington, D. C.
Extend Heat aa a Therapeutic Agent
The importance of using heat as a
therapeutic agent has been recognized for cen-
turies. Various methods, local and general,
of increasing bodily heat have been devised,
from counter irritants, hot poultices, hot-water
bottles, hot baths of the home; to f omenta-
tipns, hot packs, hot-air bake ovens, tango
mud and hot-spring baths of sanitoria and
health resorts. None of these convective
methods induce heat deep within the tis-
sues. They are successful only in so far as
they produced by reflex action an indirect
slight dilation of blood vessels and an in-
creased metabolism.
IN ALL CASES of disease or injury of a joint
various pathological changes, more or less perma-
nent, may take place. Among these are trauma of
the soft tissues about the joint; engorgement of sur-a
rounding and intracapsular tissues with exudates;
obliteration or narrowing of capillaries, resulting in
more or less circulatory stasis and impaired nutrition ;
changes in quality and character of the synovial fluid ;
roughening or hardening of articular surfaces ; forma-
tion of adhesions between tendons and their sheaths;
deposits of calcarious material in joint cavities or
in the extra or infra-capsular tissues, ligaments or
tendons, and accompanied in chronic cases with more
or less ankylosis, fibrous or bony.
Nature's Therapeutic Praceu
Nature's cardinal method of therapeusis, when a
joint is injured by trauma, or invaded by patho-
genic bacteria or toxins, is to produce inflammation.
The one ever present symptom of inflammation is
beat. This heat is produced by hyperaemia, by which
the joint is warmed, better nourished, and all metabolic
processes increased. The tissues are softened and
waste materials and exudates, due to the presence
of irritants — mechanical, chemical, thermic, or bac-
terial— are absorbed or eliminated.
X£ nature succeeds the joint is restored to normal
physiological function. But nature often fails in
this task of restoration; sometimes because the task
set before her is too great; sometimes because of
obstacles placed in her way by well meaning doctors
and surgeons in the form of cold compresses and un-
yielding casts, which hinder the normal physiological
processes, be these those of elimination of toxins, of
repair of a trauma, or repulsion of an invasion of
bacteria.
Imimced Internal Heed m Tuerapeuth
The primary indicated treatment in joint lesions
deduced from nature's processes is the production of
heat within the joint and the surrounding tissues.
This can be accomplished only by the use of diathermy.
Physiologic*.1 ly, diathermy in its therapeutic effects
is identical with local heat. Nature always generates
heat when she undertakes a task of restoration. Heat
relaxes tonus. By relaxation of the muscular fibres
of blood and lymph vessels, she dilates them. Blood
and lymph from the surrounding tissues iush in and
fill the dilated vessels. The chemical processes of
metabolism are quickened. Waste and toxic sub-
stances are more rapidly eliminated. Heat softens
the tissues and makes them susceptible to mechanical
treatment, or to voluntary exercise. Heat relievos
pain and tenderness by relieving the pressure from
exudates.
Diathermy in the treatment of acute joint lesions,
especially those of trauma, is a means of reinforcing
and speeding up of nature's restorative processes. In
the treatment of chronic joint lesions diathermy is a
means of stimulating nature to initiative restorative
processes, and of abetting her in the continuation
of these processes to a successful conclusion.
Manage an Adjunct
In the treatment of joints, the diathermic treat-
ment should be followed by deep massage of the
tissues and exercise of the muscles. This may be
accomplished by the static wave current, by the
rhythmic faradic current, by the sinusoidal cur-
rent, by mechanical vibration, by hand massage, and
by passive and active exercise.
Personally, in the treatment of sprains, fracturas,
and chronic stiff joints, I follow the diathermic treat-
ment with a faradic rhythmic massage for five to
ten minutes, and then give what I call "the faradic
grip." This consists in slowly moving the secondary
coil over the primary until the patient gives an in-
voluntary sound. This is repeated five or six times.
This mechanical massage is followed by passive and
active attempts at motion.
In some cases it is well to precede the diathermic
treatment with radiant heat. During this time a
salicylate preparation may be rubbed into the skin.
568
Medical Diathermy in Joint and Bone Lesions — Folkmar
[Philadelphia
In other cases diathermy may be followed by the
constant galvanic current or by galvanic ionization
of sodium chloride, of a salicylate, or of an iodide.
Ecommuc Vabu of Dimtkerwty
In the treatment of joint and bone lesions from
trauma, the patient demands relief from pain, and the
restoration of anatomic integrity and physiologic
function with the least permanent impairment in the
shortest possible period of time. In the industrial
world, the employers are responsible for injuries in-
curred by the employees in the line of duty. The
employer's loss is lessened by reducing (a) the time
of total incapacity, and (b) the amount of permanent
damage and partial incapacity of the injured em-
ployee. To accomplish these ends a number of large
industrial concerns have installed in their welfare
department equipment for giving diathermy treat-
ments.
By the use of diathermy in joint lesions, the time
ordinarily required for regeneration of injured parts
and their restoration to normal function can be re-
duced from 30 per cent, to 70 per cent. Moreover,
the likelihood of permanent disability is decreased
still more.
I can best make clear what may be accomplished
by diathermy in the treatment of joint and bone
lesions by citing a few case histories.
Crimp (hut — ftifuf Kmet
Case I. — Rigid fibrous ankylosis of right knee as
sequelae of acute articular rheumatism. A woman about
57 years of age was referred to me in 1916 through
Dr. E, G. Mitchell. Twenty-one years before she
recovered from an attack of articular rheumatism with
the right knee contracted at right angles. She was then
taken to a hospital, where the knee was straightened and
placed in a plaster cast by a surgeon. When the cast
was removed there was a rigid knee joint, which no
amount of massage or osteopathic treatment had been
able to limber up. For 21 years she had walked swing-
ing the right leg stiff from the hip. Diathermic treat-
ments, 40 minutes of 500 to 1000 milliamperes, followed
by five minutes of faradic rhythmic massage and five
minutes effort at passive and active motion, were given
almost daily. No perceptible change was observed until
the fifth treatment, when the knee flexed so that the
ball of the foot was brought to the floor. By the tenth
treatment the patient could go up and down stairs
with right foot leading, and when seated could draw
foot back and kick her chair. Sixteen treatments were
given during a period of three weeks, when patient
returned to her home in Pennsylvania with a very usable
knee that could be moved through an arc of 120 degrees.
Case II. — Rigid knee as sequelae of fixation for frac-
ture of hip. Woman of 60. Patient fell in September,
1921, and fractured the right hip. Fixation by traction
was maintained for several weeks. Result, an enlarged
rigid knee, that no amount of massage, or effort at
cither passive or active motion, was able to bend in the
slightest degree. Patient walked with crutches. Came
to me May 22, 1922. Up to time of writing this report
the patient has had nine treatments— diathermy fol-
lowed by faradic rhythmic massage, and effort at both
passive and active motion. The electrodes were placed
on the anterior and posterior surfaces of the knees, and
on alternate days on the lateral surfaces. This cross
fire method more completely heats all parts of the joint
She can now bend the knee to an angle of fifty degrees.
These diagrams show various positions for placing elec-
trode when treating a Joint. The broken lines show the
direction of current passing from one electrode to the other.
The space between the edges of the electrodes must always
be greater than the shortest distance between the center of
the electrodes. Cross lire treatment consists In changing
the positions of the electrodes on different days of treatment
It is well to have an x-ray made of a rigid knee to
determine if destruction of the inter-articular cartilages-
or bony ankylosis has taken place. Diathermy is of no
avail in bony ankylosis, such a§ is. often found as sequelae
of gonorrheal infection^
Clip for fastening cord to electrode.
Electrode cut from tin foil. Slits cut in from edge permif
of fitting electrode to uneven surfaces. The narrow strip of
tin foil fastened by adhesive tape to center of electrode is-
for attachment of clip.
Grmtp Tw—Sptmm of AakU
Case I. — Referred to me by Dr. Davenport White.
A woman about 60 in evading an automobile sustained
a severe sprain of ankle and foot. She was brought
to my office about three hours after the accident She-
was unable to bear her weight upon the foot which was-
much swollen and very painful. Diathermy was applied
for 30 minutes 500 to 700 milliamperes. This wa$
followed by 10 minutes of rhythmic faradic massage.
After this an adhesive boot was applied. Result, patienf
was able to walk out to car with little pain. The*
swelling was some reduced. Five treatments were
given during a period of 10 days. The milliamperage
was increased to 900 with the second treatment. After
the fourth treatment the adhesive support was not re-
Medical Diathermy in Joint and Bone LesJoi
placed. Nearly all discoloration, which was very deep,
disappeared afier the third treatment. The five treat-
ments gave nearly complete restoration of physiological
function Patient was able to go shopping without ex-
periencing any inconvenience from the sprained ankle.
and soon forms a dot between the ends of the f rag-
ments, under the separated periosteum and in the
contused soft tisanes.
Nature begins her repair work by producing in-
flammation in the injured parts. By this process
leukocytes are stimulated to migrate to the seat of
inflammation and eat up the clot. The cells of the
connective tissues begin to proliferate, and blood ves-
sels are developed in this new tissue which replaces
the blood clot. The osteoblasts begin to proliferate
and permeate the mass of fibroblasts, and form the
callus which unites the ends of the fractured bone.
The usual surgical procedure is to secure coaptation
and fixation of lacerated ends and leave the rest to
nature.
Dlatbermr In the treatment of joints.
Electrodes are fastened In place by means of
bandage.
Case II. — Also referred by Dr. Davenport White.
Laborer on a railroad, 20 years old, who had sustained
a severe sprain of an ankle. Dr. White told the boy
that he would be able to return to work in three weeks
if he had diathemy treatments. The young man was
brought to my office the next day. He wore a large
shoe and experienced excruciating pain with every step
A diathemy treatment of 40 minutes, ranging from 500
to 900 milliamperes was given. This was followed with
ten minutes of faradic rhythmic massage and the
faradic grip. After this an adhesive support was ap-
plied. The swelling was much reduced and the young
man walked "ut of the office without pain. The next
day he returned wearing an ordinary shoe, the mate to
the one on the other foot. He limped a little and had
slight pain on taking a step. The treatment of the day
before was repeated and I told the youth that he
would be able to return to work in a week. He had
his last treatment six days after the accident, when I
returned the case to Dr. White with the message that
I thought the young man able to go back to work.
In a simple fracture not only is the bone broken,
but its medullary contents are lacerated, the perios-
teum is more or less stripped from each fragment,
and the overlying soft tissues are more or less con-
tused. A considerable amount of blood is effused
Patient at t: ..._...
meat tbroag-h srcli of foot. The fi
roll nbont tbe s lie of the sole of the foot. This elec ._
icblne at the left
>ermlts a perfect
On dorsum of tbe foot is a tin foil electrode which la con-
nected to the other side of tbe d'Arsonvsl machine. (See
neit cot bow tbe electrode on dorsum of foot Is held lu
At the left band <
Riving a modified dl
d'Araonval apparatus
denser chair. To the
{lives (treat density of c
e easily moved over the area
a nee lea.
Diatfcenty in Fracfare*
Diathermy in fracture cases will produce hyper-
aemia. This will increase leukocytosis, cell prolifera-
tion, granulation, callus formation. Diathermy will
reduce the oedema, promote absorption of ecehymosis,
relieve pain. Diathermy in the most favorable cases
August, 1922]
Some Interesting Surgical Cases — Hardy
571
Some Interesting Surgical Cases
By Irvin Hardy, M.D.,
Morgantown, W. Va.
Dr. Hardy presents a series of highly inter-
esting cases, which incidentally illustrate
some of the "shocking" circumstances under
which some of our surgeons are called upon
to operate. It also demonstrates the daring,
and adaptation, and efficiency and excellent
results our surgical colleagues are securing
among trying environments in the scattered
portions of our vast country. — Editors.
Am Ectopic GeMmHom
Cask 1. — Was called one rainy night, at 10 P. M.,
to see a woman, eighteen miles distant, in the moun-
tains. Took two nurses and started for my des-
tination.
Owing to the fact that the driver of the Universal
car did not know enough to keep water in the radia-
tor, we had to get out and push up steep grades.
When within a couple of miles of my destination I
slipped off a rock (while pushing) and fell into a
mud hole. This was the proverbial last straw, and
the vocabulary utilized, in the following few minutes,
is not to be printed.
Arrived just at peep of dawn, and found Mrs. B.,
aged twenty-eight, mother of two children, uncon-
scious. Color of face, ears and lips indicated severe
loss of blood. Diagnosis of ruptured ectopic preg-
nancy made. Operated in an improvised operating
room, after giving a gloomy prognosis. Found the
foetal mass, large as a baseball, free in the peritoneal
cavity. There was so much blood in the abdomen that
it ran over the table onto the floor when the abdo-
men was opened. Removed both tubes, because it
has been observed that the other tube, if not re-
moved, would be likely to give the same trouble.
Left a good nurse with her, and had her given proc-
toclysis for three days, and she recovered nicely.
ft is my opinion that tubal pregnancy occurs
very much more frequently than is generally be-
lieved, and that nature takes care of the woman in
many cases, and the surgeon dose not see the case.
This case also emphasizes the fact that a patient who
is very ill from loss of blood may not be so bad
a surgical risk. A patient as ill as this one, and
whose condition was due to shock, instead of hemor-
rhage, would most likely die.
A CytteAkk
Case 2. — Mrs. X. came to the hospital for the
operative removal of a stone from the urinary blad-
der, the family physician having previously made the
diagnosis, by the use of the sound, and by palpa-
tion through the vagina.
She hid been troubled by this condition for sev-
eral years. More or less cystitis was kept up, and
the stone was so large she said she could feel it flop
over when she would turn over in bed. The stone
was removed by a supra-pubic incision, and measured
an inch in diameter, was circular in shape and was
quite heavy.
This case is cited because of the comparative rarity
of stone in the female bladder, and to remind us that
an enlarged prostate is not the only cause of a stone
in the bladder.
A Termti
Case 3. — Miss C. was brought to the hospital with
a diagnosis of acute appendicitis, of the ruptured
type, with peritonitis.
She had more or less rigidity of the abdominal
muscles, but the pulse and temperature did not indi-
cate peritonitis. However, the case was one of acute
abdominal trouble, and evidently a surgical case. The
point of maximum tenderness was on the right side
of the abdomen, at about McBurney's point.
Upon opening the abdomen, a large amount of
creamy fluid escaped, and ran off the operating table
upon the floor, where it immediately congealed. This
lead me to suspect a dermoid cyst, which was found
to have originated in the left ovary and proved to
be a teratoma. It had evidently been quite large,
judging from the amount of fluid that escaped it
the time of rupture. Lying in the sac of the ovarian
cyst was found a half of an inferior maxillary bone,
which contained several well-developed teeth, also a
ball of hair about the size of a baseball, which
looked as though it had been wrapped by hand. The
hair corresponded with the color of the patient's
hair.
The foetal inclusion theorv of Colinheim seems the
best, as to the origin of these cysts; and this case is
reported to emphasize the importance of operation, in
acute abdominal troubles. Also, in my practice, this
type of ovarian cyst has been very uncommon.
The EMcieucy of the Fowler ami Mmrprny Treatment
Case 4. — Was called to see a young woman, single,
age twenty-two, who lived about fourteen miles out
572
Some Interesting Surgical Cases — Hardy
[Phibddffca
in the country. Found her unconscious, temperature
104, pulse very rapid. Diagnosis of ruptured appen-
dix, with peritonitis, was made.
By this time the light of day had gone and the
patient was in a room having an open fireplace. We
had perhaps two or three drams of chloroform, but
plenty of ether. Oil lamps and lanterns were the
source of light by which to operate. The chloroform
was soon exhausted, and ether given within three
feet of an oil lamp held in the hands of a farmer
neighbor.
An incision was made in the appendicial region,
drainage tube inserted, patient put to bed in the
Fowler position, and Murphy's solution given by a
nurse who knew how. The patient recovered, and a
few months later came to the hospital, and I then
removed her appendix.
The Fowler and Murphy treatment were responsi-
ble for this girPs recovery. A few individuals, who
had not 'the nerve" to say so while Murphy lived,
are now doubting the efficacy of Murphy's Proctocly-
sis. One might say like in the Dakin-Carrell treat-
ment, "It is ninety per cent, technique," but we do
not wish to use such a statement. One who fails to
see the benefits of Murphy's solution, in pus peritoneal
cases, either does not have it properly given, or
there is a decided pathological condition of his per-
ceptive apparatus.
Had Murphy done nothing else, besides giving to
the profession this one boon, he would have done
more than any other one surgeon in the last century.
The Nepknlitk—A Pit* for Cmummthe Smrgtry
Case 5. — Mrs. E., aged forty-three, multipara. Had
been in poor health for two years. Anaemic, gen-
eral condition bad. Came to hospital for diagnosis
and treatment. Examination showed quite an enlarge-
ment of left kidney with a large stone present. In-
cision was made along the quadratus lumborum mus-
cle, and the kidney delivered. The kidney was in-
cised and about half a pint of pus released. The
stone was removed through an incision in the pelvis,
after which the pelvis was sutured. A rubber drain-
age tube was put into the kidney, and secured by a
stitch of number one plain catgut.
This drain was removed in ten days, and in three
weeks the patient left the hospital in good condi-
tion, and has enjoyed good health for five years since
operation.
A great deal of the kidney was destroyed by the
suppurative process, but I am sure that the healthy
part of that kidney is doing good work, and is a
very valuable asset to the owner.
This is a plea for conservative work on the kid-
ney. I am of the opinion that many useful kidneys
are sacrificed, that the surgeon may point with pride
to his living nephrectomy case.
Cases with multiple stones may be treated by drain-
age and removal of the stones, and later the kidney
may be removed if it is found necessary.
Serimu Imjwry, Pnamjt Smrgtry ami Skm CrmfU
Case 6. — Mary 0., age five years, was struck by a
large touring automobile and dragged for a distance
of fifty yards over a brick road. Most of the skin and
fascia had been ground off the right abdomen, and
downward on the thigh. Scarpa's triangle and its
contents were exposed. The anterior superior spine
of the right ilium and some more of the hip bone
had been ground off by contact with the brick road-
way.
She was brought to the hospital as soon as pos-
sible, and was found severely shocked. Treatment
for shock was instituted, and in the meantime the
urinary bladder was catheterized, with the result that
three or more ounces of urine, free from blood, were
drawn off. Shock had somewhat subsided, and 1
quickly opened the abdomen on the left side and
found no injury to the viscera, no blood or feces pres-
ent. We lost only twelve minutes by this procedure,
and we learned that she had a good chance for
recovery.
Had there been an intestinal rupture, and had we
waited until a diagnosis could have been made from
the symptoms, we would have lost our patient
We used skin grafts on the abdomen, which were
furnished by her mother and which were rather
disappointing. I have found autogenous grafts to
be far superior to homogenous.
The case is reported chiefly to illustrate that we
must have the courage to carry out our convictions.
The age of this patient and the serious nature of
her injuries made it a case to cause one to think
promptly and act quickly.
Smithsonian Institution to House Public Health
Exhibit
The National Committee on Exhibits Showing Ad-
vances in Sanitary Science has recently been formed in
Washington, D. G, for the purpose of collecting and
preparing material for a great popular public health
exhibit in the Capital. The members of the committee
include :
Surgeon General H. S. dimming, U. S. Public Health
Service, Chairman.
Dr. D. B. Armstrong, National Health Council.
Miss Mabel T. Boardman, American Red Cross.
Surgeon General M. W. Ireland, U. S. Army Medical
Corps. 0
Dr. Victor C. Vaughan, National Research Council.
Dr. C. D. Walcott, Smithsonian Institution.
James A. Tobey, National Health Council, Secretary.
Space for the proposed exhibit has been placed at the
disposal of the Committee by the Smithsonian Institu-
tion, which is visited by more than half a million persons
annually. Plans are under way to install exhibit material
secured from official and voluntary health agencies. The
secretary's office is m the National Headquarters of the
American Red Cross at Washington, D. C.
August, 1922]
An Effective Remedy f er Rheumatism aad Arthritic CeadHkme— Ott
573
Rheumatism and Arthritic Conditions
AND
An Effective Remedy
By Lambert Ott, M.D.,
1905 N. Broad St., Phila., Pa.
Member American Medical Association, Pennsylvania
State Medical Society, Philadelphia County Medi-
cal Society, Philadelphia Pediatric Society.
Rheumatism, a loose term, with a painful
pathology and empiric treatment, is a remin-
iscence of ancient medicine which so far has
successfully resisted scientific analysis. Dr.
Ott believes that he has established the
etiology and found a specific for this class of
morbidities. If so, this paper carries a mes-
sage of hope to the medical profession and
suffering patients. — Editors.
IN MY MANY YEARS of obervation of the so-
called rheumatic afflictions of joints producing
nodes, distortions, inflammation, ankylosis and de-
struction of elements comprising normal supple articu-
lations, I have been trying to ascertain the pathologic
causes and find a means of prevention and a curative
remedy. In our biological analysis we find many
theoretical causes, both in literature and bedside
study, so that there is ground for concluding that the
essential entity has not yet been discovered; or there
may be a combination of the multiple implied causes
which will require further examination and study.
The etiological factor has been elaborated by nu-
merous pathologists, giving many elements as the
source of the most common joint afflictions; the
bacteriological, the neurotrophic, the uric acid pre-
dominancy, staphylococcus pyogenes ind the diplo-
coccus, the microbes arising from foci of infection,
especially such as decaying teeth, diseased tonsils,
chronic middle ear and gall bladder infection and
other autointoxications arising from the perversions
of the alimentary canal.
I firmly believe in the infectious origin favored and
invited by the minor traumatisms producing a low
grade of irritation which renders the part a favor-
able nidus for location and destruction.
I base my belief on the following premises: The
small phalangeal joints, especially the distal ones —
as the index fingers in particular, are above all other
parts of the body exposed to traumatism, as in those
articulations is found in most cases the primal and
most frequent involvement of the articulations in
the human body.
The word traumatism as applied above needs more
explicit definition: The first and second phalangeal
joints are in our daily occupations either in sports
or labor subject to knocks, superflexion or exten-
sion, lateral stretching, concussions, twists and strains
which pass unnoticed by the individual because of the
minimum soreness — a low grade irritation — and foci
of infection resulting from the blood, the circulatory
medium, find an inviting area of lodgment and harm ;
once established as the source of infection and not
removed, a process of insidious disintegration fol-
lows. The index fingers have the greatest flexibility
for their manifold uses and therefore increasingly
subject to the slight trauma, seemingly insignificant
at the time, in middle life and beyond, having, accord-
ing to my observations the initial ossific developments
and these fingers involved are always affected with
larger nodes and are invariably a part of the phalan-
geal joint affliction, When the index finger articula-
tions are not involved one will find but a minor
thickening in the other fingers, and often no involve-
ment at all.
Imiex of Dmrmimm ami Extern***
The degrees of involvement of the distal forefinger
phalangeal joints is my index as to the duration and
extension of the disease. As the big toe- joint is the
point of election of gout, so the index finger is the
point of election of microbic arthritis ; although many
pathologists class the two diseases as having the same
origin, I find the distal joints first attacked and subse-
quently the larger joints, especially the knees. The
Jarger joints are the first to show improvement, under
medicinal and dietary treatment. The middle life or
beyond this period is the favorable age for the de-
velopment of nodulary arthritis. I seldom see cases
in the adolescent or young adult for whom acute artic-
ular rheumatism shows a predilection. Congenital
lues is to be considered where the articular inflamma-
tion has not the classical associated symptoms. I do
not recall a case of ever finding a patient with arth-
ritis deformans suffering with pulmonary tuberculo-
sis. This is merely a clinical experience. Also in
arthritis deformans there is a marked symmetry of
joints involved, usually more applicable to the smaller
An Effective Remedy for Rheumatism and Arthritic Conditions — Ott
joints. The diagnosis is readily made when the dis-
ease is advanced, but as its inception is insidious a
positive diagnosis is more easily made vben crepi-
tation, enlargement, pigmentation and glossiness of
the skin are evident.
Its steady progress is sometimes interrupted by a
quiescent stage without any ascertainable cause. No
two cases are alike and each one must be studied with
care as to treatment which I will outline in a general
way, having the physician in charge select such as
required for the individual case. The vast majority
of neuralgias, neuritis, myositis are caused by toxins
and morbid states of the blood found in the constitu-
tions known as gouty.
TrMbmtwt
In the Medical World, January, 1911, and the New
York Medical Journal, January 13, 1912, I called the
attention of the profession to the exceptional value
of the diacetyl derivative of methylene disalicylic acid
as being an unquestionable reagent especially destruc-
tive to the gouty or rheumatic poisoning — whether of
a uratic entity or bacterial toxin. That the joints of
children attacked by rheumatic inflammation recover
entirely, but the crippled heart never. That the con-
sensus of medical writers was to the effect that
salicylate of sodium and other salicylates and iodides
did not influence the duration of the disease; with the
quotation from the work of one universally recognized
authority — Osier's Practice, page 277:
"Salicyl compounds, which were regarded so long
as specific in the disease, are now known to act chiefly
by relieving pain. R. P. Howard's elaborate analysis
shows that they do not influence the duration of the
disease. "
In evidence that it is not the pain relieving or
analgetic properties of the acyl derivative of methyl-
ene disalicylic acid that causes the rapid subsidence
of the swelling and fever and the consequent abate-
ment of the pain, but that the duration of the attack
of acute inflammatory rheumatism could be curtailed,
and that the recovery would not have occurred just
as promptly without medical aid, I submitted in evi-
dence the clinical reports of three cases of most posi-
tive history of joint rheumatism from past genera-
tions. During every year of the previous ten, they
had been most persistently subjected to severe recur-
rent attacks of articular rheumatism in the acute form,
averaging a duration of four weeks and an interval
of recurrence of every three or four months. The
effects of those repeated attacks upon the finger joints
of those patients were also mentioned in detail. One
of those patients has since died from causes of alto-
gether different nature. The other two have not had
one recurrent attack during the past ten pears. They
did have the suggestion of an approaching attack, but
the prompt use of acyl-methylene-disalicylic acid pre-
vented any recurrence.
It is the importance of this fact in so pronouncedly
increasing the interval between attacks that proves
the reliability of my statement that it is in the chemi-
cal composition 9f this acyl-methylene-disalicylic acid
compound we have a veritable reagent especially de-
structive to the rheumatic poison.
In demonstration I showed the history of three
unique cases, of which I now report one of them:
Man, now aged 44 years, having a history of three
generations of joint rheumatism. A valvular lesion
existing. On extending the hands the fingers pre-
sented a concave dorsal surface, indicating destructive
absorption of some of the cartilages from repeated
attacks during the ten-year period of recurrent at-
tacks. He then had been confined to bed for six
weeks with both knees swollen, quite red and very
painful. He had been given the usual remedies of
salicylates, iodides, etc., but without benefit On
change of physicians he was given 30 grains of the
acyl-methylene-disalicylic acid every hour for the first
four doses, and the next day the doses were every
two hours apart. The pain disappeared— except some
caused by movement — and the redness and swelling
hod all gone by the following night. On the next
succeeding day he was up and dressed. He was in-
structed to continue its use in doses of 30 grains five
times daily for two months to loosen up his stiffened
condition from frequent repeated attacks during the
ten-year perijd. There was no influence on the heart
murmur or heart action. A looseness of the bowels
caused the use of 20 grains of subgallate of bismuth
to be administered every three hours for a few days
until the system established the toleration of the
aforementioned derivative of salicylic acid, which ne
was then taking without annoyance.
The case illustrated with the three photographs of
the hands was that of: Man, aged 69 years. For
forty years the joints of his fingers and toes gradu-
ally became more stiff and painful. Not by a direct
continuation in the increasing of the size and painful
movements, but through recurrent attacks usually
Fig. l.— s bowing b aii ils before treatment,
lasting from eight to ten days, that became more
frequent and protracted. In July, 1910, he suffered
the most severe and prolonged attack of any that he
An Effective Remedy for Rheumatism and Arthritic Conditions— Ott
bad ever had, which placed him in bed helpless. His
finger joints and wrists were swollen to over double
their normal size. Pain stopped mobility. His then
attending physician gave him frequent hypodermic
injections of morphine and sodium salicylate to the
fall extent of toleration. Whilst in this distressing
condition and before any abatement had become
manifest, through a change in physicians, he was then
given 20-grain doses four times daily of acyl-methy-
lene-disalicylic acid. The next day the swelling was
reduced and the pain was much less, with no desire
for the use of the morphia. On the fifth day of
this treatment he had recovered from this attack. He
then stated that he felt some improvement in the
mobility of his stiffened joints and was in general
more easy. He continued the use of the remedy. In
three weeks he noticed that the enlargement of the
finger and toe joints, that had been growing worse
Fig: 2.-
for two decades, showed signs of reduction, with an
increase in their flexibility. He persisted in the use
of that compound derivative of salicylic acid for one
year, averaging' about 90 grains per day. He is now
in better health, without one recurrent attack since,
and much more free of rheumatism than at any time
in the ten years prior to his use of that chemical
reagent. He is now working at his occupation as a
jeweler, in which he had gradually become fully in-
capacitated. The photographs of his two hands show
the joints fairly restored to normal size. The carpal
and metacarpal joints had been for a long time con-
siderably increased in size. There are still some effects
of disfigurement of the first fingers from the thicken-
ing of the capsule of the joints and the adhesions
formed between them and the ligaments and other
surrounding structures. Now there is movement in
every joint, without crepitus, thus manifesting a
thickening of the capsules of the joints without any
destruction of the articular cartilages. This important
diagnostic distinction of true' rheumatic arthritis :h
made clear by the use of this chemical reagent just
referred to, and serves to distinguish from that other
condition where the articular cartilages have been
destroyed beyond repair and callus material thrown
out to produce further deformity, where there is no
lubrication in the synovial capsule.
In the treatment of these heretofore intractable
conditions, considerable advance has been made by
the invention of the benzyl-ethyl esters of pyruvic
acid compound of methylene disalicylie acid. As a
curative remedy in decreasing the formation of uric
acid, with the saving of the nutritive values of the
protein foods the action of this synthetic compound
coincides with the statement of Percy Mays in his
text-book on the "Chemistry of Synthetic Drugs.-"
"The presence of organic acids in the organism
generally decreases the amount of uric acid formed,
and that effect is greater in proportion to the number
of carbon atoms in the acid."
As a systemic antiseptic, especially for the intes-
tinal tract where it increases the peristaltic action,
with laxative effect in small doses and purgative in
large doses, this synthetic is efficient. By its use I
have been able to cause the prompt subsidence of the
acute symptoms of arthritis deformans, inflammatory
rheumatism, acute gout and the eczema of rheumatic
origin. I have used it continuously over prolonged
periods in chronic cases without injury to the human
organism. And thus I have removed from the sys-
tem some of the defects of faulty metabolism.
In the case illustrated by the radiograph of the
foot, of a woman aged 54 years, this foot had be-
come almost ankylosed by deposits of urates in the
joint area. This trouble came on insidiously over a
period of ten week*), accompanied with pain in the left
knee on motion and pressure, with swelling and
crepitation. The heart, blood pressure and urine
appeared normal. She was given dibenzyl-diethyl-
mcthylene-disalicylic-dipyruvic (cinchoninic) acid in
20-grain doses every two hours, with graded exercise,
salt baths and colonic flushing. Gratifying results
were obtained in two weeks of this treatment. In six
weeks the results were striking. Much of the deposits
in the joint area had been absorbed with quite an
increase in the articulation. In two months there was
a major degree of flexibility of the foot.
Fig. 3.— Showing bands after treatment.
Another case of equally beneficial results in a pro-
nounced and unique case of rheumatoid arthritis:
G. B., male, aged 49 years, of good habits and good
576 An Effective Remedy for Rheumatism and Arthritic Omdittow— Ott [Fia-Up*
family history. He was suddenly seized with pains 75 per cent. More or less hypertrophy pervaded all
in nearly all parts of the body, excepting the hips, joints, producing pain on motion. Excepting a slight
The pains varied in intensity with intermissions and elevation in temperature in the evening he seemed
remissions, not severe enough to interfere with his normal otherwise, including blood pressure, blood
vocation of traveling salesman. Gradually and in- count and urine. He had in the early stages used
sidiously, swelling appeared in some of his artieula- considerable acetyl -salicylic acid. Then for some time
lions, especially the phalangeal, knees and ankles, he used acetyl methylene disalicylic acid. Being in
Tills root t
It had becoi
deposits.
Apart from his joint affection he seemed normal, intelligent man he is very well posted on the effects
He had submitted to all kinds of treatment, auto- of each kind if treatment. In consequence thereof Ik
serums, baths, baking, running the gauntlet of all can speak with some authority on that question. Three
methods without relief. Locomotion was becoming months ago he was placed on 30 grains of dibeojrvl-
difficult, especially in the ankle joints where the diethyl -methylene disalicylic -dipyruvic (rirtchonuue)
deposits seemed greatest, reducing the range of motion acid every three hours. After four weeks of this
Aofost, 1922]
Cancer of the Liver mad Gall Bladder — Goldstein
577
treatment there was noticeable improvement in his
joints. The ankles, which had most hampered his
locomotion, showed the greatest improvement. The
use of the synthetic just mentioned was continued in
conjunction with massage and general motion. As a
result there has been a marked improvement.
Children are also equally benefited by this new
invention, and they bear proportionately large doses
well.
In giving for publication my experience in obtain-
ing these beneficial results, I am returning what I
received from others who brought me knowledge on
the subject, and patients who had been recommended
to me by those who had had their attacks of rheuma-
tism, sciatica and gout abbreviated by me with this
treatment. I do it without fear, for the facts are
readily confirmed.
We have in this synthetic something tangible to
save the valves of the heart from permanent injury
from the erosive effects of the rheumatic poison,
without depressing the heart's action in the least.
Something efficient to meet the emergency with relia-
bility. Something positively curative when given in
adequate dosage with sufficient frequency. Some-
thing having no contraindications to its use as is fre-
quently the case with sodium salicylate and those
products whose continued use destroy the red blood
corpuscles, such as cinchophen.
Cancer of the Liver and Gall-Bladder
OFTEN CONFUSED IN DIAGNOSIS WITH OTHER DISORDERS OF GA3TRO-PYLORIQ DUODENAL,
HEPATIC OR CHOLECYST1C ORIGIN
By Hykan I. Goldstein, M.D.,
1425 Broadway, Camden, N. J.
Assistant Visiting Physician, Philadelphia General
Hospital; Assistant Visiting Physician and Chief
of Medical Clinic, Northwestern General Hospital,
Philadelphia; Assistant in Medicine, Post-Gradu-
ate Medical School, University of Pennsylvania.
CARCINOMA of the liver is the most common and
most important tumor we have to deal with in
this organ. Cancer may be, and not infrequently is,
associated with cirrhosis of this organ. Primary car-
cinomata of the liver parenchyma are rare, and
primary carcinomata of the bile-passages are very
rare. These primary cancers of the liver are derived
either from the epithelium of the parenchyma or from
that of the gall-ducts. The cells are usually poly-
hedral or cylindrical and may be grouped irregu-
larly in alveoli or may form more or less well-defined
tubular structures.
Age mad Typt W R—flmtm
Tiedemann states that sixty is the average age for
carcinoma of the gall-bladder, primary carcinoma of
the gall-bladder being chiefly seen in old-aged pa-
tients. Leiehtenstem says that primary carcinoma
of the liver oecurs in younger patients, the average
age being below forty. My own case of primary can-
cer of the hepatic duct and region of the fissure of
the liver (John Y.) was thirty-eight years old.
Gilbert and Claude (1895), Hansemann (1890),
Hercheimer (1902 and 1906), Sokoloff (1900), Gold-
zieher and v. Bokay, Eggel, Griffith and Castle re-
ported cases of primary malignant tumors of the
liver. Hanselmann (1900) and Blumberg (1912) dis-
cuss malignant adenoma.
In (L/Esperance) Journal Medical Research, 1915,
N. S. XXVII, 225, is described a rather atypical dif-
fuse carcinoma of the liver under the name of
"atypical hemorrhagic malignant hepatoma.19 Fischer
(1913) reported a unique case of primary chorloepi-
thelioma of the liver.
Secondary carcinomata of the liver are, of course,
very much more common than primary growths of the
liver. They are usually due to dissemination of
cells from cancers of the stomach, intestine, pancreas
or gall-bladder and at times they may be the result
of metastases from the breasts, esophagus, uterus and
other organs.
Howard (1890), Benner (1902), Deetjen (1894),
and Schreiber (1877) reported cases of primary car-
cinoma of the biliary passages.
Primary cancers of the gall-bladder were reported
by Brunswig (1893), Bwald (1897), Grawitz, Hart-
mann (1896), Held (1892), Oberwarth (1897),
Schmidt (1891), Seigert (1893), Tiedemann (1891),
Wagner (1863), Weber (1891), and Zenker (1889).
Harris (1885), Holker (1898), Laveran (1880),
Leichtenstern, Litten (1880), Naunyn (1866), Nolke
(1894), Willigk (1869), Weigert (1876), Waring
(1897), Wagner, Thorel, Skorna (1895), Sigenbeck
van Heukelom (adenocarcinoma with cirrhosis), Roh-
wedder (1888), Perls (1872), and Porter and Brooks
(1902) have reported cases of primary carcinoma of
578
Cancer of the Liver and Gall Bladder — Goldstein
[Philadelphia
the liver and discussed this subject.
In St. Bartholomew's Hospital Reports for the year
ending September 30, 1909, page 227, of the list of
specimens added to the Museum, there is mentioned
(2219a) a primary supra-renal type of carcinoma of
the liver associated with glycosuria. The centre of the
liver is the seat of a solid growth, faintly stained
by bile. It is encapsulated, but has replaced the
greater part of liver tissue. The patient was a
woman aged twenty-three years, a congenital im-
becile. She died six hours after an exploratory oper-
ation. There were no secondary deposits and the
pancreas and kidneys seemed healthy. Microscopic
examination showed the tumor to be a carcinoma of
supra-renal type.
It may not be out of place to discuss very briefly
some of the interesting features and symptoms of
malignant disease of the liver and biliary passages.
ic ami CUmdtdar EnlmrgemeM
In cancer of the gall-bladder and bile ducts the
liver is generaly enlarged. The liver enlarges be-
cause of the dilatation of the intrahepatic bile-pas-
sages, and later biliary cirrhosis develops. The pa-
tients usually complain of pain in the upper right
abdomen and a sense of fullness or discomfort in
the liver region. The pain may radiate to the chest
or the back, and under the right scapula. In Mac-
Kenzie's case, neuralgia of the right arm was one of
the prominent symptoms — he attributed this to the
anastamotic connection between the phrenic and the
fourth and fifth cervical nerves, branches from the
latter of which supply the shoulder and upper arm.
Pain over the liver may be due to irritation of the
nerves that enter the liver with the arteries or to the
tension of the serosa by the enlargement of the
liver.
Primary tumors seem to have a predilection for
the lymph-channels at the hilum, so that carcinomatous
infiltration of portal lymph-glands or of mesenteric
and retroperitoneal glands frequently occur.
Leichtenstern has called attention to a swelling of
the jugular gland that is occasionally observed, but
is not always present in primary cancer of the liver.
Jarchette, in two cases of carcinoma of the liver
which he reports, found, as an early sign, enlargement
of the supraclavicular and cervical glands.
Fever, Amewtia ami Jmmiice
In some cases of cancer of the liver fever may be
a persistent feature. It may be intermittent, remit-
tent, or irregular. In some cases the fever may be
long continued, frequently seen in rapidly growing
primary cancer of the liver.
Ebstein has called attention to a chronic recurrent
form of fever in lymphosarcomata.
Anemia may occur early and show a very low red
cell-count, even less than 1,000,000.
Symptoms from occlusion of the bile-passages are,
of course, particularly seen in cancers that start from
the common, hepatic or cystic ducts, or from the gall-
bladder. Of course, jaundice may be caused by
intrahepatic growths that lead to obstruction of the
bile-passages, by compression, or by direct growth or
by infiltrating the porta hepatis, producing cancerous
degeneration of the glands of the hilum or by com-
pression of the large bile ducts on the under surface
of the liver.
Atcite*
Ascites may result from compression of the portal
vein, or it may itself be occluded by new growth for-
mation which penetrates the walls of the vein. Car-
cinomatous metastases may develop at the hilum of
the liver and so occlude the vessel. Where cardiac
weakness occurs early with the liver cancer, symptoms
of portal stasis may become very evident at an early
date. Early cirrhotic changes in the liver may also
be concerned in the rapid appearance of ascites.
Hanot and Gilbert even go so far as to divide the
cancers of the liver and biliary passages according to
the symptomatology depending on the location of the
growth into a cachectic, icteric, dyspeptic and a
painful form.
A few cases of hepatic tumors have been operated
on, with success. Of course, such cases are rare, as
the neoplasm must be primary, no metastases must be
present, and the tumor must be so situated on the sur-
face of the liver that it can be completely removed by
an operation.
In a paper of this kind it is not essential nor de-
sirable to go into the subject of differential diagnosis,
prognosis and treatment.
Origin amd CkmrmcUriMic$ •/ Pr'ammry ami Secemdmry Cercmmm
Primary Carcinoma of the liver is divided into
several different types — such as the massive, nodular
and infiltrating cancer.
Hoppe-Seyler states that Hanot and Gilbert differ-
entiate between massive cancer, nodular cancer, and
cancer with cirrhosis. The last type corresponds to
adenocarcinoma (Siegenbeck van Henkolom) and the
adenoma of the liver described by Kelsch and Kiener,
Sabourin, and others.
According to the same author secondary carcinoma
of the liver may often be distinguished from the
primary form by the greater enlargement of the liver,
the formation of nodules on its surface, a greater
tendency to degenerative change, and to the formation
of depressions in the nodules. The tumors are usually
light in color, whitish-gray or greenish, and are fairly
definitely outlined, both on transverse sections and
upon the surface of the organ, from the rest of the
normal liver substance. The organ may weigh 8 kg.
or more. Cancerous thrombi are seen in the portal
vein or its branches in many cases of secondary cancer.
Bland-Sutton, in his little book (1910, p. 130) on
August, 1922]
Cancer of the Liver and Gall Bladder — Goldstein
579
"Gallstones and Diseases of the Bile Ducts/' says in
reference to cancer of the gall-bladder that cancer
may arise in any part of the mucous membrane of 'the
bladder and may spread directly into the subjacent
hepatic tissue. It is not uncommon for the gall-
bladder to be implicated with cancer of the liver, both
primary and secondary; it requires some care to dis-
criminate between primary cancer of the gall-bladder
infiltrating the liver and cancer of the liver, implicat-
ing the gall-bladder.
"The most important feature connected with
primary cancer of the gall-bladder is its almost
constant association with gallstones. Careful investi-
gations on this point prove that in at least 95 per
cent, of cases gallstones are present.'9 Bland-Sutton
further adds, that "although cancer of the gall-
bladder is nearly always complicated with gall-
stones, this association is quite exceptional when
primary cancer arises in the common bile duct or
the ampulla."
Primary cancer of the gall-bladder is three times
more common in women than in men (gallstones are
much more common in women), and the period of
greatest liability is between the fiftieth and sixtieth
years.
Bland-Sutton calls attention to the fact that the
beginning of the disease is very insidious and it is
remarkable that notwithstanding the presence of
gallstones, the familiar signs and symptoms of
cholelithiasis are usually absent. Primary cancer of
the gall-bladder runs a rapid course, and is usually
fatal within 6 months of the onset of definite symp-
toms. In reference to primary carcinoma of the
common and hepatic ducts, Bland-Sutton says, "it
is a rare disease" and that the association of gall-
stones with cancerous bile-ducts is uncommon.
Schnabel (Am. J. M. Scs., July, 1921, page 102),
says, "that gallstones predispose to cancer is a point
for much argument.,, "It is true that 70 to 90%
of operated primary carcinoma cases of the gall-
bladder are accompanied by stone. This is not true
for primary duct carcinoma." He intimates that
stones may frequently follow rather than precede
carcinomatous changes in the gall-bladder. He
further adds that "primary bladder malignancy is
sometimes accomplished by stone formation" and that
"secondary carcinoma of the gall-bladder seldom is
accompanied by stones."
Ernest Glynn (November 4, 1911, Brit. Med. Jour.,
p. 1192) states that "primary cancer of the liver is a
comparatively rare disease, and cancer associated with
cirrhosis is even less common."
Sixteen primary cancers of the liver occurred in
2,050 post-mortems made at the Liverpool Royal In-
firmary during 13 years. Of these 16, five were
associated with gallstones and apparently originated
i n the gall-bladder or large bile ducts ; in three of the
remaining 11 there was definite cirrhosis. He re-
ports a case of primary hepatic cancer with cirrhosis
in a man aged 49 years, a laborer by occupation.
Ascites and edema of the feet were present.
The liver weighed 119 ounces, the spleen 27 ounces.
There were a few scattered hobnails on the surface
of the liver. The left lobe measured 25 x 21 x 9 cm.,
while the right lobe was a little smaller, 18 x 10 x 10
cm. There was considerable compensatory hyper-
trophy of the Spigelian lobe. The enormous enlarge-
ment of the left lobe was almost entirely due to
compensatory hypertrophy. Here and there ap-
peared green and yellow adenomatous nodules, cir-
cumscribed by fibrous {issue from 1 (o 2 cm. in
diameter. The right lobe showed the usual appear-
ance of multilobular cirrhosis. Malignant tumor was
in the right lobe, and an adenocarcinoma.
Glynn refers to two other cases of cirrhosis with
carcinoma, one in a man aged 32 and the other in a
butcher aged 54. There was an alcoholic history in
all three of his cases. He mentions cases reported
by Drennan (1911), Beattie (1911) ; Van Huekelom
(1894), who gives a table of 30 cases; Muir (1908),
and others. The liver in Glynn's case was remark-
able because of the great variation in the extent of
the cirrhosis, and the different types of growth
affecting different portions of the liver, namely,
hyperplasia, hypertrophy, adenoma, and carcinoma.
He says the growth evidently originated in the hepa-
tic cells, not bile ducts.
Castle (Surgery, Gynecology and Obstetrics, p.
477, 1914, XVIII) states primary carcinoma of the
liver at any age is rare. He reports a case of the
massive type of primary parenchymatous adeno-
carcinoma of the liver in a male infant aged 10%
months old. He tabulates a total of 42 cases of
primary hepatic cancer in childhood, (under 16 years
of age). He states that his is the first case reported
in which complete surgical excision was done. He
refers to cases reported by Hanot and Gilbert" (24
cases — in adults), Deschamps, Wulff, Eggel (117
cases microscopically diagnosed), Pepper, Pye-
Smith, Phillip (12 cases authentic — in childhood),
Karsner, Ackland and Dudgeon (report 7 cases and
their own in a boy aged 15 years), Burt, Peifer (9
months old infant), Fussell and Kelly (girl aged 16
years), Nagasawa and Nakamura (17 months old
infant); Miwi and Saito (girl, 5% years old),
Yamagiwa (girl, 1 year old) ; Musser (tabulates 10
cases of hepatic cancer occurring in childhood),
Kotlman (9 years old), and Birch-Hirschfeld (aged
12 years). Idzumi's case of primary hepatic carci-
noma occurred in an infant aged 7 months.
Miwi and Utsumi reported a case similar to Naga-
sawa and Nakamura's case.
Hanot and Gilbert (Etude sur les Maladies du foie,
1888) say that primary cancer of the liver presents
580
Cancer of the Liver and Gall Bladder — Goldstein
[Phibdelpha
its maximum frequency from 40 to 48 years, is rare
from 30 to 40 and is exceptional under 30. White
believes the proportion (as estimated) of undoubtedly
primary to secondary carcinoma of the liver is as
1:25.
Magoun and Renshaw (Ann. Surg., December,
1921, p. 700), in their paper on "Malignant neoplasia
in the gall-bladder" state "primary sarcoma is con-
sidered exceedingly rare;" Rollestone (1914) cites
only fourteen references to this type of growth. In
my paper on "Primary Sarcoma of the Gall-bladder"
(Amer. Jour, of Surg., November, 1921, p. 361) I
stated I was able to find only about sixteen authentic
and accepted cases of primary sarcoma. In a review
of the literature Magoun and Renshaw mention the
three cases of cancer of the gall-bladder reported by
Stoll (two in 1777) and by Halte (one in 1786), a
doubtful case reported by Baillie (1794) and 7
cases reported from 1800 to 1850. Durand-Fardel
(1840) being the first fully to describe the condition.
They quote Fawcett and Rippmann's statistics of 48
cases of malignant disease in the gall-bladder, found
in 592 necropsies in cases of gallstone. Deaver's
series of 1,000 operations for gallstones with 1.6%
malignancy and Smithies' series of 1,000 operations
on the gall-bladder with 2.3% malignancies.
Musser found stones in 69% of the cases of pri-
mary malignant disease of the gall-bladder, Deaver
in 89% and Courvosier in 91%.
From January, 1907, to January, 1921, 7,878
operations were performed for gallstones at the
Mayo Clinic. Within this period primary malignancy
of the gall-bladder was found in 84 cases — 82 cancers,
1 epithelioma, and 1 lymphosarcoma. The lympho-
sarcoma involved both the fundus and the pelvis.
38 cholecystectomies were done in the series of 84
malignant cases and stones were found in 37 of 'the
38. The epithelioma case was unaccompanied by
stones, while the lymphosarcoma was associated
with them.
Frank Smithies, of Chicago, reviewed 23 cases of
primary cancer of the gall-bladder (in the American
Journal of Medical Sciences, 1919, CLVII, p. 67).
ReftremctM
Appel (Arch. f. Schiffs- u. Tropen-Hyg., Leipzig,
1921, XXV, 309-314) reported a case of multiple
adenocarcinoma of the liver in a negress.
Buscemi (Riv. d'ostet. e ginec. prat., Palermo, 1921,
III, 383-388) reports a case of primary cancer of
the liver in a pregnant woman.
Massey (Jour. Trop. Med., London, August 15,
1921, XXIV, 216) discusses cancer of the liver in the
African native.
In Annales de M6decine, Paris (X, 295-302, Octo-
ber, 1921, No. 4), /. Catsaras reports a case of pri-
mary eancer of the liver with metastasis in bone. The
primary adenocarcinoma in the liver with cirrhosis
had entailed metastasis in the head and neck of the
right femur. The cells of the tumor in the femur
showed 'the same arrangement as in the liver, and
abundant production of bile, the tumor tissue bong
deep green in color. He was able to find only one
other case on record in which there was metastasis
in several bones from a cancer of the liver. His was
the second case.
S. Matsin (Gann, XV, 4, February, 1921) reports
an instance of primary cancer of the liver, and de-
scribes some special histologic findings, emphasizing
the resemblance between hepatoma and malignant
syncytioma, from both the morphologic and metastatic
standpoints.
Recently (May, 1922), before the Association of
American Physicians, Br. Geo. Morris Piersol and
Dr. Bockus, of Philadelphia, reported favorably on
the use of phenoltetrachlorphthalein (Hynson, West*
cott, and Dunning) as a liver function test. They
tried this out in about fifty cases at the Polyclinic
Hospital, Graduate School of Medicine, University of
Pennsylvania, and found that the elimination of this
dye was definitely decreased in liver disease. They
used the Rehfuss and Lyon duodenal tube for ob-
taining the specimens.
Smmmmry of Tlmr Techmqme
(1) With the tip of the duodenal tube in the
duodenum 150 mgms. of the di-sodium salt of phenol-'
tetrachlorphthalein are injected intravenously. [Each
cc. of solution containing 50 mgms. of dye.]
(2) Time of injection is recorded.
(3) 500 cc. of water is given by mouth every
half -hour to insure a constant drip from the tube.
The dye is not injected until this drip has been
established.
(4) The bile stained fluid is collected in white
basins. The appearance time of the first faint pink
color is recorded as the first appearance time and
that of the maximum intensity of color (purple) is
recorded as the maximum color change. (3 or 4
cc. of 40 per cent. NaOH is added to the basins to
bring out the color.)
(5) All the bile eliminated through the duodenal
tube over a period of two hours following the in-
jection of the dye is collected in basins, each half-
hour's output being segregated.
(6) The dye excreted is separated from the bile
and the amount estimated by a simple colorimetric
method.
(1) We have presented here a technique in detail
which we believe yields information of decided value
concerning the functional competency of the liver.
(2) As the duodenal tube is now being generally
(Continued on page 592)
I
Anfut, 1922]
The Anti-Malaria Campaign — Rand
581
The Anti-Malaria Campaign
By W. H. Rand, M.D.,
1440 Clifton Street, Washington, D. C.
Malaria, a problem of ages, is still a prob-
lem of today. We have discovered its
etiology. We learned its mode of pretention,
control and cure, but we still have it and we
have it because we fail to enforce the several
factors concerned in its eradication, as we
learn from Dr. Band's excellent paper. —
Editors.
TWO CONDITIONS are prerequisite for the
genesis of malaria. First, there must be an
unprotected or non-immunized man; and, second, an
infected mosquito to bite him. These are the neces-
sary dual antecedents of malaria. Eliminate either
of the factors and the disease cannot exist.
Hence, it follows that the man whose blood is
charged with sufficient quinine to kill the Plasmodium
malariae will remain immune to the infection when
inoculated with it; or, though unfortified by qui-
nine, he will still escape the disease, provided he is
shielded by mosquito bars and screens, so that the
germ-bearing anopheles cannot get at him.
But the anopheline mosquito is not infected when
she emerges from the stagnant pool which serves
as her procreant cradle, and she remains inocuous
until she ingests blood drawn from a victim of
malaria. Then she becomes a menace to the com-
munity as intermediate hostess of the parasite of
malaria, and in about nine days she is capable of
conveying the infection to all that come within reach
of her proboscis.
There are, therefore, but two requisites for prophy-
laxis. The first consists in immunizing the man
against malaria by einchonizing him. The other
means is to prevent mosquitoes from obtaining ac-
cess to susceptible people and to malarial patients
alike. Unimmunized persons need protection from
the insects in order to escape infection from their
bites, and mosquitoes must not be suffered to feed
upon malarial patients, for by so doing they would
contract the infection and spread it far and wide
among: the victims of their thirst for blood.
Mtdmrim Frevemtiom
The best way to rid a locality of mosquitoes is to
make their habitat intolerable for them. Drain
swamps, fill in marshy ground, let top minnows
feed on the larvae incubated in ponds, oil the sur-
face of stagnant water; in short, destroy their breed-
ing places, and you abate the mosquito nuisance at
once.
Render a man's blood-stream lethal to malarial
protozoa by saturating it with quinine, and the para-
sites will soon die in the uncongenial environment.
However, these are not alternative expedients, but
co-ordinate procedures, both of which should be em-
ployed simultaneously, for it is not safe to rely
exclusively upon either measure alone, since per-
fect observance of a sanitary regimen cannot be
expected or enforced. Each of these preventive
measures supplements the other, and in combination
they constitute a complete system of prophylaxis.
Of course, there is nothing new in the foregoing
recital. The conditions necessary for the control
of malaria are everywhere understood and admitted,
and the sole reason that the familiar facts have
been cited in this connection is that they constitute
a common basis of agreement as to the measures
requisite for the conquest of an infection which
from remote antiquity has wrought greater damage
to mankind than any other disease, with the possible
exception of tuberculosis, and it is often the precursor
of the great white plague.
Rnphytmdk EMcitmcy
Now it is demonstrable that, whenever and wherever
the attempt has been made to apply the principles of
prophylaxis to the solution of the malaria problem,
either on a large scale or in a limited area, a grati-
fying measure of success has uniformly rewarded the
endeavor. Data to support this claim are abundant
and unequivocal.
For example, in Italy during recent years an
aggressive eampaign against malaria has been car-
ried out under governmental authority. At the be-
ginning of this century, sixty-three of the sixty-
nine Italian provinces were infected, and the mor-
tality from the disease in fifteen years (1887 to
1901) aggregated 227,265. About 12,000,000 sub-
jects of King Victor Emmanuel were at that period
subject to the odious domination of paludism, the
morbidity among residents of the malarial zone
being 87 per cent, of the entire population. In 1905,
the rate fell to 25 per cent, and to 6 per cent, in
1914.
This reduction of malaria is due to the activity of
the public authorities in enforcing sanitary legis-
lation, which Professor Celli's experiments caused to
be enacted after the futility of drainage, screening,
582
The Anti-Malaria Campaign — Rand
[Philadelphia
etc., in that country had been demonstrated.
Quinine
Celli gives a detailed account of the experimental
distribution of quinine as a preventive, first at Cer-
velletta, and subsequently in the Roman Campagna.
He cites instances where mosquito nettings were
used around beds, and where irrigation waters were
treated with kerosene. "But in spite of all that,
malaria persisted in the gravest form until within
the last few years, when quinine prophylaxis has
been strictly required of every inhabitant, causing the
disappearance of the disease." (The Restriction of
Malaria in Italy, p. 528.)
Under the Italian law, employers must pay for
the quinine which is supplied gratuitously to work-
men in malarious localities. Twenty-four hundred
kilograms of quinine tablets are distributed annually
to the employes of the Italian railways. In 1920
more than 2300 of these workmen were immunized
at a cost of 100,000 lire. (II Lavors, July 31, 1921,
p. 93.)
Since the epoch described by Celli there has been
an epidemic recrudescence of the disease. Perhaps
the war may have demoralized the health service.
However that may be, in 1920 21 per cent, of the
personnel of the Italian railway force were victims
of the infection. The lax administration of sanitary
law naturally incurs a penalty, and this example
illustrates the necessity of continuous, unremitting
quinine protection.
The Preventable Not Prevented
The report of the Sanitary Commission of the
British Government in India for the year 1918 re-
veals the fact that an inefficient and makeshift policy
prevails there in reference to malaria. The situation
in that country is indicated by the following ex-
tract from the official report of the medical direc-
tor: "As malaria is undoubtedly a preventable dis-
ease, the old query, if preventable, why not pre-
vented f will continue to be asked. If the sanitary
measures required were carried out, mosquitoes would
cease to be prevalent. If quinine were administered,
the troops would be rendered immune; if mosquito
nets were used, they would be protected. The results
that have been obtained in Italy, Panama and else-
where prove beyond question that under the most
difficult conditions of environment, satisfactory
prophylaxis is practicable." (Lancet, June 25, 1921,
p. 1394.)
Everywhere one hears enthusiastic approval }f
the comprehensive system of malaria suppression
practiced so successfully in Italy and at Panama,
though individual opinion may regard with too ex-
clusive attention a single phase of the preventive
treatment.
When this subject was under discussion, at the
Fifteenth International Congress of Hygiene and
Demography in 1912, Dr. Craig, of the Medical Corps,
U. 8. A., declared that the results achieved in Italy
"furnish an incontrovertible argument in favor of
quinine prophylaxis." Prof. Wellman, of New Or-
leans; Dr. Thayer, of Baltimore, and others ex-
pressed the same opinion, deeming quinine indis-
pensable for the control of the infection.
Drainage ami Screening
Dr. Orenstein maintained that in Panama "drain-
age was the best defence against malaria," and this
view was apparently endorsed by Col. Havard,
who referred to the extensive drainage work done
by the Italian Government as an important factor
in malaria control.
Col. Mans emphasized the importance of barrack
screening with wire counting eighteen meshes to the
inch, "since both the anopheles and the stegomyia
can pass through the sixteen-mesh screens."
This fact is too often ignored, and the screen-wire
usually kept in stock at hardware shops and used
for door and window screening is of the fourteen-
mesh gauge. Anyone that carries a tape measure
may easily verify this fact for himself. It is in-
effectual screening with wide-meshed wire, which
often nullifies all other measures of malaria preven-
tion; for, while fourteen-mesh screen-wire serves to
* keep out flies, it is no barrier to the anopheline mos-
quito. Personally, I have been unsuccessful in my
hunt for screen-wire finer than fourteen-mesh to
the inch in this neck of the woods.
Covering the screen with a coat of paint or var-
nish, however, narrows the interstices of the wire
netting so that mosquitoes cannot pass. This ex-
pedient also prolongs the life of the wire.
Accessary Agenciet e4 Prevention
Among the accessory agencies or methods of
malaria prophylaxis enumerated by Professor Rage,
of Kiel, during the discussion of this question were
the introduction into mosquito-breeding waters of
fishes which feed upon the larvae of the anopheles;
destruction of water plants which are a shelter and
hiding place for the larvae; the use of petroleum as
a larvacidal film on the surface of undrainable pools;
effective screening; thorough drainage of swampv
land; quinine preventive treatment; and the segre-
gation of newcomers from the native inhabitants. (Die
Bekampfung der Malaria, Trans. 15th Int. Cong, of
Hyg. and Demog., Vol. V, Pt. 2, pp. 631 to 542.)
In his Rapport sur la Lutte contre le Paludisme,
Edmond Sergent describes an ingenious measure in-
stituted by him in Algeria, where the irrigation
ditches form breeding places for mosquitoes. It con-
sists of an intermittent or alternating water supply.
The ditches are allowed to become dry at weekly inter-
vals, so that the larvae perish. "To attain this ob-
August, 1922]
The Anti-Malaria Campaign — Rand
583
ject it is sufficient to have two ditches operating
alternately." (16., p. 637.)
Prior to 1904 the Panama Canal zone was one
oi the most insalubrious regions in the world on
account of the prevalence there of malaria and yel-
low fever, both mosquito-borne diseases. As everyone
knows, that pestilent country has been transformed
by sanitation and made inhabitable, so that white
people in the civil and military service are able to
maintain robust health and engage in strenuous
work in a terrain which was once shunned as a
graveyard of the human race. The construction of
the Isthmian Canal was made possible by the sani-
tary reclamation of that Gehenna, and the success-
ful administration of the great waterway is abso-
lutely contingent upon the maintenance of hygienic
conditions there.
Preeeiemce im ike United Sietee
it were devoutly to be wished that conditions fav-
orable to malaria] infection could not be found to
exist anywhere within the jurisdiction of Ihe United
States outside of the canal zone. But it is impos-
sible to ignore the unwelcome fact that the inci-
dence of malaria in some of the states of the Union
exceeds the ratio of its prevalence in Panama at a
period prior to the occupancy of that territory by the
United State*;.
In Arkansas, according to Public Health Bulletin,
No. 88, (September, 1917), "Malaria is widely preva-
lent in a sevnie form, and exerts a sinister influence
on the sanitary and economic well-being of a large
population." The report adds that malaria is "the
chief cause of all illness in this region, and responsi-
ble for a high proportion of pernicious attacks,
hemofrlobinuric fever and deaths." (p. 8.)
In this unpromising environment the Public Health
Service began control operations in April, 1916. It
vas a formidable undertaking. But the work was
>lanned and prosecuted with the energy and system
>f a military campaign. As a result, the incidence
►f malaria was reduced 77.33 per cent, in a single
eason.
To appreciate the scope of this achievement, one
lust remember what was involved in it. There were
ro bl ems of hydraulic engineering to be solved. House-
greening against the anopheles required patience and
lertness. Extermination of mosquito larvae in their
idifl cation lairs demanded knowledge and skill. Im-
lunissation of the people and sterilization of the
ifected called for a standardized treatment which
nly qualified physicians could give.
Eraiieetiem Ernsy
Whoever reads the fifty-ftve-page history of this
sa. I tli crusade will gain from the perusal an inkling
? toe difficulties met and overcome, and will frankly
Imire and profoundly respect both the character
and the devotion of the crusaders.
It is not, then, an illusion of hope or the vagary
of an unbalanced mind to anticipate that, in the
near future, malaria may become extinct. It has
already been demonstrated by hard-headed sanitarians
that control of the infection is not only feasible, but
easy. The sole requisite is that communities should
be made to understand the situation and to realize
that emancipation from the bondage of the disease
is assured, if people want it. The descendants of
ancestors who won their independence f rom a royal
parasite will not forever submit to the domination of
a parasitic insect.
Already patriot groups are in revolt against the
tyranny of the mosquito. In New Jersey public
sentiment is aroused, and soon the incubus of ma-
laria in that state will be shaken off "like a dew-
drop from a lion's mane."
The price of the new freedom is not prohibitory.
Near Augusta, Georgia, on July 18, 1921, anopheline
mosquitoes were found in great numbers, and a
neighboring pond swarmed with their larvae. On
July 19, two thousand top-feeding minnows were
transferred to this pond. On July 20, no wiggle-
tails were visible. "The cost in this instance for
complete, prompt and continual control of mosquito
production was not more than $1.00." (Public Health
Reports, September 9, p. 2221.)
Tke DdtcmUy el CemtreU'mt ike Heme* F meter
Unfortunately, it is more difficult to control the
human factor that helps to multiply and perpetuate
malaria. Men cannot always be induced to adopt
protective measures in order to promote the general
welfare. On this point an editorial comment in the
American Journal of Clinical Medicine >f May, 1917,
is so apt as to justify its reproduction here:
"Were it a question of inoculating the cattle or
sheep, it could readily be accomplished, but man —
it would be more arduous than any cleansing of
stables Augean to pass in review the entire popu-
lation of the malaria sections to detect those in whose
systems lurked the plasmodia and to eradicate the
parasites with effective plasmodicides. Yet, by so
doing we should reduce the possibilities of malaria
infection to the few who might escape disinfection
by the imperfections incident to the practical
application of the method."
In the long run the propaganda of hygiene is sure
to attain its goal. Ultimately health will become
fashionable and invalidism unpopular. This implies
that the obstacles which impede the progress of sani-
tary reforms must be removed. Malaria is one of
these, and as the Roman orator concluded every
speech with "Delenda est Carthago," (Carthage must
be destroyed) so should the public health worker de-
584
Conduct of the Third Stage of Labor — Gordon
[Philadelphia
mand with repetition and emphasis the absolute sup-
pression of this infection.
Some day, as civilization advances, nations will
relegate war (the fine art of wholesale murder) to
a subordinate place as a means of redeeming the
world, and will cease to venerate the kiilers of man-
kind. In the new earth that is to be, monuments
more enduring than brass shall be erected to the
memory of those who, in every age, have labored
to safeguard the lives and promote the health of
their brother men.
Conduct of Third Stage of Labor — Cordon
(Continued from page 566)
4. A patient, a primipara, aged thirty-five years,
was under the care of another physician, who called
me to give the anesthetic for a forceps delivery,
after thirteen hours' labor, during which she had
received four injections of pituitrin. After delivery
there was considerable hemorrhage. The bleeding
could not be controlled by massage of the uterus.
In spite of urgings to remove the placenta manually,
he continued his efforts to massage the uterus and
in pulling on the cord, tore it off at its insertion
into the placenta. Only when the patient was mori-
bund would he recognize her serious condition. The
patient died. The fear of entering the uterus had
been so instilled into him that he waited too long.
Medical Diathermy — Folkmar
The following summarized cases are illustrative of
some of the above conditions.
1. Placenta Circumvallata.—FbeTVLary 28, 1920, I
manually removed a placenta circumvallata from a
primipara aged twenty years, who had been deliv-
ered after a normal labor of eighteen hours, with-
out cervical or perineal lacerations. After the usual
attempts to deliver the placenta by expression, pitui-
trin, and Crede during two hours, she was allowed to
rest for several hours since there was no hemorrhage.
The placenta was fully adherent in the right cornu.
2. Adehsion t) Fibroid. — In August, 1921, I was
called to deliver a patient for Dr. Adolph Ruff. She
was a multipara who had no history of difficulty in
her previous labors. A fetus in transverse presenta-
tion was delivered by podalic version. There was
sharp hemorrhage, which was controlled by massage
of the uterus, but which recurred when the uterus
relaxed. Manual separation of a partially adherent
placenta was accomplished in what at first felt like
a bicornuate uterus. The condition proved to be a
submucous fibroid about three inches in diameter, to
which the placenta was adherent over part of its
surface. The placenta was partly atrophied over
the area of adhesion. Growth of the tumor had prob-
ably occurred after the placenta had developed.
3. Adherent Polypus of Chorion Near Placenta. —
On December 4, 1921, I delivered a tripara, aged
thirty-two years, of a seven-pound child after a dry
labor of six hours. With the head at the outlet,
seven minims of pituitrin were given to stimulate
the uterine contractions which had lessened in force.
After delivery of the child she was given seven more
minims of pituitrin. There was a steady oozing of
blood, which was only partially controlled by mas-
sage. An ampoule of pituitrin was given during the
next hour, and during the following half-hour two
Orede expressions were tried. These nearly caused
syncope and were not further employed. Manual
exploration showed adhesion of an atrophied chorionic
mass close to the upper edge of the placenta.
These patients made uneventful afebrile recoveries,
(Continued from page 570)
portant to prevent deforming sequelae as it is to
properly apply a splint or to prescribe a drug.
The laymen now demand radiographs in the case
of dislocation or of fracture; and they will soon de-
mand diathermy in the treatment of many joint and
bone lesions.
In the last paragraph of my article on Medical
Diathermy appearing in the June issue of the Ameri-
can Physician, I stated briefly that Dr. Sampson had
demonstrated the importance of exposure to the
actinic rays before giving x-ray treatments.
Dr. Sampson's (Major Chris. M. Sampson) paper
will be published in the American Journal of Electro-
therapeutics and Radiology, But in justice to Major
Sampson, who has been doing very commendable
work in developing a technique which renders the
skin more resistant x-ray burns, and to the readers
of the American Physician who may not see Dr.
Sampson's paper, I wish to quote a few conclusions
from Dr. Sampson's paper which he has permitted
me to read. He says "Surfaces tanned gradually by
exposure to sunlight or weak application of the
actinic ray without erythema being produced show a
slightly increased tolerance to x-ray dosage, but noth-
ing like the increase caused by repeated heavy ery-
thema, rapidly produced, by the Quartz mercury
burner. This increased tolerance seems to follow
whether the surface tans or not, but possibly not so
great a degree where tanning does not take place.1'
Major Sampson not only proceeds x-ray treatments
by a course of actinic ray exposures, but he follows
x-ray dosage by more exposures to actinic rays. He
states that by this technique he has been able to
"greatly exceed doses, which before the use of this
method, regularly gave us a dermatitis, without a
single depilation occurring or symptoms which indi-
cate that a dermatitis had occurred." Dr. Sampson
feels that much more research work must be done to
determine to what degrees x-ray dosage may be
safely increased when the actinic ray is employed in
conjunction with x-ray therapy.
This Journal, having now published several articles proponent
of Diathermy, wishes contributions on the subject from phy-
sicians whose experiences with this measure have not been en.
tirely satisfactory. The profession wants both sides. — Editors.
Efficient Organization of Medical I ractice
THE GENERAL PRACTITIONER IS THE FUNDAMENTAL FACTOR IN EFFICIENT MEDICAL SERVICE
While surgery, the specialties, hospitals, people are to be served, the primary «m- ordinated in constructive co-operation with
institutional medicine, public health work, portance of the function of the General the essential service of the Family Physician,
industrial medicine, etc., have their definite Practioner must be recognised. Other divir This is an integral purpose of The American
functions, if the best health interests of the sions of medical service must be properly co- Physician.
That Vexed Question of Diagnosis
DR. J., OF CLEVELAND, complains that the
general practitioners fail to take advantage of
cystoscopy, urethral catheterization, renal function
tests, pyelography and other diagnostic means in
their management of urologie conditions. Dr. B., of
Oh '-ago, blames the family doctor for neglecting serial
titration in the determination of total gastric acidity,
Uffleman's test for lactic acid, Hanimerschlag's method
for estimating peptic activity, etc. Someone else
blames him for not employing the meiostagmin reac-
tion in serodiagnosis, and fifty-seven other kinds of
specialists become equally excited over the fact that
their pet diagnostic measures are not employed by
every general practitioner in the land. Sometimes
we wonder how many of these perfervid special
pleaders could make a full and consistent, bedside,
physical diagnosis, such as the general practitioners
become skilled in making.
We are quite willing to concede the value of
probably 25 per cent, of the diagnostic measures
exploited and the concession includes the admission
that an equal percentage of the specialists know
what these diagnostic findings mean in the con-
crete case before the real and final diagnosis is ar-
rived at by ordinary clinical means. To come to
the point, most of these special tests are merely
contour lines in a topographical survey of the whole
ease, no one line counting for much until after the
chief engineer — the general practitioner — goes over
the map and sizes up the whole situation, determin-
ing1 what is to be done and the far greater number
of things that do not need to be done. If all of the
findings of the specialists actually led to doing things,
the patient would be "done to death" with a maze
of instrumentations and special measures human flesh
could not stand.
The DmgmaUc Tower ok BaM
We are led to these observations from a letter
received from a former colleague now practicing in
Los Angeles, and in which he says the general prac-
titioner is almost extinct there, a maze of specialists
treating the case medically, surgically, osteopathically,
chiropractically and psychopathically until the pa-
tient lands in one of the hospitals, where he finally
gets sane attention and may get well after recovering
from the multitude of things that have been done
to him and his pocketbook.
Los Angeles is only a few jumps ahead of the
rest of the country in this, as in other things, so
we can see what we are coming to back East. 'Tis
not a consummation devoutly to be wished.
Seriously, it is not the fix of the general practi-
tioner that we are mourning over, for he can become
a specialist himself in short order and profit finan-
cially by doing so; but it is the menace to medicine
itself and the public health in particular that con-
cerns us. The question is, how shall we unscramble
the messf A clever Japanese gentleman has de-
scribed the United States as "The Land of Liverty."
It is: also of kidneyty, appendixty, hormonety and
insanity. Our people are wild on having things done
to their interiors and finding out what the specialists
think ought to be done; and it is becoming a very
profitable line of business to exploit this national
weakness. In this, we must admit, the medical pro-
fession itself is taking its full share.
Shafting Roam Engineering
Let us give a parallel illustration. One can spend
four years in a university becoming a landscape
engineer, learning French, German, botany, psy-
chology, mathematics, ecology, nomenclature and
pretty drafting ; and then the graduate goes out advo-
cating some school of design, wears fine clothes and
sets up as a professional adviser at so much per hour.
But the experienced gardener and contractor walks
circles around him, gets the business, and lets the
college man strut — and starve. This poor chap, full
of professional enthusiam, gets up a water-tight or-
ganization of his kind and asks for a State Board
to protect him and keep the practical men out. We
medical men can't throw any stones at bim; for we
have pursued the same tacties ourselves, the result
586
That Vexed Question of Diagnosis
[Philadelphia
being that we have also evolved some very pretty
technic, split up into specialists, strut — and there
are many educated doctors working in diagnostic
laboratories at starvation wages instead of being
useful practitioners where they are actually needed.
Now, all of this is drafting room engineering, the
chaps in the drafting room being poorly paid college
men after they have failed in business for themselves,
while the hard-fisted field foremen and headquarters
ofificers-^usually not college men — pull down big
money. It is rapidly coming to the same thing in
medicine. At present the drafting room men in medi-
cine are trying to belittle the field workers, splitting
up into narrow specialties. It is easy to see what will
happen. The big engineering firms are printing
standardized designs on tracing cloth, employing
cheap draftsmen to letter in dimensions and shop
directions, making blue prints from such a tracing,
and getting to work outside in a business-like way
with Mike and Jake getting the big pay every week
to stuff down in the pockets of their greasy overalls,
and the big Corporation getting the profits. The
engineering profession is only a few jumps toward
poverty ahead of us; and the big foundations, exclu-
sive hospitals, etc., will soon put us where they think
we belong. The specialists who depend mostly on
laboratory findings Will then be in the position of the
college graduates getting seventy-five dollars a month
in the drafting room.
Even now the big-income men in medicine are the
ones who know how to do things with their hands.
These men have taken the advice of the old Yankee,
"Always whittle toward you."
The time is fast coming when it will be the field
man in medicine who nakes the money; and even he
will not do it if the medico-political line-up of today
gets its way, except for the few favored ones. Despite
the ultra-scientific sound of our modern laboratory
technic and diagnostic methods, girls and young
women, not medical graduates, are being trained to
do it because they will work cheaply, and because it
really does not take a medical education to do the
work. As in engineering, science has entered the
medical field and has given opportunity for shop
standardization. If you don't believe this, go through
Henry Ford's Hospital in Detroit and keep your
eyes open. Is Uncle Henry running that hospital to
help the medical profession at large f It is a good
hospital, at that, but most of the doctors in Detroit
never saw the inside of it beyond the office. One
can't blame Uncle Henry, either.
The Remedy
Doctor, view yourself* as an engineer; and be a
chief one doing field work, just like general prac-
titioners have long been doing. But buck up. Don't
vield to the clamor that the mere technician and labo-
ratory worker who seldom sees a real patient outside
is It, while you are "small potatoes." Send to most
any big college for women and ask them to send you
a laboratory worker. She will be glad to get the job.
Thus you will have a laboratory expert working for
you and you will be in position to branch out Get a
nurse for certain hours and make these diagnostic
surveys yourself. You and she can soon get the hang
of it all, for it is not so difficult after all, despite
ponderous talk by specialists.
If you do not feel like doing this by yourself, yoke
up with three or four other doctors, or all in town
for that matter, and open a diagnostic laboratory
with appliances and facilities for special technic You
will get it going more easily than you think. Then
all of you use it like the big firm of engineers use a
drafting room. It is unthinkable, now-a-days, that
the drafting room and technicians boss the engineer-
ing firm. Then why should the general practitioners
in medicine weakly surrender their position to technic-
ians doing work that any new graduate can dot
This is not said in disparagement of real specialism
in medicine; but it is said directly in opposition to the
rampant and bombastic alleged specialism that is
driving medicine on the rocks, to be salvaged by big
foundations and organizations who, once they get
control, will make the lot of the medical man hard
indeed.
Doctor J. and Dr. R., referred to in the opening
of this editorial, are right in principle, but not in
detail. Let us take our cue from them and step right
out into the middle of the stage, letting the men be-
hind shift the scenes for us. Only in Chinese theatres
do the stage carpenters work in front of the actors
and get most of the attention. It is true that general
practitioners are neglecting very valuable diagnostic
measures and necessary technic We ought not to do
it, but just so long as we do the patients get results
elsewhere. Doctor, think it over. Then get in
medical practice right. You will not regret it—
T. S. B.
Om tk* Mmnaftment of tk* Ckrome
Arthur A. Herold, Shreveport (N. O. Med. and Surg.
Jour., December, 1921), sums up the management in
general, as follows :
1. Do not try to do too much; avoid over-eating.
Place some reliance on nature.
2. Advise against over-taxing organs; patient should
not overeat or overdrink.
3. Get co-operation of intelligent member of family
or competent nurse; if patient not seen regularly, get
frequent reports.
4. Remove probable foci of infection. Treat any
cachexia or diathesis. Avoid useless drugging, but 'do
not hesitate to employ morphia promptly, when indi-
cated.
5. Use common sense as to clothing, exercise and
fresh air. Avoid danger of chilling, but remember tbe
patient is no hot-house plant Secure his confidence and
there will be no trouble about his co-operation in these
respects.
6. Be guarded as to prognosis.
August, 1922)
Physical Culture Propaganda
587
Physical Culture Propaganda
A PHYSICIAN of ability recently suffered a
breakdown and an examination showed a dilated
heart; he attributed it to over-exercise years ago, more
especially to the strain incident to a "century run"
during the bicycle craze that was productive of many
such cases, several to our own knowledge. Formerly
living next door to a vaudeville theatre, we were con-
sulted by numerous acrobats, and they were prac-
tically a unit in the expression of belief that their
class were rather short-lived and were very subject .
to cardiac and nervous affections. Formerly the con-
sulting physician to a gymnasium, we realized the
great value of properly directed physical education
but also were constantly impelled to advise a slow-
down in the cases of many who placed more value
on the ability to do stunts than to rationally develop
the physical being.
We were much interested this summer in the river
sports adjacent to our home. The municipal beach
and hath house was the most popular place in the city,
there being no foolish restrictions against young peo-
ple enjoying themselves in any sort of costume not
actually immodest. Bathing, swimming, beach sports,
canoeing, sailing and other sports were indulged in
bathing costume, hundreds of young men and women
becoming brown as Southern Europe people, and
this without damage to health, serious accident or
scandal. Every pleasant night boats accommodating
about three hundred people made up-river trips and
their dancing floors were usually comfortably filled.
There was no strain in these outdoor sports and we
know they did an infinite amount of good to a lot
of people who worked regularly at store and office
but who hastened to the ferry soon as they were
free to go.
Gardening is a splendid form of exercise, and we
have known of many office workers who were im-
mensely improved in health by making this their fad.
Motoring, golf, tennis as ordinarily played, and other
outdoor sports with some object to them, all tend to
the rational form of physical development; but the
gymnasium systems of exercise designed to make ath-
letes, so exploited in the magazines devoted to
physical culture, often do infinite harm to health.
In no sense do we condemn the gymnasium; but it
needs medical supervision and less of the tactics of
the "professor" who is constantly measuring muscles
and urging severe tests. This freaky individual usu-
ally is obsessed with some foolish cult notion — raw
food, fasting, vegetarianism, or one of the speudo-
medical propagandas that makes drugs their devil.
Ont-SUU PuhBcmtion,
It is really amusing to a trained physician to read
the various magazines devoted to physical culture.
While it is true they print many articles of value,
they also publish much foolishness. We don't par-
ticularly mind their slams at drug-taking, for people
dose themselves entirely too much, and there are many
physicians who use drugs unwisely; but it is the gen-
eral experience of physicians that when the readers of
these publications become really ill and need medicine,
they take it readily enough, as do even Christian
Scientists when they get a pain. What we object to
is propaganda against vaccination, the surgical re-
moval of adenoids, the surgical treatment of appen-
dicitis, and other definite measures productive of a
reduced morbidity and mortality. These magazines
could do infinite good were they to print articles
written by balanced physicians of ability who would
warn against the abuse of drugs and various medical
and surgical procedures — articles such as the Saturday
Evening Post occasionally prints — and that would
guide their readers in sane living. But they do little
of this; for just as soon as some half -cooked physi-
cian gets sore at regular medicine and starts to write
yellow stuff, these magazines open their pages to
these vaporings of the soured mind and exploit one-
sided ideas that are harmful to the reader, who knows
too little of medicine to differentiate between mere
literature and science.
There is a real place for magazines devoted to
physical culture; but they should select competent
contributors, of whom there is no dearth. There is
little place in the everyday world for a set of acrobats,
but there is a dire need for men and women in busi-
ness and professional life to be properly developed
physically, to be guided in sane and hygienic living,
to understand the principles of sanitation and per-
sonal hygiene, and to be warned against quackery,
both in and out of the medical profession. And it
can do no harm to roast the medical and surgical
extremists once in awhile; some of them need it.
Yellow Adwtrtisimg
These magazines preen themselves on refusing ad-
vertising copy of patent medicines, tobacco, etc. Well
and good! But they accept even worse copy — ad-
vertisements of worthless and quacky appliances,
cards of "professors" of every useless thing under the
sun, and the fake systems galore. In some ways the
worst kind of advertising is that of the by-mail sys-
tems for making super-men of failures and lazy
young chaps who are hunting some royal road to
wealth by a short cut in which ability and hard work
cut little of a figure. We have met some of these
cocky young chaps who have taken "a course" in one
of these systems for breeding success in life, and it
takes about a year extra of hard knocks to hammer
a little sense into them — one year longer than with
the average young chap who has not taken "the
course." It is deplorable that any publication should
be allowed to exploit the young in this way.
588
Best Current Medical Thought
[Philadelphia
Best Current Medical Thought
The Origin of the Original Syndrome
Charlton Briscoe (The Lancet, Dec, 1921,) in his
work on the mechanism of lung expansion and the action
of the accessory muscles concerned in respiration, has
come upon facts which seem to bear a definite relation
to the origin of the anginal syndrome.
Briefly, these facts are as follows : Overfatigued mus-
cles give rise to referred pain in distant areas. The
upper respiratory mechanism is exceedingly active under
the same conditions in which attacks of angina pectoris
occur, and stress of this nature affords a better explana-
tion for nocturnal attacks than does cardiac strain.
The respiratory muscles of this region, when hyper-
sensitive, are the last structures in the segment to lose
local tenderness and the faculty of producing referred
pains by pressure. When these muscles are hypersensi-
tive and subjected to pressure the areas to which pain
is referred correspond to those similarly affected in
angina pectoris, and are frequently recognized.
The author has demonstrated a phenomenon which
offers an explanation for the warning and sequence of
pain in angina pectoris. This is dependent upon irri-
tation of one of the expiratory muscles involved, and
results in marked thoracic elevation.
Treatment by alleviating the stress of these muscles
has frequently — not always — been effective in relieving
the pain without other treatment.
Two attacks of angina pectoris have been observed
as the result of irritation of the respiratory muscles.
The phenomena generally which accompany an attack
of angina pectoris can equally well be explained on a
respiratory hypothesis as on one of vascular origin. It
is of further significance that the age incidence of
angina pectoris corresponds wth that of ossification of
the ribs and cartilages — a source of increased difficulty
in respiration.
Stricture of the Urethra in Women
Wm. E. Stevens (Cal. State Jour, of Med., Feb.,
1922), says: Stricture of the urethra in women is a
condition which is very often overlooked, although it
may be responsible for marked functional and organic
disorders in the genito- urinary tract of this sex. Her-
man, of London, following the examination of 55
women without symptoms, concluded that the normal
size of the female urethra is F 29, a little less than 10
millimeters. Van de Warker expressed the opinion
that a urethra from F 23 to F 28 should be considered
normal. Examination of 114 patients at the Stanford
Women's Clinic disclosed the fact that only 18 or about
16 per cent, had never suffered from symptoms refer-
able to the urinary tract. Following urethral calibration
in these 18 cases, the author found the average size of
their urethra to be F 26 or a little less than 9 milli-
meters. As to symptoms, frequent urination is the most
common. It occurs in over 85 per cent, of the author's
clinic and private cases. Subjective symptomatology
was not taken into consideration in the patients confined
in the detention ward of the San Francisco Hospital as
many of these deny disability, hoping to be released as
soon as possible. Next to this symptom, pain referred
.to the urethral or bladder regions is the most prominent
symptom. This symptom occurs in 64 per cent of the
cases. Burning or smarting are present in 26 per cent,
urgency in five per cent., and difficulty, constant desire
to urinate, partial incontinence, dribbling and retention
of urine, were each present in two and a half per cent,
of the patients. Residual urine is seldom found except
in the presence of very tight strictures. The diagnosis
is best made by means of the olive-tipped bougie. A
urethrotome or sound is much less reliable, as stricture
usually yields to slight pressure, and consequently higher
readings result from use of the latter instruments. The
majority of urethral strictures should be treated oy
means of gradual dilation, absorption of the constricting
exudate being best promoted by this procedure.
His conclusions are as follows:
Stricture of the female urethra is relatively common,
and consequently calibration of this organ should be
part of the urological examination of every woman and
child complaining of symptoms referable to the genito-
urinary tract.
Strictures of the female urethra respond readily lo
proper treatment, and their early detection will prevent
pathological lesions of the upper -urinary tract secondary
to this condition.
Curettage and the Treatment of Uterine Hemorrhage
Beckwith Whitehouse (British Med. Jour., Dec, 1921.)
groups cases of pathological uterine hemorrhage undtr
one of the following headings:
(1) Menorrhagia, a term limited to excessive hem-
orrhage relating simply to the quantity of blood lost at
a menstrual period.
(2) Menostaxis, denoting excessive menstruation as
regards duration of the flow, the discharge consisting
chiefly of the secretion of the uterine glands.
(3) Epimenorrheq, signifying too frequent menstru-
ation, in other words, an alteration of rhythm.
(4) Metrostaxis, denoting uterine hemorrhage apart
from and having no relation wtih menstrual bleeding.
It includes not only all hemorrhages before puberty
and after the menopause, but also all irregular bleeding
during a woman's active sexual life.
This classification the writer has found very useful
in practice, as it divides one's cases into well-defined
groups, and affords a basis for investigation and treat-
ment along rational pathological lines.
Whitehouse repeats his protest against indiscriminate
curetting for all cases of obscure uterine hemorrhage.
The operation may do good, but the chances are equally
against it if the cause of bleeding is not directly dependent
upon pregnancy.
As a diagnostic procedure, however, curettage is of
{continued one leaf over.)
August, 1922]
The American Physician Advertising Service
589
Constipation in Young Girls and Women—
especially those who spend much time indoors engaged in sedentary pursuits — is
almost invariably attended by a retention of waste and toxic substances. Sooner
or later these make their way from the bowel into the general system and give rise
to a host of autotoxic ilk.
Correction of this condition is imperative, and the safest, simplest and most effect-
ive remedy for the purpose is
INTEROL
Directions s
To reliere the constipa-
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morning and night, in*
creasing or decreasing the
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to the action of INTEROL
gradually cut down the
dose to the least amount
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Besides lubricating the canal, INTEROL renders the feces
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It would indeed be difficult to suggest any more serviceable
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99
—ARAB PROVERB.
One can read convincing reasons why ANASARCIN
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heart, overcoming circulatory stasis and bringing about
resorption of effused fluid.
But to test ANASARCIN clinically, either in the dropsy
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590
Best Current Medical Thought
[Philadelphia
paramount importance, especially when the microscopical
appearances of the endometrium are considered in rela-
tion to the history of the case and the character of the
uterine discharge.
To curette a uterus and throw away the curettings is
comparable to treating hemoptysis without examining the
sputum.
Hemorrhage from the uterus is a symptom of such
diverse conditions involving the whole realm of medi-
cine that no one remedy such as curettage can ever be
expected to prove effective in all cases.
Radium is no doubt a valuable agent for controlling
uterine hemorrhage due to ovarian and endometrial in-
coordination. It is also a useful remedy in those cases
due to hypertrophy or atrophy of the endometrium.
In checking hemorrhage at puberty and the meno-
pause radium must exert its peripheral action on the
ovaries, as the endometrium is inactive from under-
development or atrophy respectively.
When uterine hemorrhage is the result of inco-or dona-
tion of various hormones, curettage will be but palliative,
or will fail completely, unless combined with other
therapeutic measures designed to combat the primary
cause.
The Hysterical Nature of So-called Pernicious
Vomiting of Pregnancy
A. F Hurst (Tht Lancet) believes that pernicious
vomiting of pregnancy is always hysterical. He de-
scribed a case of a patient under his care which makes
it possible to prove with certainty that the case was one
which would generally be regarded as of the toxemia
class.
Clinically the patient was a typical example of severe
pernicious vomiting; she vomited constantly whether
she took food or starved, her tongue was dry, her pulse
rapid as in -any case of toxemia vomiting.
Two days before the writer saw her the ammonia in-
dex was 28, nearly three times as high as the point
which Whitridge Williams regarded as the danger sig-
nal. The urine also contained a very large quantity of
diacetic acid. Yet relief followed after half an hour's
psychotherapy; the vomiting ceased, the pulse rate fell,
the ammonia index dropped to normal for pregnant
women, the diacetic acid disappeared from the urine,
and the patient gained sixteen pounds in weight in four
weeks.
It is obvious from this case that no reliance can in
the future be placed either on the clinical or the chem-
ical diagnosis of toxemia vomiting of pregnancy. Per-
sonally, the writer does not believe that such a condition
exists apart from eclampsia and acute yellow atrophy.
The high ammonia index and the great excess of
diacetic acid in this patient's urine were clearly not
caused by toxemia, but were the result of starvation and
dehydration.
It is clear, therefore, that the division into the nervous
and toxemic classes is fallacious. All cases are nervous,
but the term hysterical should be substituted for nerv-
ous, as the condition is typically hysterical, caused by
suggestions and curable by psychotherapy.
Alimentary Infections in Chronic Arthritis
N. Mutch (The Lancet) gives the following observa-
tions made on two hundred cases, half of which were
hospital patients and the other half private patients.
Gout, venereal or tuberculous disease of the joints,
and all cases of nonarthritis were excluded, but other-
wise no selection was exercised.
He finds that the condition of the alimentary tract
dominates the outlook in rheumatoid and osteoarthritis.
The general scheme employed in the treatment of the
present series of cases was as follows : The entire ali-
mentary tract was surveyed carefully in each case and
an estimate formed of the relative degrees of septic
absorption occurring at the various levels. The more
accessible areas of infection in the jaws, throat and
intestines were treated surgically, and all the disorders
of the digestive tract which had encouraged the develop-
ment of chronic infection were dealt with.
Autogenous vaccines proved of great value when used
to supplement these measures. They were prepared
from infective bacteria of all the principal zones of
sepsis. Streptococci obtained from different foci in the
same patient usually vary in their cultural characteris-
tics, and each strain was included in the vaccine.
Chronic infection frequently damages the thyroid
gland. In the present series minor forms of subthy-
roidism were very common, while well-defined myxe-
dema or goiters of considerable size were seen in 14
per cent, of the cases.
There is an intimate association between immunity
reactions and the functions of the thyroid <gland. The
dry extract of the thyroid was given in all such cases
with great benefit to the joints. In the present series
of cases, which have been followed for varying periods
up to nine years, 89 per cent show very marked improve-
ment or complete arrest. If it had been possible to
exclude those cases in which circumstances such as age,
temperament, and position in life prevented the full
use of radical methods the results would have been still
more encouraging.
Some Varieties of Traumatic and Toxic
Ulnar Neuritis
E. Farquhar Buzzard observes in a number of cases
which suggests that the ulnar nerve is particularly prone
to disturbances of function on what appear to be at
first very slight provocations.
Looking for a common factor in the various groups
which he outlines one is struck by the fact that in the
majority of cases the ulnar nerve is unprotected by any
bony parapet at the end of the elbow, or so badly pro-
tected that during extension and flexion, of that joint it
is apt to slip in and out of its proper position. During
flexion especially it may lie exposed to friction and
pressure on the internal condyle.
A consideration of many cases seems to justify the
conclusion that movement, especially of a strenuous and
frequently repeated character, is an important factor in
the production of an interstitial neuritis.
This moving contact with a bony surface is probably
an important factor in producing the symptoms associated
with a cervical rib, although so far as the writer knows
it has not been shown thajt in the latter case the nervous
tissue becomes surrounded by a definite thickening of
connective tissue. In the case of the ulnar nerve, how-
ever, the nervous tissue is constantly exposed to minor
injuries, and the neuromatous condition so often found
must be ascribed to chronic inflammation of traumatic
origin.
In one group of cases one may find an additional etio-
logical factor in the form of some toxic agent The
writer has seen fairly good results from merely dividing
the connective tissue strands by means of longitudinal
incisions, but he is still more impressed with the advan-
tages of placing the nerve in front of the joint and so
insuring its complete relaxation. He suggests that pos-
sibly a combination of both methods may be the ideal
treatment.
August, 1922] The American Physician Advertising Service 591
"Then is No Art to Read
the Mind's Construction
in the Face. "
— ohakespeare
C*OR the same reason it is quite impossible to gauge
* the potentialities for harm in a few cups of coffee.
Sometimes they do— and sometimes they don't —
manifest their full capacity for serious forms of physio-
logical mischief.
A patient doesn't know — and perhaps a doctor
cannot tell— except by testing the matter clinically —
whether it's coffee, or something else, that is causing
tachycardia, nervous irritability, insomnia, indigestion
or headaches.
There's one way to find out, however — stop the
coffee for a week, and have him drink Instant Postum
instead.
Postum is an absolutely pure cereal beverage. It
is scientifically prepared in a modern, sanitary plant,
and serves every purpose of a hot meal-time drink.
With thousands of people, Postum is as satisfying
in flavor as the average coffee — undoubtedly one of the
reasons for its increasing popularity.
Doctor, why not suggest Instant Postum to your
next neurasthenic, and see if it does not help your
general sedative and reconstructive treatment?
Samples of Instant Postum for individual and clinical
test will be sent to any physician who will write for
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Cancer of the Liver and Gall Bladder — Goldstein
[Philadelphia
Cancer of the Liver and Call Bladder — Goldstein
(Continued from page 580)
used, this test can be carried out in the average
clinic with ease.
(3) In a series of fifty (50) cases we found that
in a general way a delay in the appearance time of
the dye is proportionate to a decrease in the dye
output.
(4) In fifteen normal cases the average appear-
ance time of the maximum color was 11.6 minutes.
In ten cases with grossly pathological livers it was
23.2 min. In twenty-five cases with moderate and
slight liver disease there was a proportionate delay
in the appearance time as a rule. The appearance
time of the maximum color is of more significance
than that of the first faint pink color.
(5) The dye output in two hours in the normal
series averaged 22.4 mgms.; in the grossly pathologi-
cal cases it averaged but 2.7 mgms.
(6) In grossly pathological livers the maximum
color is twice as long in making its appearance as
in normal cases (23.2 min.; 11.6 min.), but the dye
output in grossly path, livers averaged but one-
eighth that for normal cases (2.7 mgms.; 22.4 mgms.).
The dye output is of more significance than the ap-
pearance time of the dye.
(7) 30-35 per cent, of the dye was recovered
in the feces in forty-eight hours in normal cases by
the older method. We recovered 15 per cent, of the
dye in two hours with the duodenal tube in normal
cases.
(8) In the normal cases the twenty-four-hour urine
following the injection was free from dye.
(9) We suspect that the output of dye will vary
within normal limits with the age, the younger the
individual, the greater the dye output.
(10) When a larger number of cases are accumu-
lated and our normal standards become more definite,
this test should be comparable with the sulphona-
phthalein kidney function test, for the liver reserve is
probably no greater than that of the kidney when
their relative size and importance in the body economy
are taken into consideration.
(11) Finally we believe that in this test we have
a method of measuring the functional capacity of
the liver when it is clinically negative to other
methods of examination. It is in this group of cases
particularly that the quantitative two-hour output will
be of particular significance.
Garcia Guijarro (Siglo Medico, Madrid, February
5, 1921, 68, No. 3504, p. 124) confirms the results
of others, that the alimentary tests of liver function-
ing are not very reliable, on account of the complexity
of the intermediary metabolism. He regards the
amount of fibrinogen in the blood as a fairly reliable
index of the functional capacity of the liver, and
also as determination of the bile salts and pigments
in the blood, urine and stools. The lipase in the
blood is an unreliable indicator of the sufficiency of
the liver cells.
Sir John Moore, President of the Royal Academy
of Medicine in Ireland (Dublin Jour, of Med. Science,
March, 1921, 4th series, No. 13, p. 97), reported a
case of very rapidly developing cancer of the liver
in a man, aged 38 years, in the Epidemic Wing of
the Meath Hospital. No jaundice was present. Nodu-
lar masses were found scattered throughout the lower
lobe of the right lung. The liver was more than
twice the normal size; its texture was dense and firm;
the surface was nodular in places. The liver weighed
170 ounces. The gall-bladder was normal. Budd
("Diseases of the Liver," 3rd Ed., p. 407), states
that a cancerous liver has been known to weigh 384
ounces, or about seven times the normal weight
The absence of jaundice in rapid cases is prob-
ably due to alcholia, caused by the extensive destruc-
tion of the liver cells. Frerichs collected 52 eases of
cancer of the liver in a series of 91, that died with-
out ever having been jaundiced. Jaundice, there-
fore, is not so commonly present in hepatic eaneer
as is usually supposed.
1. J. Foote— J. A. M. A. Hemangio endotheliosarcoma
of the Liver, 73:1042, Oct 4, 1919.
2. J. R. Harger — Sarcoma of liver in a 17 months old
child. Surg. Clinics, Chicago, 3:121, Feb., 1919.
3. Morrow and McKinstry — Primary Sarcoma of Liver-
Brit. U. J. 2:378, Sept. 20, 1919.
4. de Ahna — Hypernephroma of Liver: Charite.-Ann.,
Berl., 1912, xxxvi, 390-393.
5. Pepper- Pearce: Jour. M. Research, 37:171, Sept,
1917, Myeloma of Liver with metastasis to spleen.
6. Fischer: Primary chorionepitbelioma of liver.
Frankfurt. Ztschr. f. Path., 1913, xii, 462.
7. J. Arnold: Zieglers Beltr., 1890, vlll. 123, Jena.
8. Marx : Centralbl. f. Allg. Path., 1904, xv, 433.
9. Knott: Surg., Gynec. and Obst, 1908, vit 328.
10. Hetzel: A case of melanosarcoma of the Liver.
Inaug. Dissert., Erlangen, 1895, also abst in Centralbl. t
allg. Path., 1896, vil, 917.
11. Hektoen and Herrick, Trans. Assn. Am. Phya* 1898,
xiii, 385 (Secondary Sarcoma of liver).
12. Swenson — Hypernephroma of liver — Surg., Gynec.
and Obst, Chicago, 1917, xxv, 570.
13. Starr — Hypernephroma: Ann. Surg., Phlla.. 1917.
lxvi, 318-320. 2 pi; also Trans. Am. Surg. Assoc., 1917,
xxxv, 364-311.
14. R. H. Major— Bull. Johns Hopkins Hosp., Bait, 1918,
xxix, 223-231.
15. Dmochowskl and Janowski; Cysts: Zieglers Beltr..
1894, xvi, 102.
16. Hanot et Gilbert — Etudes sur lea maladies du fole.
Paris, 1888.
17. Hektoen, L.: Trans. Chicago Path. Socty., 1896-
1897, ii, pp. 137-146.
18. Pepper, W.— Congenital sarcoma of liver and supra-
renal, with report of a caae. Am. J. Med. Scs., Phila., 1801.
N. S., exxi, 287-299.
19. Moore, N.: Melanotic Sarcoma, Trans. Path. Soc.,
Lond., 1888-9, xl, 138; also Brit M. J., Lond., 1889, i, »2.
and Lancet, Lond., 1889, i, 577.
20. Lang, W. S. — Primary sarcoma of Uver— Edlnbur?,
M. J., 1888-9, xxxiv, 904.
2L Heaton, G. — Congenital round -celled sarcoma of
liver, Trans. Path. Socty., Lond„ 1897-8, xUx, 140-141
22. Delepine, S. — Primary melanotic sarcoma of liver.
Trans. Path. Socty., Lond., 1890-91, xlii, 161-172.
23. H. Zielenzleger— A leukemic lymphoma of liver-
Wurzburg, 1921.
24. Fowler, R. 8.— Tumors of the Liver, Brooklyn, N. Y.,
1900. xiv, 943-953. Also Med. News, N. Y„ 1902, lxxx, 2»-fl,
and Tr. M. Soc. N. Y., Albany, 1902, 136-141.
(Continued one leaf over)
The American Phytician Advertising Service
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Household pages of newspapers frequently give
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Kellogg's Bran contains all the wonderful ele-
ments that are so beneficial in food, aside from its
being a natural regulator. It can be prescribed
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patient is advised to use it regularly — two table-
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Mentioning The American Physician Insures Prompt, Careful Service
594
Book Reviews
[Philadelphia
25. Fischer, K. — Weber primare sarcome der Leben
Wurzburg, 1900.
26. Hetzel, K. — A case of Melansarcoma of the Liver,
Erlangen, 1894.
27. Ortb, M. Neber primaes Lebersarkom, Strasburg,
1886.
28. Soave, L. — A case of melanotic sarcoma of Liver.
Vicenza, 1894.
29. Paul: Adenoma and Primary Cancer of Liver.
Trans. Patb. Sooty., London, 1885, xxxvi, p. 238.
30. Slade: Gall- Stones and Cancer. Lancet, 1905, 1,
p. 1052.
31. Cockle: Cancer of Duodenum and Perforation of
Gail-Bladder. Medical Times, 1883, i. p. 435.
32. Rolleston : Primary Cancer of tbe Ampulla of Vater.
Lancet. 1901, i, p. 467.
33. Weber and Mlchels: Primary Cancer of the Extra-
hepatic Bile-Ducts. Med. Chir. Trans., 1905, lxxxvili, p. 247.
34. Coats and Finlayson: Cancer of Common Bile-Duct.
Path, and Clin. Soc. Trans., Glasgow, ill, p. 144.
35. Primary Carcinoma of Liver. F. C. Yeomans. N. Y.
Acad, of Med., Sect, on Surg. Meeting held December 4,
1908. Reported in Med. Record, January 9, 1909.
36. Operative Treatment of Primary Cancer of Liver.
E. Bunschuh, Beltrage zur klinischen Chlrurgle, Tubingen,
July, 1914, xcili, No. 1. p. 1-222.
37. Primary Sarcoma of the Liver. G. Pisano. Comm.
in No. 4. Policlinlco, Rome, May 1, 1914, Med. Sect.,
No. 5, pp. 193-214.
38. Cancer of the Bile Passages and Liver. S. Saltykow.
Correspondent. Blatt fur Schweizer Aerzte, Basel, April
11, 1914. xliv, No. 15, pp. 449-480.
39. Cirrhosis and Primary Sarcoma of the Liver. E.
Glynn, Brit. Med. Journ. London, Nov. 4. 1911, 2653, pp.
1145-1240.
40. Resection of Left Lobe of Liver for Cancer. H. Klose.
Beltrage zur klinischen Chirurgie. Tubingen, lxxiv, pp.
1-754, L. Rehn Festschrift Abstract in J. A. M. A., Oct. 21,
1911, Vol. lvii, No. 17, page 1409.
41. Melanotic Sarcoma of tbe Liver, Secondary to a
Melanotic Sarcoma of the Eye. Removed by operation 10
years previously. C Lilley Lancet, London, August 5,
1911
Muir: Jour. Path. & Bacter., 1908, xil, 287.
DYennan: Proc. Path. Soc, June, 1911, P. H.
(London).
44. Beattie: Trans. Path. Soc., Lond., June, 1911, p. 7.
45. Bland-Sutton: Tumours, 1917, pp. 385-406, 6th edi-
tion.
46. Bland-Sutton : Gall Stones and Diseases of the Bile-
Ducts, 1910, pp. 130-148.
47. Schnabel: Disease of the Gail-Bladder. Amer. J. M.
Scs., July, 1921, clxi, No. 7, p. 102.
48. Goldstein, Hyman I.: Sarcoma of the Liver. Inter-
net. Clinics, June, 1921, p. 73 (Phila.).
Benign Stupors
By the late August Hoch, M.D., formerly Director of
the Psychiatric Institute of the New York State
Hospitals and Professor of Psychiatry, Cornell
University Medical College, New York. Edited by
John T. MacCurdy, M.D. Cloth, 284 pages. The
Macmillan Company, New York City. Price, $2.50.
This book presents a study of manic-depressive re-
action types marked by stupor, and an attempt is made
to separate the benign from the malignant stupors, and
with a large degree of success. Disagreeing with some
current views on the functional psychoses, Dr. Hoch,
with infinite patience, undertook a rather speculative
line of psychological research, finally reaching certain
clinical conclusions that seem to be justified. At all
events, the book opens up a fertile field for further
psychiatric research and in the hope that the theories
set forth may lead to practical results in the treatment
of borderland insanities, apathy, mutism, catalepsy and
negativism. — T. S. B.
Management of the Sick Infant
By Langley Porter^ B.S., M.D., M.R.C.S. (Eng.),
L.R.C.P. (Lond.), Professor of Clinical Pediatrics,
University of California Medical School; Visiting
Physician, San Francisco Children's Hospital; Con-
sulting Pediatrician, Babies' Hospital, Oakland, Con-
sulting Pediatrician, Mary's Help Hospital, San
Francisco and William E. Carter, M.D., Assistant in
Pediatrics and Chief of Out Patient Department,
University of California Medical School; Atending
Physician, San Francisco Hospital, San Francisco.
Illustrated. St. Louis. V. S. Mosby Company, 1922.
$7.50.
Diseases of infants, like their bodies and minds, differ
radically from those of adults. Such being the case, it
is rather out of the ordinary that "The writers . . .
have been unable to find any text book in the English
language which deals exclusively with the peculiarities
of disease as it occurs in infants." Thus impressed, they
have written this text on the Management of the Sick
Infant. The book has been given serious attention, is
well written and excellently compiled. There is, no
doubt, a need for such a commendable work, and both
the pediatrician and general practitioner can make pood
use of it.
The Life of Jacob Henle
By Victor Robinson, M.D., Editor of Medical Life, 12
Mount Morris Park West, New York City, and
published there. Cloth, illustrated 117 pages, edition
very limited. Price, $3.00.
This is the first biography in English covering the life
and attainments of Henle, whose career was most inter-
esting and who added much to medical science, more
especially anatomy. The book is interesting and especi-
ally so from its intimate views of medical life in the old
days of German power, for Henle was, by turns, a state
teacher and a state prisoner, and he was a strange mix-
ture of agitator and scientist The book is a worthy one,
recording the career of a strange character who really
did much, in his day, to make medicine an exact science.
Radium Therapy
By Frank Edward Simpson, A.B., M.D., Professor of
Dermatology, Chicago Policlinic; Adjunct Clinical
Professor of Dermatology, Northwestern University
Medical School; Attending Dermatologist to Mercy
Hospital, Alexian Brothers Hospital, Henrotin
Hospital, etc. ; Former President American Radium
Society ; Former Vice-Chairman, Section of Derma-
tology and Syphilology, American Medical Associa-
tion; Director of the Frank- Edward Simpson
Radium Institute. With 166 original engravings. St
Louis. C. V. Mosby Company, 1922. $7.00.
Radium is a new therapeutic agency of positive effi-
ciency. Whatever the claims of extremists ; whether it
cures, whether it replaces surgery or merely supplements
(continued one leaf over.)
August, 1922]
The American Physician Advertising Service
595
Ml
If you have not received your copy of
the last Breon's Medical Gleanings, a magazine
devoted to Intravenous Therapeutics, write to
the nearest Breon Branch and a copy will be
sent to you at once.
GEO. A. BREON & COMPANY
New York
Chicago
Kansas City
Atlanta
Pioneers in Intravenous Therapy
Mentioning The American Physician Insures Prompt, Careful Service
596
Best Current Mcdkal Tko«fht
[Ptikddpfe
it, its action, its influence on tissues is prompt and
powerful, and does, should and will occupy a prominent
position in the armamentarium of modern medicine.
There are specialists well versed in radium therapy, the
average physician though knows little, often very little,
of its physical characteristics and therapeutic properties.
It is because of this that there is a need of good texts
on radium therapy, and it is because this need is ex-
cellently supplied in this book that we unhesitatingly
recommend it. It is well compiled, well written and up
to date, and should occupy a worthy position in the
physician's library.
Abdominal Pain
By Prof. Dr. Norbert Ortner Chief of the Second
Medical Clinic at the University of Vienna. Trans-
lated into English by William A. Brams, M.D., and
Dr. Alfred P. Luger. Cloth, 362 pages. The Reb-
man Company, 141-145 W. 36th Street, New York
City.
It needs no word of ours to commend to professional
attention the writings of Ortner. This work on abdomi-
nal pain is thorough and painstaking and is of the utmost
value in diagnosis, especially in the surgical field. The
work is of very direct clinical value and the translators
have conferred a favor on the English reader in making
the teachings of Ortnor available to him.
Bacterial Irritants in Hay Fever
That pollen irritation favors the development of
pyogenic bacteria in the respiratory tract and that the
bacterial irritation which develops becomes a primary
factor in hay fever is now gaining recognition.
Dr. William Scheppegrell, president American Hay
Fever Preventive Association, has just published a book
on the subject of "Hay Fever and Asthma," in which
he states:
"If the patient applies for treatment during an at-
tack of hay fever, the pollen extracts are usually in-
effective, and a vaccine should be used, these being
injected at intervals of one or two days until the sever-
ity of the attack subsides. . . .
"Our reason for using the vaccine during serere
paroxysms is that at this time the patient is suffer-
ing, not only from the effects of the pollen protein, but
also from the great increase in the pathogenic micro-
oiganisms resulting from the lowered resistance of the
respiratory membranes. The use of vaccine therapy at
this state is therefore logical, and has given us satis-
factory results. ...
"We use three forms of stock vaccines, each contain-
ing one thousand millions to the cubic centimeter in
various proportions of the following micro-organisms:
B. Friedlander, M. cartarrhalis, pneumococcus, Strep-
tococcus pyogenes. Staphylococcus aureus and albus."
It will be observed that the formula employed by Dr.
Scheppegrell is for all practical purposes identical with
Sherman's No. 36.
In this connection it is interesting to note Hat Dr.
G .H. Sherman was the first physician to call attention
to the role played by pathogenic micro-organisms in
hay fever and to utilize therapeutic immunization with
bacterial vaccines in this disease, to control tiie com*
plicating infection. And as Dr. Sherman says, in his
book, Vaccine Therapy in General Practice, "We know
that pathogenic bacteria are always liable to invade
accessible tissues where normal resistance has been
lowered by irritants. Pneumococci, streptococci, staphy-
lococci and other organisms are found on the mrcous
(continued one leaf over.)
0 Pil. Cascara Compound — Robins a
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Most cathartics altogether overlook this factor and addr
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©themselves solely to a stimulation of the musculature. Some even ^5^
inhibit intestinal secretion. The result is a rapid, unsatisfactory \p
0 bowel movement, followed by paralytic reaction. f^
^^ Pil. Cascara Comp. (Robins) is a rational therapeutic formula, j£
fA which promotes a natural flow of secretions, which is, in turn, the (A
Jj^ physiologic stimulant of peristalsis. Thus a normal evacuation i»5^
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August, 1922]
The American Physician Advertising Service
597
New Salt of Marked Value in Gonorrhea
Zinc Borosalicylate (G«H.B<» 2Zn.— NEISSER-SAN-KAHN—
by a fusing process in manufacture, the germicidal properties of the
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The definite gonococcocidal strength of NE1SSER-SAN-KAHN with its
freedom from irritation and other objectionable features — stamps this new agent
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ounces of hot DISTILLED water injected at body temperature, three times
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Vaginal Suppositories NEISSER-SAN-KAHN— each containing 5 grains
N-S-K are stainless, non-irritating, definitely germicidal — EFFECTIVE. Supplied
in boxes of ten.
Procured on prescription (druggists not stocked being supplied through
the regular trade channels) or direct from our Laboratories.
Writs for Literature
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Home Treatment In
Tuberculosis
With orer a million active cases of tuberculosis, home treatment is
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mented by proper medical attention and medication.
Dr. Beverly Robinson has stated "that we have absolutely no medi-
cal treatment of pulmonary tuberculosis at all equal to the creosote
treatment properly used and insisted upon."
Mistura Creosote Comp. (Killgore's) contains the genuine wood
creosote unchanged by the addition of chemicals and will meet all the
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Dose : — Teaspoon f ul in one-third of a glass of milk or water after
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CHARLES KILLGORE
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Helpful Point*
membrane of the nose and throat of roost normal in-
dividuals and in hay fever cases these organisms are
found in abundance. That these organisms are im-
portant complicating factors and are responsible for
much of the irritation and most of the fever is quite
apparent.
Here the immunizing influence of bacterial vaccines
is of real value in the treatment of hay fever. By
this means sufficient resistance to these pyogenic organ- ■
isms is developed to prevent them from becoming in-
fective agents following the pollen irritation, 'i he re-
sult is that the patient either goes on to lomulete re-
covery or the disease runs a modified course, the pollen
irritation being the only factor left, which causes com-
paratively little distress.
Clean Intestinal Canal Imperative
The paramount importance of a clean gut is recog-
nized by every man doing operative work.
The means whereby this may be acquired is a mat-
ter of keen interest. For the success or the failure of
.an otherwise perfect piece of abdominal surgery may
depend upon whether or not any complications may be
developed from the toxins retained in the intestinal
canal, or adherent to the intestinal walls.
One of the surest of all means of eliminating this
complication lies in the use of Liquid Alboline — the
genuine Russian mineral oil.
Liquid Alboline has a particularly higher degree of
mix, penetration and lubrication. It softens and re-
moves scybalLe, and all intestinal debris, and lore
the gut in the most perfect condition for normal post-
operative functioning.
Remember, it was with Russian mineral oil that the
original experiments of Sir Arbuthnot Lane were made,
proving the superior value of mineral oil for providing
the completes! possible intestinal evacuation.
Send to McKesson & Robbins for a most instmtiw
and interesting booklet. "Below the Equator." Address
them at S3 Fulton Street, New York.
In Gastrointestinal Disturbances in Infants
Associated with diarrhea, Tannalbin has been found
soon to change the character and color of the stools,
while at the same time the other symptoms of pain
and distress, emaciation and so forth, were ameliorated.
In intestinal affections of adults, likewise, such at
diarrhea of consumptives or in gastrointestinal disturb-
ances of influenza, improvement has followed the ad-
ministration of this drug. Tannalbin is a thoroughly
exsiccated and hardened albumin compound of tannic
acid. It is a light brown, odorless and tasteless pow-
der containing about 50 per cent of tannin. It has
the advantage over other tannin preparations that it
does not give rise to gastric disturbances, the tannic
effect being manifest in the intestinal tract Tannalbb
is marketed by E. Bithuber, Inc., 45 John street New
York, who will be glad to send literature to Axeucak
Physician readers on request
(Hetpful Points continued one leaf over.)
INTESTINAL INFECTIONS
CALCREOSE is an ideal intestinal antiseptic It is useful
in cases of intestinal sepsis, either primary or secondary.
CREOSOTE Is oh of the few dm*, which appeal
to hava a Juit data to be useful aa Intestinal
antiseptics, but It Impair* U» appetite and dis-
turb. dlgaatioD, besides causing gastric distress.
Pricn — Powder, lb., $3.00. (Prepared by adding I lb. to I gallon of
water.) Tablet.: 4gr., 1000, $3.00; 500, $1.60; 100, 40c
Sample* (tablets) and
THE MALTBIE CHEMICAL CO.
Newark, N. J.
You can buy with confidence — See "Service Guarantee to Readers" on page 614
The American Phjukian Advertising Service
Don't decide on operation in hemorrhoid cases
until Anusol Suppositories have had a con-
scientious trial.
The well-weighed evidence of a quarter-century
stands solidly behind this advice.
Ample Trial Quantity and Information on
Genuine Anusol Suppositories
from
SCHERING & GLATZ, Inc.
150 Maiden Lane NEW YORK
*J* (Ncoarsphenamine-Metz)
i I ** un8UIPassecl *n reliability, trypanocidal effi-
tL jY ciency and ease of administration.
LAB Neosalvarsan is manufactured by the process
used in preparing the original Ehrlich product
and offers the physician the ideal means for
treating the luetic.
HftMETZ IABORimmiES.hc
Onr-7i*mty7i<)0 Hudrvn Strwt.NevllXyrk.
Mentioning The American Physician Insures Prompt. Careful Service
Helpful Points
lived no treatment far several
herefore welt advanced.
Ill featnre, of the fact were P
rated and am tar badly swolle
tpplied radianl lighl and heal
if* or iix times the first day, .
to lilt first nielli. Second day
licalion and after tf kauri the only manifesta-
tion of the disease wining was a slight smiling
0/ (111 involved tar which entirely disappeared an
third day after a fen short applications."
tpermoljtg,
LIGHT AND HEAT APPLICATOR
Is a sclent ideally designed and well-made »p-
fllanee that reflects a flood of I'KNKTRAT-
NO light and heat Id PARALLEL rays— no
focal spot to burn or blister.
Par superior to ordinary bot applications
because the beat penetrates deep Into tissue.
Is constant, always ready, sets Quickly sad Is
combined with beneficial light.
USED IN ALU, flOVEKNMENT HOSPITALS
Sold fry electrical and surgical supply dealers.
TBI' THEBMOL1TE
NO. 0«T0 OFFICE AP-
PLICATOR
Reflector 12" dlam.
idjnstable from
. . a 38" from reflector.
Finish, Olive and Nickel. Price com-
plete wltb stsnd $30.00 ench.
NO. WHO HAND APPLICATOR
Same design as 0070 only 8" diaui.
Consumes a» wafts. 120 rolls A. C.
" " Made of Aluminum, weight
Finish. Black and Nickel.
e complete without stand $10.00
Folding Stand only for ™-
^0645, W.00 — e
Write for Interesting: and inBtructtvi
Effective New Synthetic Relieve* Pain
Peralga, a new synthetic for the treatment of pain,
possessing a highly potentiated action, especially adapted
to the relief of manifestations customarily referred to
as "headaches," is the most recent addition lo the list of
well-known medicinal products marketed by Schering &
Glatz, Inc.
Known in Europe as "Veramon" and originated in
the Pharmacologic Laboratory of Professor Starken-
stein, University of Prague, Czechu-Slovakia, well known
for his Atophan researches, Peralga furnishes a rather
brilliant example of the successful endeavor to in-
tensify a given, therapeutically valuable, radical in one
chemical compound by synthesis with a radical of
similar therapeutic properties in another. In this in-
stance, the excellent and rational pain -relieving proper-
ties of Amidopyrine have been chemically potentiated
by the highly valued sedative properties of Diethylbar-
bituric Acid, while the hypnotic effect of the latter has
been suppressed.
Peralga certainly appears to excel other analgesics
in its pain -relieving action, especially in the promptness
and endurance of the same. No injurious or disagree-
able by-effects, even on fairly continued use, hare been
observed. It is interesting that in spite of the absence
of hypnotic action, sleeplessness due to pain, irritation
and congestion, is most favorably affected by the new
synthetic Its use is advocated in "headaches" of tie
habitual type, more especially those due to menstrual
and climacteric disorders, nervous conditions, hysteria,
mental exhaustion from overwork, migraine, etc., diffi-
cult and painful mestruation, "breast pains" of nursing
mothers, traumatic pains from accidental injury, or
after surgical operations, the pains of locomotor ataxia,
acute forms of neuralgia, neuritis, sciatica, etc
A complimentary original tin of Peralga Tablets with
literature will be sent to American Physician readers.
Address Schering & Glatz, Inc., ISO Maiden Lane,
New York,
Theory vs. Practice
"The old doctor and the young one were discussing
diuretics. The young man had championed the use of
digitalis. The elder smiled. 'You are right, son,' be
said, 'in theory." I used to say the same. But J«
will learn better after a while. Digitalis has its uses,
it's a valuable drug. But when you want to increase
renal secretion, not only of fluid, but of urinary solids,
take my tip and use Anasarcin Tablets. You will 8"
a definite action and a safe action. When you hate »
dropsical condition present; when you have effusion of
fluid into the tissues, in say, a cardiac valvular lesion.
chronic B rights, postscarlatinal nephritis, or albuminuria
in pregnancy, use Anasarcin.
"It is a good combination. Two of the active prin-
ciples of squill with sambucus and oxydendron. It not
only strengthens the heart action, but it controls and
regulates cardiac rhythm as well as acting as a diuretfc.
So that you can use Anasarcin with benefit, also in
oxophthalmic goitre, and cardiac neuroses.
"I suggest that you drop a post card to the Anasarcin
Company, Winchester, Tenn., asking them to send vnu
a sample and literature. Then 'go to it I"*
(Continued one leaf over)
1 buy with confidence— See "Service Guarantee to Readtrsf on page 614
The American Physician Advertising Service
I(gclUg)l
McK & R Compound Stearate of Zinc
for the Baby's Summer Comfort
THE summer season is
particularly trying On
hnbies. They develop
irritative ■ k i n condition,
eruptions and chafing* from
the acid perspiration stimu-
lated by the excessive heat
and humidity.
They are more liable to
"diaper rash" than in colder
weather— a* the akin surface
is more susceptible to the
irritating effects of urinary
and fecal discharge.
You greatly relieve all
these trouble* for your little patients,
Doctor, if only you will advise the
liberal use of McK ft R Compound
Stearate of Zinc.
After the bath, Compound Stearate
of Zinc applied aa a routine measure,
tends to overcome prickly heat, and
■kin discomforts generally. A liberal
dusting with MclC 6c R Com-
pound Stearate of Zinc
around the genitals and in
the tissue folds, will render
the local surfaces moisture-
proof, and prevent the irrita-
tion following acid d i s -
charges. Do not forget Com-
pound Stearate of Zinc aa a
valuable aid in preventing
and overcoming sunburn, in
adults a* well as children.
If you're not already fa-
milial with McK 6c R Com-
pound Stearate of Zinc send
card for literature and aamplee of
this valuable product.
McKESSON & ROBBINS
INCORPORATED
Manajacluring Chtmiiti
91 Fulton Start, New York Cily
For the Doctor Who Wants Results
we supply a number of practical, ethical products such aa
PUL VOIDS NATRIUM COMP., which U rapidly becoming recog-
nized aa the most reliable and effective combination for
reducing high blood pressure and maintaining normal tension.
Salvarols Suppositories
Rectal
squire no technique and obtain
ction and result* equal or superior
Pulvoids Aurazyme
No. 41S
conjunction with other indicated
:ure satisfactory results
diabetes mellitus. A trial will
ENDOCR1N AND GONAD products, a complete line, at r.
price, and of premier quality.
Sen J for literature, case reports, price lists and our little periodical
"Drug Products," gratis to physicians
THE DRUG PRODUCTS CO., Inc.
150 Meadow Street, Long Island City, N. Y.
Mentioning The Am
i Physician Insures Prompt, Careful Service
Helpful Points
Salicylate* and Intravenous Administration
"Salicylate of soda has long been regarded as almost
specific in the treatment of acute forms of what is gen-
erally described as rheumatism, both of the articular
variety and allied conditions in which some pathogenic
organism, such as the strepticoccus, plays an important
role. Like the iodides, salicylates are very rapidly
excreted in great part through the urine. Such ex-
cretion begins with fifteen minutes after taking a dose
per os, and is practically completed in from six to
forty-eight hours. Hence, in works on pharmacology
occurs the statement: The rapid excretion explains the
need of large and frequent doses."
"It follows, therefore, that what is true of the iodides
holds equally true of the salicylates, i. 1., that the ideal
as well as the most effective method of administration
is by the intravenous route. By placing a relatively
small dose of sodium salicylate directly into the blood,
which means its circulation over the entire body in a
few seconds, is to assure, on the one hand, rapid
physiological action, and to prevent, on the other hand,
irritation and unpleasant effects that accompany its use
in large and frequent doses when given per OS." — Jour-
nal of Intravenous Therapy, 100 West 21st Street, New
York.
Intravenous injection, offering as it does the most
effective therapeutic method, is a serious procedure, re-
quiring the selection of standardized solutions from a re-
liable laboratory, and knowledge of the contents of the
solution.
You will find the Loeser's Intravenous Solutions are
scientific solutions of U. S. P. and standard remedies
of established therapeutic value, the contents being
plainly stated on the label. They are standardized by
chemical, physical and animal tests. Clinical report;,
reprints and price lists will be sent on request Address:
New York Intravenous Laboratory, 100 West Twenty-
first street, New York.
The Beat for Yonr Car
The busy physician may not have time to figure cost,
but depend on it, if big repair bills are coming in.
poor lubricating oil has something to do with it Keep
i'our car in good condition and at your service for the
owest cost in the long run by using Emco Automobile
Oils, the pure mineral oil, refined from famous Brad-
ford crude.
For full information address: Emery Manufacturing
Co., Main street, Bradford, Pa.
Administration of Yeast Effective
Malnutrition, general debility and lack of appetite arc
symptoms rather than diseases, and while they arc com-
mon after exhausting diseases, these conditions are also
often the result of errors in diet
A frequent cause of general debility is lack of a suf-
ficient quantity of vitamine B in the diet The first
symptoms of lowered intake of this vitamine are loss of
appetite and evidence of malnutrition, general debility
and lack of vitality follow. A vicious circle is estab-
lished and the patient frequently goes from lad to
worse. The presence of vitamine B seems necessary
for the proper assimilation of the energy foods.
It has been pointed out by Osborne that the adminis-
tration of vitamine B raises a lowered plane of metabo-
lism when due to a lack of this vitamine, so that addi-
tional food can be assimilated, and he calls attention to
(Helpful Points continued one leaf over.)
You can buy with confidence — See "Service Guarantee to Readers" on page 614
The Amerkm Phstician Advaluing Service
Tested Organotherapeutic Formulas in a
New and Better Package
Tk. H.r,ow.r Pluriglandu-
• are now lupplied
■bleta. Each doee
ly wrapped in par-
lor— air-tight and
t»f. "SANITAB-
i urn h era and price*
Minding Harruwei
lulent
rower "SANITAB-
inot bo counter-
THE HARROWER LABORATORY
Horn* Office: Box 68, ClaneUo, California
NEW YORK. SI Park Place BALTIMORE, 4 E. Redwood St.
CHICAGOYlM N. La SaUa St. KANSAS CITY. MO, 711 K. C. Life Bid,.
DENVER, 031 Cemtre! Serine* Beak Bid*. PORTLAND. ORE, 807 Pltteck Block
DALLAS. IBOaVt Coou—rce Street
Operative
Surgery
Special course in general
surgery, operative
technique and gynecologic
surgery given to physicians
of both sexes. Enrollment
limited to THREE.
First aubantihip— No cadaver or dog-work
For particular* nddreea,
DR. MAX THOREK
AMERICAN HOSPITAL
846-856 Irving Park BonlaTard, CHICAGO
Of Absorbing Interest to the
Medical Practitioner!
The Emile Cone Syetem of Auto Suggee-
tion which atartled the medical world
of London ia fully explained
SELF-MASTERY
CONSCIOUS
AUTOSUGGESTION
(IN ENGLISH)
EMILE' COUE
Famou
Nancy
croat. d
French P
aro the talk
e enuetfen
rcaelcgiit
ef Euro.
Id London
whnea clinic, at
and who recently
aad Peria.
Thi. hook,
■cathode "
Hon. for
ezplelned.
written br Dr. Ealla Coua, con-
in plate aipoalticm ef hie tbaoriee,
ed cure*, with practical ■uf(«.
application, .Imply and clearly
Price $1.00 Poitpaid
AMERICAN LIBRARY SERVICE
800 Fifth Avenue, Oept. 600, New York
Mentioning The A,
Physician Insures Prompt, Careful Service
604
Hdpful Points
(Phihddplu
If
il
Often Overlooked
ADHERENCE to some
^V pet theory of baby feed-
ing may blind a physi-
cian to its fallacies, or bias
his viewpoint so that they
are overlooked.
Physicians who insist upon
the home modification of
cow's milk sometimes fail to
consider the inability of the
average mother to follow
properly a complicated for-
mula. They overlook the pro-
bability that the purest milk
may sour in hot weather, be-
come tainted by other food in
a refrigerator, or be contam-
inated through carelessness.
You can eliminate these dan-
gers for your patients by
prescribing a food of pro-
tected purity which is easily
prepared by the most inex-
perienced mother and which
can be kept pure under the
most trying conditions.
NESTLE'S MILK FOOD
is pure cow's milk modified
by the addition of malt, cer-
eals, and sugar and then
reduced to powder form. It
is milk, free from pathogenic
bacteria, in a form which is
easily prepared and readily
digested.
Send for free samples to Nettle's
Food Company, Nestle Building,
New York City, or 112 Market
Street, San Francisco.
NESTLE'S
MILK
FOOD
the futility of trying to increase the caloric intake until
the plane of metabolism has been raised by foods rich
in vitamine.
Gratifying results have been reported from the ad-
ministration of yeast. The almost immediate improve-
ment of the appetite is followed by gradual gain in
weight, which may readily be controlled by regulation
of the diet and exercise. The increased metabolism is
accompanied by a feeling of greater vigor of both mind
and body. These results may be brought about by the
addition to the diet of two to three cakes of yeast daily.
For further information, send for the new authorita-
tive book on yeast, which will be sent free to American
Physician readers. Address: The Fleischmann Co.,
Dept. S-8, 701 Washington street, New York City.
Diatussin for Persistent Cough
When other remedies fail try Diatussin as a cough
sedative and antispasmodic. This product has proven
its value in all such cases and particularly in whooping
cough during the paroxysmal stages, when Diatussin
administered regularly will reduce expiratory blasts and
quickly terminates the disease. With Diatussin you will
benefit through diminished individual attention in all
cases of persistent cough.
Samples and literature will be sent to American
Physician readers. Address: Ernst Bischoff Co., Inc,
85 West Broadway, New York.
Valuable in Urethral Infections
Neisser-San-Kahn — a new germicide for gonorrhea-
has the quality of quick penetration of the epithelium
of the mucosa, is non- toxic, freely soluble in hot water,
forming a stable solution which does not stain. It is
germicidal and astringent, making it an ideal drug for
the treatment of all forms of gonorrhea.
Physicians are finding that in Neisser-San-Kahn we
have at our command a new salt of marked value in
urethral infections. This new agent may be procured
on prescription (druggists not stocked being supplied
through the regular trade channels) or direct from
the home office. Formula and literature will be sent
to American Physician readers on request Address:
York Laboratories Company, Inc., Court avenue and
Jackson street, York, Penna.
An Ideal Arsenical
Sodium Diarsenol has the therapeutic advantage of
arsphenamine with the solubility and convenience of
neoarsphenamine, and gfves clinical results equal to or
better than either of the two. Neutralization with alkali
being obviated, there is no undue handling and conse-
quent decomposition of the highly reactive solution; it
dissolves very quickly in water, giving a solution rady
for immediate injection.
Samples and literature will be sent gladly to American
Physician readers. Address: Diarsenol Company.
Inc., Buffalo, Boston or Atlanta.
In the Workshop and Factory
The development of industrial medicine and surgery
has brought many special demands to the medical prac-
titioner. First-aid work fills an important place in
these new lines of practice and as a consequence the
demand for an efficient, non-toxic and cleanly anti-
septic is one of the most constant The medical rata
who use Dioxogen have no trouble in this directiciu
however, for they have learned to appreciate its unique
(Helpful Points continued one leaf over.)
You can buy with confidence — See "Service Guarantee to Readers" on page 614
August, 1922]
The American Physician Advertising Service
605
MARKED COLOPTOSIS
Acute Splenic Flexure —
A, cecum; B, partly air-
filled hepatic flexure; C,
splenic flexure with left por-
tion of transverse colon
coming up and forming an
acute angle with descend-
ing colon, D.
Prom Diaemaea of the Diget
tlveOrgmna,"
by CHA8. D. AARON,
Sc.D., M.D., P.A.CP,
A NORMAL COLON
The Value of
Lubrication
in Coloptosis
A gostroenterologist of wide reputation calls attention to
the efficacy of liquid petrolatum in ptosis of the intestines*
He points out that it is not only a means of healing super*
ficial lesions of the intestinal tract and softening the feces,
hut that it also inhibits bacterial growth.
NUJOL offers invaluable aid in the treat-
ment of coloptosis and resulting stasis.
Its correct viscosity, high uniform quality
and absolute purity are due to the unsur-
passed equipment and resources of its makers.
In determining a viscosity for Nujol best
adapted to general requirements, consisten-
cies were tried ranging from a water-like
fluid to a jelly. The viscosity of Nujol was
fixed upon after exhaustive clinical test and
research, and is in accord with the highest
medical opinion.
That the value of Nujol to the medical pro-
fession is generally recognized is attested by
its use by physicians and in hospitals the
world over.
Sample and authoritative literature dealing
with the general and special uses of Nujol
will be sent gratis upon request to Nujol
Laboratories, Standard Oil Co. (New Jersey),
Room 765, 44 Beaver Street, New York.
REG. US. PAT. OFF,
A Lubricant; not a Laxative
Guaranteed by Nujol Laboratories, Standard Oil Co. (New Jersey)
Mentioning The American Physician Insures Prompt, Careful Service
606
Helpful Points
[Phifedelpbb
advantages as an antiseptic for routine surgical
purposes.
In fact, extended experience in practical, every-
day surgery has conclusively demonstrated that peroxide
of hydrogen is peculiarly adapted for cleansing in-
fected wounds, or dressing' fresh cuts or abrasions.
But it is primarily essential to make sure that the
peroxide of hydrogen employed is free from any residual
impurities or ingredients which can interfere in any
way with the unrestricted release and full potency of
its active constituent, pure oxygen. It is the possession
of these properties in such a marked and uniform de-
gree that has made Dioxogen the standard peroxide of
hydrogen. Because of its greater volume of pure,
nascent oxygen, which far exceeds U. S. Pkar. re-
quirements, no other antiseptic is so prompt in its con-
trol of suppuration, so gratifying in its promotion of
tissue repair, or so satisfactory in every way to use.
A supply of Dioxogen in the workshop clinic, and a
bottle in the first-aid chest or surgical grip gives the
attending physician the gratifying assurance that he
is prepared to meet any demand for antiseptic treat-
ment
High Blood Pressure
Clinicians generally have found that high-blood pres-
sure means something. It is sometimes the first indica-
tion of coming serious trouble. Consequently, the phy-
sician who makes it a habit, as well as a rule, to
carefully take blood-pressure readings in such cases as
suggest to him the possibility of hypertension, is often
able to save his patients difficulty or even fatal disease.
When suitable remedies are to be administered to
overcome the condition and prevent its effects, Pulvoid's
Natrium Compound seems to be a preparation of
choice. It is composed of tested and proven agents
whose action is at the same time safe and sure. It
can be given without disturbing the stomach or affect-
ing renal function, and what is most important, 'tis
use can be continued in suitable dosage over long
periods of time, not only to bring down the blood
pressure, but to keep it down.
An interesting booklet on blood pressure, what it
means, how it is produced and how it should be
treated, will be sent to American Physician readers.
Address: The Drug Products Co., Inc, ISO Meadow
street, Long Island City, N. Y.
Yeastone for
Yeastone — the purified, active principles and vitamines
of yeast — is given in place of yeast for medicinal par-
poses. It keeps well, is pleasant to take and is a
reliable product. Made by Merck & Co., 45 Park Place,
New York.
Address them for samples and literature, which will
be sent gladly to American Physician readers.
A Standing Invitation
The various departments of the Mulford pharmaceuti-
cal laboratories are gradually being transferred to the
Mulford Building, at Broad and Wallace streets, Phila-
delphia, where the general offices and stock rooms
have been located for some time.
Within the next few months it is planned tha+ all
the pharmaceutical and executive activities shall be
conducted under one roof, with the operation of the
biological work at the Glenolden Laboratories as a
(continued one leaf over.)
"Success is Measured by the
Difference Between Does and Does Not
ALKALOL is therapeutically successful because—
yy
IT DOES
Feed depleted mucous membrane cells with
physiologically needed salts.
Possess the indicated salinity and proper
alkalinity.
Act in a soothing and healing way upon irri-
tated or inflamed mucous membrane or skin.
IT DOES NOT
Overstimulate secretion or relax tissue,
being hypotonic it reverses osmotic
action.
Resemble the many so-called antiseptic
solutions.
ALKALOL IS SUCCESSFUL
in the ear, eye, nose, throat, urethra, bladder, vagina; as a douche, irrigating so-
lution or wet dressing on ulcers, dermatitis, cuts, burns; internally as an antacid.
Sample and literature tent em request
THE ALKALOL COMPANY
Taunton, Mass.
You can buy with confidence — See "Service Guarantee to Reader^* on page 614
The American Physician Advertising Service
Stomachic
Rebellion
is not in the clinical picture when you use
BENZYLETS.
That is an outstanding consistently constant
clinical fact when these gelatin globules each
carrying five minims of medicinally pure benzyl
benzoate are used. At your druggist's in 24's.
BENZYLETS-
Sharp & Dohme
Jr.
K Compound Containing the Bile !
Glycocholaic. Sodium Taurocholiic -
Siii.di and Phenolphlhall
TAUROCOL COMPOUND TABLETS
\=
THE PAUL PLESSNER CO.
Mentioning The American Physician Insurer Prompt, Careful Service
Helpful Points
History of Dental Anaesthetics — No. 2
1846— "Letheon"
IN September, 1846, Dr. W. T. G.
1 Morton, a former pupil of Dr. Horace
C Weill in Dentil try, went to a chemist
in Boston, Cbartei T. Jackson, to learn
how to moke Nitroui Oiida Gas.
i the advice of Jackson, he purchased
•ome Sulphuric Ether and on September
30th, I 846, tried it on a boy named Ebon
Froit. Following up the tucceu of this
operation Morton and Jacltion experi-
mented further with Ether, resulting in
their patenting the discovery of anaes-
thetic effects of Ether, the patenta being
issued to Dr. Morton, who then called
s product "Letheon."
Anaesthesia is the name suggested by
Oliver Wendell Holmes to Dr. Morton, to
describe the condition produced by the
inhalation of Sulphuric Ether.
'Tie a far cry, indeed, from the anaes-
thesia aa produced by this anaesthetic to
that as uow induced by the Conduction
method with
Antiseptic Local
Anaesthetic
Bit* COCJIHI /%')
The quality and duration
of the anas* thesis am
such that the most com-
plicated and extensive
formed without the ps-
whlch persist! long after
the operation relieves any
factor of Safety must
also
neldered.
fatality from lte use t
ina thirty year* tha
hae been used In ei
country In the world
million, of operation.
IN BOTTLES
1 01, 2 ox.
IN AMPULES
I Mail Tha Coupon Nob!
□ Plsase seed sample box of ampules •
Dr. R. B. Walte'a Local Anaesthetic Free.
(Send profsssiooal card or stationary)
THE ANT1D0LOR MFG. CO.
32 Mala St., Sprinsville, N. Y.
The plan of the building, whereby each floor has an
area of approximately one acre, offers wonderful facil-
ities for an economical and practical layout of the
various departments. The space devoted to execotirt
offices is one-half acre in extent. The finished slock
room is one acre, while another entire floor will bt
devoted to the manufacture of fluid preparations.
Up-to-date mechanical means have been installed for
the handling of the products in course of manufacture,
finishing and shipping, all formulated with the idea of
improving the Mulford service.
Any of our readers visiting Philadelphia would do
well to reserve the time necessary for a visit to the
Mulford Building; it will prove not only a revelation,
but an inspiration.
Natural Way to Relieve Constipation
It is stated by medical authorities that if the use of
bran were to become general— as general as is the
eating of white bread— inside of twenty-five years a
stronger and more vigorous race of mankind wonkf
result. Not only this, but human life would be in-
creased from ten to fifteen years.
It has been found that Kellogg's Bran, cooked and
krumbled, through its mineral salts and its ability to
absorb water, giving bulk and moisture, is nature's way
of assisting in perfect elimination of waste matter. By
the use of bran the system is rid of these waste ma-
terials, quickly and naturally. Bran will permanently
relieve constipation, if it is eaten regularly; it is in-
valuable as a constipation relief for the aged and for
the bedridden.
You will find Kellogg's Bran, cooked and kmrnbled.
a very easy and delightful way of administering this
very necessary dietary element. With this product ii
is no longer difficult to get patients to carry out your
instructions. If it's Kellogg's Bran they will enjoy it.
A large package will be sent complimentary to A memo x
Physician readers. Address: Kellogg Toasted Com
Flake Co., Battle Creek, Mich.
Where Liquid Petrolatum ia Indicated
A noted authority, whose observations have covered
hundreds of cases, states that aside from routine meas-
ures, the regular use of liquid petrolatum is the most
effective means of combating incompetency of the ileoce-
cal valve. Medicinal laxatives increase the antiperistal-
sis by which the reflux from the colon into the small
intestine is increased. Liquid petrolatum increases the
motility of the small intestine, but does not increase
ant (peristalsis.
The correct viscosity, high uniform quality and ab-
solute purify of Nujol make it the dependable aid of
physicians in the host of conditions where liquid petro-
latum is indicated.
Sample and authoritative literature dealing with the
general and special uses of Nujol will be sent gratis
on request: Address: Nujol Laboratories. Standard
- Oil Co. (New Jersey), Room 765, 44 Beaver street,
New York.
A Boon to Suffering Humanity
It has been said that 30% of the entire population of
the United States is afflicted to some degree with spinal
trouble. Of this percentage it is earnestly believed tib%
could be cured by the use of the Philo Burt Method of
Spinal Correction; and 90% of cures could be effected
in childhood by its use. There are records of hundreds
of cases showing splendid recovery of children who
otherwise would have been doomed to a hopeless, help-
less life as a hunchback or cripple
(continued one leaf over.)
You can buy with confidence — See "Service Guarantee to Readers" on page 614
The American Physician Advertising Service
To ALLEVIATE PAIN, to PROMOTE DIURESIS
and to PROTECT the membrane of the urethra, ejpeciallr
THE POSTERIOR PORTION— theae arc the important
object* of the treatment of acute case* of Gonorrhea.
The entire urinary tract ihould be influenced by mean*
of proper internal medication. Local injection! alone will
not be mffident.
Thii it the rationale of GONOSAN.
RIEDEL & CO., Inc.
104-1 14 Sooth Fourth St Brooklyn, N. Y.
IABETIC FLOUR
Sfa
Starch-free. Produces Bread,
Muffins. Pastry that makes the
distressing features
Grow
Less and
Less ■
Luteff prepared casein Diabetic Flout — self rising. A month'* supply of 30 boxes $4.85
LISTER BROS. Inc., 405 Lexintton Avenue, Mew York City
TEi
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
A Stand-By in
Uterine Troubles
VIBURNO
(BEACH)
The best evidence of this is the
repeat order* received from physi-
cian* and druggist*.
Nervine-Tonic and Anticongest-
ive, with calmative and corrective
action on the bladder. Employed
with much satisfaction in ovarian
congestion and congestive dysmenor-
rhea; weak pregnancy and deficient
lactation; menopause and its phe-
nomena, including hallucinations, hot
Bushes, etc; nervous and menstrual
derangements after "flu," and the
troubles of adolescent girls. Sterility
often responds after 2 or 3 bottles if
no lesion exists.
Unlika aimilar products, VIBURNO
1* palatable mud pWasswt to tab*.
Pot up la 11 os. bottles
Sample and Formula on Rr.qaai
THE VIBURNO COMPANY
118 Maldsn Uu, New York
Sal Hepatica
Bristol-Myers Co.
NEW YORK
The following is what one physician has to tar re-
garding a case of "Lordosis," which he relieved: The
little Pelham child has made a wonderful improvement
since she commenced to wear the Philo Burt Appliance.
She is a very nervous, active child, and before she wore
the appliance could not stand on her feet alone and
had to be wheeled in a chair. Now she runs and plays
like the rest of the children and enjoys life. The Philo
Burt Appliance is certainly a great boon to suffering
humanity."
The Philo Burt Co., 115-20 Odd Fellows' Temple.
Jamestown, N. Y., will make a spinal appliance to your
order for any case and allow a 30-day trial. Write to
them for full information, prices. Physician's Portfolio
and their plan of co-operation with the physician.
Spasmodic Summer Complaint
When intestinal troubles are so prevalent, accom-
panied by the usual manifestations, abdominal cramps,
etc., nothing seems to relieve this distressing condi-
tion so promptly as Hay den's Viburnum Compound,
a true and safe anti-spasmodic Dose r Mix two
teaspoonfuls in seven of boiling water, slightly sweet-
ened, and drink as hot as possible. Repeat every
half-hour until relief is obtained. Liberal samples of
H. V. C. will be sent to Amebic an Phvsiciak readers
on request Address : New York Pharmaceutical Co,
Bedford Springs, Bedford, Mass.
(Our Advertising Standards C
• leaf o
r.)
Woodlaum
Maternity Home
A itrtettr pririte sod ethical Home Retreat
far unmarried (iris and women daring pre*"
saner and confinement, with beat medical
MORPHINE
NEW HOME TREATMENT
■aukwl t« ■» who oW.. Each* Stasia fal <•*•*-
DR. QUAYLE'S SANITARIUM
MADISON. OHIO
Pond's
Extract
I
relief of the aymptoma of hay fern:
T> Adrenalin Chlor. n.
** Pood'i Extract dr
Aquae deatil. q. %. ad. ox.
^» If *t Sif. Uie as a apraj ever/ ho
^P POND'S EXTRACT CO., Niw Yo»i
I
Hay
Fever
n buy with confidence — See "Service Guarantee to Readers" on page 614
August, 1922]
The American Physician Advertising Service
611
HAYFEVER
Rhinol for Hayfever and all affections
of the Nose and Throat.
HAYFEVER
Rhinol a reliable remedy.
Dr. A. Z. Hall, of Eaton, Colorado, says in a quite recent
letter:
"I believe that you have in Rhinol the most
superior remedy on the market for Hayfever.
Please send me 6 complete outfits C. O. D."
Use Rhinol one week before your attack and you will be
free from all trouble.
RHINOL CO., Inc., 1416 Broadway, New York City
■i™
"J.NICl'I
IN1QLT
AMPMO
HEN13UE
PHYSICIANS
SAFETY FIRST!
When in the vicinity of POISON OAK- IVY- SUMAC or any plant 9
that poieon by contact, apply CAMPHO-PHENIQUE (Liquid) to
part* expoeed.
LAST AND
In camee ofpoieoning apply every hour and eprinhle with CAMPHO-
PHENIQUE Powder. A email hottlm and box (JOc) arm mostly
carried,
ALL THE TIME
Remember that for MOSQUITO BITES and INSECT STINGS,
CAMPHO-PHENIQUE gwee prompt and permanent relief.
Samples and Literature on reamest.
CAMPHO-PHENIQUE LIQUID, email eime 30c, large eUe $1.20
CAMPHO-PHENIQUE POWDER, email eime 30c, large sise 75c
Campho-Pheniqae Co., St. Louis, Mo., U. S. A.
HENIQU!
>pv
Mentioning The American Physician Insures Prompt, Careful SerxAce
612
Helpful Points
[August, 1922
Amenorrhoea
Dysmenorrhoea
and other disturbances of the
menstrual function call for the
tnie active principle of Parsley:
APIOLINE
(Chapoteaut)
It Secures Results
ky acting directly upon the uterine
nerve endings and producing ovarian
hyperemia, but without disturbing
gastric or renal functions.
Avoid impure or unreliable substitutes.
Prescribe original vials of 24 capsules.
Laboratory of
Dr. Ph. Chapette, New York-Paris
Physician* tample and literature on rtqueMt to
E. Fouf era & Co., Inc., American Agents
90 Beakman Street, New York
Canada t Lyman* Limited, Montreal
AFSAL ^C0*^?).
x "" v-n *..»-# Diacetyl Metbylene-disalfcylic Add.
UNQUESTIONABLE REMEDY FOR RHEUMATISM.
Price, 75 cents per Box.
BEFSAL
AN
CuHmOu
zylaietDyimeinyieneaisaiicyuc L»ip-
ivk (Cinchoninic) Acid. AN EFFICI-
ESTRUCnONOF THE RHEUMATIC
POISON AND A SOLVENT OF URATIC DEPOSITS.
Price, $1.00 per Box.
Dibenzyldietbylmethylenedisdicylk Di
ynr
ENT AGENT FOR THE DE5
CREASEP
CuHmOioIi
Diacet Benzylidenedibenzyldiethyl
MethylenediiododiRuaiacol. Contains
25% of Iodine, VALUABLE ALTERATIVE AND ANTISEPTIC.
ESPECIALLY USEFUL IN INFLUENZA, PNEUMONIA, BRON-
CHITIS AND PULMONARY TUBERCULOSIS.
Price, $1.00 per Box.
TODOlVlFyR Mercury-Difododiaryl. Hold!
tusceptible
syphilis.
organic combination s
on the s
VALUE
35% Mercury and 29% Iodine in
PYR-AZO-PHEN SSfBsft
Benzol Methylene Disalicylic Dicinchoninic Add. FOR NEURITIS
OF GOUTY ORIGIN AND FOR RHEUMATISM AND GOUT.
Price, $1.00 per Box.
ARS AMINE
AsCioHiaO<)i
DIARYL-DIARSONATE.
CHEMICALLY ANALO-
GOUS TO SALVARSAN. BUT CAPABLE OF ADMINISTRA-
TION VIA THE STOMACH. Price, $1.00 per Box of 30
Capsules of 2y4 Grains Each.
DR. S. LEWIS SUMMERS
Prodiiow of
Synthetic Organic Chemical Compounds
Port Washington, Penna.
These Advertising Pages are
A Constructive Market
Our Advertising Standard!
Advertisements must give honest service to <mr
readers and their patients is the basic principle for these
standards and for the conduct of The America!
Physician's advertising pages.
Our attitude in applying these standards is not one
of narrow technicality but of practical service.
Advertisements of the following classes are not
acceptable for the pages of The American Physician:
Fraudulent pharmaceuticals; those making dishonest
claims.
Pharmaceuticals charging excessive price; price not
warranted by content and by trade conditions.
Pharmaceuticals and other mixtures for internal use
and containing ' narcotics or other habit-inducing drags
in quantities sufficient to promote their improper repeti-
tion on prescription (chloral-bearing proprietaries, etc).
Potent pharmaceuticals which justly merit profes-
sional disapproval because of their lay advertising or
manifestly unethical exploitation.
Financial advertisements that claim returns not com-
patible with conservative investment Only cotuervo-
tive investments are advertised.
Further
Advertising copy is subject to revision by the editorial
staff. m
The American Physician agrees heartily with the
principles of the Council on Pharmacy and Ck*0"-**
of the American Medical Association and we wc™
from our advertising pages such pharmaceutical prod-
ucts as they have definitely shown to be unworthy of
professional confidence and the manufacturers of which
have not removed the cause of objection; but we <w
not accept such findings as are based on academic data
without due recognition of general clinical experience.
Concerning formula. The American Physician «
urging pharmaceutical manufacturers to give full thera-
peutic data regarding formulae, stating quantitatively
active medicinal content, in order that physicians may
intelligently prescribe. We do not accept advertising ot
secret pharmaceuticals.
But We do not Decline —
Advertising of original drags, compounds or V**S***b£*J£
tated in current editions of the U. S. Pharmacopoeia or Njww
Formulary (except habit-inducing preparations) ; new PJ^F^
that seem to be nonest and valuable, out which hire ?SL^
reported upon by the Council on Pharmacy and C^gJ^JJ'iC
similar products whose manufacturers have not yet sobmineo^
same to them for approval or rejection. We use our ownirj
ment in these cases, but will always consider proper cbut"
against this class of remedies.
Preparations containing a limited number of drugs m
(Continued out Ucf over)
You can buy with confidence— See "Service Guarantee to Readers" on page 614
The American Physician Advertising Service
A glance at the formula of PNEUMO-PHTHYS1NE
will at once suggest its mode of action, as also the numer-
ous indications for its clinical application. The anti-
bacterial properties of all the drugs contained in
FNEUMO PHTH YS1NE are well established. In addition,
guaiacol and quinine tend to reduce fever temperature;
methyl salicylate lessens pain; quinine also promotes
healing.
PNEUMO-PHTHYSINE is indicated in all localized
and painful inflammatory conditions.
The fact that .1] (tie active druR. contained in PNEUMO-PHTHYSINE are readily
abaorbed through the akin; that they are taken Up into the circulation and exert their
characteristic effecti, both locally and tytematically, will he diicuiaed in detail in the
Fall, 1922. iaiue of Endermie Medication, which will probably appear early in September.
Aik far jour copy no*-.
Pneumo-Phthytine Chemical Co. Chicago, 111.
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
Clinical Evidence
proves the most satisfying
results are obtained by pie-
scribing
Pluto Water
in cases of habitual consti-
pation, gout, rheumatism
and all cases when a uric
acid solvent is desired.
Many practitioners direct
convalescent patients to the
spring for rest and complete
treatment where can be
found two well-known
members of the American
Medical Association with
trained assistance.
French lick Spring* Hotel Co.
Fr-act Lick, IwL
Onr Advcrtiimt St—dank
[Cv*,i,.td avtr from STMrd.no Hqi\
qualified phyiician who u *
pharmacy in place of u t
<•---■-— -imposed of ■
:e, provided these drue> ba»c ■ real plac
anJ are well defined in materia medic.
"Tlino**"!!'/.
to both physic
food produc
Service Guarantee to Readers
IF YOU HAVE ANY UNSA TISPACTORY
DEAUNG WITH AN ADVERTISER IN THE
AMERICAN PHYSICIAN, WRITE US THE
PARTICULARS AT ONCE.
WE WILL IMMEDIATELY TAKE THE MAT-
TER UP WITH THE ADVERTISER AND SEE
THAT THE ADVERTISER EITHER MAKES
GOOD, OR HIS ADVERTISEMENT IS ELIMI-
NATED FROM THE AMERICAN PHYSICIANS
PAGES.
»- STORM »
Binder and Abdominal Supporter
For Men, Women and Children
For Ptosis, Hernia, Obesity. Pregnancy,
Relaxed Sacro-lliac Articulations, High
and Low Operation*, etc
Ask f<" 36 pate Descriptive Folder
■Catherine L. Storm, M. D.
Orff Mao*. Prntinl*. 5,fc Omit aiW M.kt ,
1701 Diamond St. Philadelphia, Pa.
Your Druggist Has It
Marvel Whirling Spray
MARVEL COMPANY
26 W. 45th Stnat Now York
i buy with confidence — See "Service Guarantee to Readtrs" top of this page.
August, 1922]
The American Physician Advertising Service
561
Quting
Infections
Summer Uses
ofDioxogen
As an Antiseptic
For cuts, lacerations, abra-
sions, and all open wounds.
As a Lotion
For ivy poisoning, sunburn*
chafes, and skin irritations.
As a Spray and Gargle
For colds, sore throat, eye
infections and as a mouth
cleanser.
As a Compress
For strains, sprains, contuse
ions and swollen muscles.
As an Internal Remedy
For gastro - intestinal ills,
diarrhea, etc., from changes
in food and water.
As a Water Purifier
For routine addition to all
drinking water used from
bcooks, springs and wells.
Many a physician has
saved an outing from
ending badly by his
advice to carry a supply
of Dioxogen in the fast
aid kit
Directions
Locally — A teaapoonf ul of
Dioxogen to five to eight of
water makes an ideal anti-
septic lotion.
Internally — One half to a
teaspoonful of Dioxogen
well diluted, stops ferment**
tion, gastric irritation and
pain at once.
arc complications that— like specters at
the feast— always stand ready to spoil the
annual vacation that means so much to
those who live and work in the city.
Simple cuts or abrasions, the bites or
stings of insects, a severe sunburn,' derm-
iritis from poisonous shrubs* are all apt
to lead to graver conditions, if neglected
or improperly treated.
Medical men who have learned from
many gratifying experiences how service-
able
Dioxo
is, as a non-toxic, non-irritating but tho-
roughly dependable antiseptic, have no
difficulty in promptly relieving the
immediate effects of these emergency
afflictions of the vacationist and prevent-
ing the development of infection.
The large amount of pure uncontaminated oxy*
gen — nature s ownantiseptic— which Dioxogen brings
directly to the point of injury, in its most active form
enables the practitioner to accomplish results in the
direction both of healing and of prophylaxis that can*
not be expected from germicidal measures of a toxic
or irritating character.
At no time of the year does the physician find
the special advantages of Dioxogen a greater source of
satisfaction than during the Summer and Fall months.
A bottle on the surgical dressing table or in the doo
tor's bag is a bulwark against the many simple but
none the less dangerous emergencies that arc prone
to occur throughout the outdoor season.
The Oakland Chemical Co.
59 Fourth Avraue, N*»w York City
Mentioning The American Physician Insures Prompt, Careful Service
Diphtheria Control and Prevention
CORRELATING INTERNAL AND PROPHYLACTIC MEDICINE. HARMONIZING
EXPERIENCES AND STANDING FACTS. (paf637)
Typhoid Fever Diagnosis
SOME ORIGINAL ANGLES WITH SPLENDID RESUME OF
STANDARD LABORATORY ASPECTS, (pafe 648)
Tagged, Gagged, Nagged and Dragged
(peg* 657)
Full Content! on Page 622
2.00 The Year
'Most Width Circulated Medical Monthly '
50c The Copy
1 420 Walnut St, Philadelphia, U. 3. A. 1
A Constructive Market for Buyer and Seller
Rheumatitm
Gout
Neuralgia
Neuritii
Sciatica
Lumbago
Migraine
"Twice gives he, who
gives promptly"
says a Latin proverb. The remarkably
prompt pain and inflammation relief be-
stowed by ATOPHAN, is truly such a two-
fold gift.
What's more, it's rational, safe and reliable
relief.
Genuine ATOPHAN ia manufactured
at out Bloomneld, N. J., plant by a
special process, precluding the pos-
sibility of even traces of irritating
empyreumatic admixture!.
Complimentary Trial Pac^agt and Information from
Schering & Glatz, Inc.
150 Maiden Lane NEW YORK
REDUCED PRICES
NEODIARSENOL
(NMarlphanamine)
D1ARSENOL SODIUM DIARSENOL
( Ariphenamine) (Sodium Ar>ph«iamit»)
0.6 gm 1.00 0.9 gm.
0.5 gm 90 0.75 gm.
0.4 gm 80 0.6 gm.
0.3 gm 70 0.45 gm.
0.2 gm 60 0.3 gm.
0.1 gm SO 0.15 gm.
Orders for 50 ampoule9^10% discount.
Discount on larKtr nuantilies on request
of Diarsenol. Neorfut':' »"<■...,'{ an'l So.'lmm ],)iar-.'^iin]rfs made. They will now be supplied at approximately
ONE-HALF the amount you nan ben paying For arsenical, of any brand in (be past.
_ This reduction ia made uowUc throuidi the ;j<.-r[«lin* of rasnufsEtnring procesae. which ensure very
United State* Public Health*' Service. "' * "' mJ "'* *" "'* " mLL
Diaraenol brand products are now unexcelled for solubility, liability, low toxicity and therapeutic
power. All are tested at standards very much liiiilirr than Government requirement*. Each lot ia officially
teated and pasaed by the U, S. P. H. S. before being shipped, as all material ia made under regulation
and control of the Government.
line to any of the offices below will have' prompt and careful attention. Literature on" comparative
""''""dIaSnOL COMPANY, Inc.
ATLANTA, GA. BUFFALO, N. Y. BOSTON, MASS.
Forsyth Bldg. EUicott Square 53 State St.
You can buy with Confidence— Sec "Service Guarantee to Readers" on page 686
September, 1922]
The American Physician Advertising Service
619
WILLIAM SCHEPPEGRELL, A. M., M. D.
Says: —
President American Hayfever Prevention Association.
Chief of Hayfever Clinic, Charity Hospital, New Orleans,
"IF the patient applies for treatment during
* an attack of hayfever, the pollen extracts
are usually ineffective, and a vaccine should
be used, these being injected at intervals of
one or two days until the severity of the attack
subsides."*
The Vaccine used by Dr. Scheppegrell is practically iden-
tical with Sherman's No. 36 which is being extensively
used in the prophylaxis and treatment of Hayfever.
• Prom Dr. William Seheppegrell's new book on Hayfever and Asthma
Lea & Febiger, Publishers
Bacteriological Laboratories of
G. H. SHERMAN, M.D.
DETROIT, MICH.
The combination of tonics and stimulants ex-
plains the clinical results obtained in the
treatment pf nervous disorders by the use of
FELLOWS' COMPOUND SYRUP
OF HYP0PH0SPH1TES
€t
A true stabilizer of shaken nerves?9
It contains the "mineral foods", Sodium, Potassium, Calcium, Manganese,
Iron and Phosphorous, and the stimulating agents, Quinine and Strychnine.
Samples and Literature sent upon request.
FELLOWS MEDICAL MANUFACTURING CO., Inc.
26 Christopher Street, New York, N. Y.
Vol. Z7, **°- 9. Published monthly— The Taylors; C. C. Taylor, Publisher; Mrs. J. J. Taxlor, Ed. Mgr. Entered as
second-doss matter Feb. 13, 1896 at the post office at Philadelphia, Pa., under Act of March 3, 1879. The American
Physician, Most Widely Circulated Medical Monthly," continuing the quarter century of distinctive service of
COPYRIGHT 1922, by The Taylors, Publishers, 420 Walnut St., Philadelphia, U. S. A. All rights reserved.
September, 1922]
The American Physician Advertising Service
JHL
]■[
mi
1BC
]■[
Why Do Leading Physicians Prescribe
STYPTYSATE
In Cases of Accidental, Concealed,
Petechial, Postpartum and
Vicarious Hemorrhages?
BECAUSE
Styptysate meets all specifications for a
reliable non-toxic styptic — free from
narcotics.
BECAUSE
Styptysate is particularly suited in the
treatment of vicarious and other recur-
ring hemorrhages.
BECAUSE
Styptysate produced satisfactory results
where ergot and hydrastis had failed.
Send for samples and literature
Enut BUchoff Co., Inc^ 85 West Broadway, New York
inr
]■[
]■[
621
inr
]■£
Mentioning The American Physician Insures Prompt, Careful Service
622
Contents
Copyright, I9*i, by The Tmylors. All right* reserved.
Editorials
Epidemic Psychic Imbalance 633
Significant New Publication— "The American Medical
Press" «34
Immunizing Against Diphtheria with Toxin- Antitoxin.. 635
Original Articles
Diphtheria Control and Prevention.
By Dwlght M. Lewis, M.D 637
A preventable death not prevented is a stigma on
civilisation in general and medicine in particular. To
correlate internal and prophylactic medicine, to har-
monise epidemic experiences and standing facts, read
Dr. Lewis's paper. You will find it sensible, instructive
and practical.
The Problem of "Nervous Indigestion."
By Geo. M. Niles, Ph.G., M.D 641
The problems of "nervous indigestion" are numerous
and difficult, chiefly so because of the organic and
neurotic elements combined. Unless the gastro-enterolo-
gist supplements his medication with common-sense
psychology, he is doomed to positive failure. The
factors here involved have been happily solved by
Dr. Niles in this delightful paper. He truly succeeded,
to use his expression, in playing a poor hand remark-
ably well.
Varicose Veins.
By A. Wiese Hammer. M.D., F.A.C.S 643
In deciding for or against operation, the dictum of
Mayo is applicable: "An elastic bandage is applied
from the foot to above the knee. If this bandage can
(Content*
be worn with comfort, an operation should glie relief."
Discomfort from the bandage would show that the
superficial vessels are necessary to the circulation.
Analgesia and Sleep, Without Narcosis.
By M. R. Dlnkelspiel, M.D M5
The narcotic and habit -forming properties of opium
and its derivatives have undoubtedly been the primary
cause for stimulating investigations in the search for a
less objectionable substitute. While many substitute
have been and are being tried out, and each has its
individual value, none or them has attained that mini-
mum of risk which is the ultimate goal
Diagnosis of Typhoid Fever.
By Bruce Snow, M.D M*
The paper by Dr. Snow comprises several interestiag
features — it reviews typhoid fever vividly; it presents
some original angles, together with a splendid rfcum*
on the standard laboratory aspects of this undeniably
Important disease, a disease which, in spite of its
constantly reduced prevalence, is still intermittently
pandemic, endemic, and epidemic practically throughout
the world.
Can Obstetrical Conditions Bo Improved in Rural
Communities?
By Mayer Shoyer, M.D «
The propaganda Dr. Shoyer condemns is a gratuitous
libel against the hard-working country doctor, woo
could give points to ninety per cent, of the city prac-
titioners who attend an occasional obstetrical caw-
Pellagra and tbe Negro of the South.
By A. L. Nason, M.D
.666
•n pagm 624)
Chinosol
"A POWERFUL ANTISEPTIC, SOMEWHAT STRONGER IN
THIS RESPECT THAN MERCURIC CHLORIDE AND CONSID-
ERABLY STRONGER THAN PHENOL."
(COUNCIL ON PHARM. AND CHEM. A. M. A.)
ASEPTIKONS (su ppositori es,
44
producing complete antisepsis
But
Non-poisonous, Non-irritating and No injury to membranes
Indicated in cervicitis, leucorrhea,
specific and non-specific vulvo-vaginitis, in all cases
where complete vaginal antisepsis is desired.
PARMELE PHARMACAL CO., 47-49 WEST STREET. NEW YORK.
You can buy with confidence — See "Service Guarantee to Readers" on page 686
September, 1922]
The American Physician Advertising Service
623
When appetite must be increased
without the aid of exercise
TNVALIDS are often unable to stimulate their metab*
**■ olism with exercise, yet appetite must be increased,
more food ingested and the plane of metabolism raised.
Many foods fail in such a situation because the vita-
min they contain is associated with substances rich in
calories.
M
In such cases," says one of America's foremost
physiological chemists, "Yeast appears to offer the best
means for furnishing a relatively large quantity of the
water-soluble vitamin together with a comparatively
small proportion of calories."
rFHE importance of good appetite is brought out in
*- one of the leading works on deficiency disease.
Loss of appetite, says the author, interferes with the
liberal consumption of food which is the first necessary
step in maintaining health, and the depressed function
of the gastro-intestinal tract interferes with prompt
digestion and absorption and also with the prompt
evacuation of undigested residue from the intestine
which is an absolute essential of health and vigor.
Fleischmann's Yeast is a pure food, proved by
strictly scientific tests to be potent in increasing ap-
petite and raising the plane of metabolism.
Send for recently published free brochure on the man-
ufacture, physiology, chemistry and therapy of yeast.
Please use coupon, addressing The Flbischmann
Company, Dept. S-9, 701 Washington St., New York.
New brochure on yeast therapy sent
on physician 's request
The Fldschmann Company
Dept S-9, 701 Washington St., New York
Please send me free a copy of the brochure on yeast
based on the published findings of distinguished
investigators.
Street.
City.
.State
Mentioning The American Physician Insures Prompt, Careful Service
A Constructive Market for Bayer and Seller [Phiiadtipbi.
COTltentS conllnutJ/nm pofc 622
Efficient Future of Medical Practice
We Are Tagged, Gigged, Nigged and Dragged 657
Beet Current Medical Thought
Acute Abdominal Condition* In Children Due ta Error*
in Diet 6M
The Nature and Came of Old Age Enlargement of the
Proetate 6»
The Indication* for Operation* in the Treatment of
Injuria* Involving the Brain MO
Effect* of Faulty Food* on Endocrine Gland* SCO
Book Reviewt
Doctor* — Entre Nou* *W
Adventure* In Endocrinology HI
Ringworm and It* Succeiiful Treatment Hi
A Compend on Bacteriology HI
New Prices on
Merz Santal Comp.
Capsules
DISPENSING PHYSICIANS CAN BUY
OF US DIRECT
10 Minim Elastic Capsule*, box of 100
Alio bexa* of 12 and bona of 24
5 Minim Perles bottle of 36
5 " " bottle of 500
S " " bottle of 1000
Unsurpassed for happy effect in Urethritis,
Cystitis, Prostatic Troubles, difficult mic-
turition, etc.
PUCES AND SAMPLES UPON APPLICATION
THE MERZ CAPSULE CO.
DETROIT, MICH.
Money Back Guarantee to Subscriber*
Tut Am
> Pkvuciaw i* publiahed for eftf *nd Mij *•"
. 117 IMIPIM IB I'
oil, to be financially edriupparting *nd to
»««[*« or entanrlement in my wmj with titktr.
If any *ub*eriber, at any Mnw, fed* that Thi
Phyiiciah ia not giving him fmU ncaiure ("pro'"1
manioc oyer") of auefa, aervice, or i* di***ti*fied U
if he will write a* we will cktrrfutty Tifnnd, without nnemw.
the money he paid for the yttri mbtcnptitm, even if he ha*
Tn* Auhicav Funiciu aechn «nly Mtufied. iatoeatei
ader*.
SaewcTipriow Centbmmc*
Practically all of our anbecriber*, a* a matter t
..jrirr aubacription to be continued, to avoid mil*
cwmdl luffly bach ia»«), and to be baled when .
inleo, of eourie, paid ahead for I"**3
the *ubaeriber'a deaire, it ia tar^a"? ■
dirtritrat* frnfU t*F=* '
auMly B«* t
e Jyearly in adra
""Where thia ii m
However, if for
■ubacri prion bill, it will
with no charge for the •
Th< Aiciucu Panic
free copiea of any hind.
Sabttription Prie*
Fifty cent* a copy current iaaue (back ana 11.00 e ««
moat (una not available); |2.00 for One Year; fJ.OO for T*
Year* rtl.Stt a year); |S.O0 for Four Year* «1JJ a I*"*)!
110.00 for Ten Year* (only $1.00 a year).
Thi* ia for Domeatic pottage — U. S. and
Hexico, Canada and Foreign, SOc *Mi*im
TKr Amtricmu Physician.
4M IPaJaat Strttt, PhtJaaelehia, D
i buy with confidence — See "Service Guarantee to Readers" on page 686
September, 1922]
The American Physician Advertising Service
625
In January, 1917
THE BACILLUS ACIDOPHILUS
was introduced and made available to the medical profession for the
first time through
Bacid Preparations
which were created solely to make possible the therapeutic use of this
antiputrefactive organism, the Normal Habitat of which is the Human
Intestine in health.
Bacid Preparations
Tablets— Capsules— Liquid Cultures
do not now and never have contained the
B. bulgaricus— either Type A or Type B
Literature — Bibliography — on request
Guaranteed and Manufactured ONLY by
The Arlington Chemical Company, Yonkers, N. Y.
i
n
i
i
BF=y=3Eff=ff=S=3S
COMPLETE LIST OF
PROTEOGENS
Pew l"~roc Mopcffwls
* ana ■prow I
Us. 1— For th
! Of pOOf 10 ttfctl
Ms. 4-For Hay F<
cMalArfna*.
fts.5-For
aotoWlo
Ms. t-Fof Penidosi
except ths spmidc type.
Ik. i-For Simple Goitre.
H*.t-A-F«r Esophthtlam
Ps. lv— roc Syphas.
He. 11— For Gwtnhe>.
ft*. 12-For Poem** tail b-
Ms* 1* rot "jrmnies*
Clinical Experience
is after all, the deciding factor in determin-
ing the worth of any remedy, and a tabu-
lation of reports from physicians all over
the world ahowa that
PROTEOGENS
i
hare been used with favorable results m
67% of the caaaa treatecL
If you hare a case with any of the diseases
listed, that is not responding to ordinary
treatment, remember the Proteogens can be
relied upon for beneficial results in almost
seven cases out of ten.
Your patients expect you to use every pos-
sible means to effect a core, and because of
the high percentage of favorable results ob-
tained, it is to your advantage to use the
Proteogen treatment regularly in your
practice.
We have some interesting literature on the
Protein Therapy and the use of Proteogens.
Shall we send it to you?
m_jf FOUNDS* ISIS
TO! WH SMERREIJ.COM'***
1 *ctacmiMTi.usA
a!HrHr-Hr-Hc^fcHcHfcdc=a=R^^
Mentioning The American Physician Insures Prompt, Careful Service
A CorulrucJMc Market far Buyer and Seller
-MORE AUTHORITATIVE EVIDENCES
CONGESTIVE
DYSMENORRHEA
Thi* painful condition ii readily
relievsble by proper mediation. Ac-
knowledged gynecological authorities
have found
KAYDDTS VBUtNUM COMPOUND
DYSMENORRHEA
P. H. Davenport, AB, M.D., of
Harvard, m bil text book on ■'Dis-
eases of Women." page 144' (herewith
reproduced) referring to various rem-
edies for the relief of congested
dysmenorrhea, states "That Harden' ■
Virburnum Compound is the roost ef-
fectual remedy in its class."
There arc many imitation! and sub-
stitutes for Haydn's Vtb»n»m Com-
found. We shall be glad to send you
a sample of the original product as
compounded by Dr Hayden, and
which was so effectively used by Dr
Davenport and Dr Sims.
A card will bring you literature and
sample of the original H. V C
HEW YORK PHARMACEUTICAL Gil,
Bedford Springs. Bedford, Mass
Wish [hi-u, !i;ic cfliKlilioiis ... so" picv.lrnt.
You can buy with confidence— See "Service Guarantee to Readers" on page 6
September, 1922]
The American Physician Advertising Service
627
(D
Indigestion:
Its Symptomatic Relief
DOCTORS are sometimes surprised to learn that Taka-Diastase
is an excellent symptomatic remedy in many cases of proteid
indigestion. Although its effect in these cases is indirect, it is never-
theless gratifying.
Taka-Diastase seems to liquefy the starchy elements of the stom-
ach contents, giving the gastric juice free access to the proteid food
which would otherwise be encased in a rather impervious starchy mass.
That explains why Taka-Diastase or a combination of Taka-
Diastase and Pepsin is a favorite prescription of many physicians in
cases in which the digestive functions need a little temporary help.
Of course, in cases of amylaceous dyspepsia— marked deficiency
of ptyalin or amylopsin or both— Taka-Diastase is the outstanding
indication. It steps into the breach at once and carries on the dis-
turbed digestive process. The patient gets rapid relief from the
distressing symptoms.
The dose of Taka-Diastase in powder, tablets or capsules is 5
grains, to be taken immediately after meals. Liquid Taka-Diastase,
an extremely palatable hydro-alcoholic solution of Taka-Diastase, is
usually prescribed in doses of one to two teaspoonfuls.
New ltttratnr* gladly eeatpbyelci— oa req
VACCINES-GLAND THERAPY. Wi
b THE 1922 CATALOGUE-TYPHOID
rrite to our ncarot brasdi: Detroit, New York.
Ckiwgo, Kabmm City, Baltimore, New Orleaa*, St. Loau, Mineapolie, or Seattle.
Parke, Davis & Company
Mentioning T!te American Physician Insures Prompt, Careful Service
628
A Constructive Market for Buyer and Seller
[Philadelphia
The Management of an Infant's Di<
For Infants
Rational ProcediireV^ of SLUY age
ummerUiairhea
Mellin's Food
4 level tablespoonfuls
Water (boiled, then cooled)
16 fluidounces
Give one to three ounces every hour or two, according to the age of the
baby, continuing until stools lessen in number and improve in character.
Milk, preferably skimmed, may then be substituted for water — one
ounce each day — until regular proportions of milk and water, adapted to
the age of the baby, are reached.
PUMIII!
""illlliilllli
:iiiiiiiii:iiiiiiiii!i,i,,,i,!i
NOVARTAMIN
tPhenyl-Quinolin-Di-Carboxylic A cid)
In tablets.
Indications: Gout, Rheumatisms, Neuralgia,
Neuritis, etc., eliminating Uric Acid without
causing gastric disturbances. No disagreeable
taste.
Dose: One or two tablets three to four times
after meals dissolved in a little water followed
by a large glass of water.
NEUTRALON
(Synthetic Aluminum Silicate)
Indications: Hyperchlorhydria, Hypersecre-
tion, Ulcus Ventriculi and Duodeni.
A neutral and yet neutralizing substitute for
the Bismuth Salts, Sodium Bicarbonate and
Silver Compounds, etc. It reacts gradually
and its effect is more permanent than that of
the Alkalies and of Magnesia. A white, taste-
less, odorless powder.
The average dose is one teaspoonful in a glass
of water (preferably warm) a half hour before
food.
CHLORYLEN
(Trichlor Ethylene in its purest form)
Liquid in bottles of 25 grams each.
A new treatment for Facial Neuralgia.
Chlorylen is used with marked success in the
treatment of Facial Neuralgia. It has a spe-
cific action on the sensitive Trigeminus, gives
immediate relief and the pain disappears after
a few treatments.
Chlorylen is applied by inhalation. 20 to 30
drops are placed on cotton or the handkerchief
and inhaled through the nostrils until the
odor disappears.
VALAMIN
(Amylene-Hydrate Iso-Valeric-Esler)
In capsules.
A sedative and soporific, easily absorbed and
promptly acting.
Indications: Neurasthenia, Nervous Insomnia,
Hysteria, Palpitation of the Heart, etc
Dose: As a Sedative one to two capsules, as
a Hypnotic two to four capsules followed by
a drink of water. In nervous insomnia two to
four capsules should be taken before retiring.
For further information and literature address:
Kirbach, Inc., General Agents, 227-229 Fulton St, NX
You can buy with confidence — See "Service Guarantee to Readers" on page 686
The American P/iyw'cian Advaiuing Service
Diphtheria
Treatment
Diphtheria Antitoxin
For treatment of acute cases and to produce
immediate temporary immunity.
to 20.000 Unit*
T-A. Mixture (!
To create lasting immunity, which develops
in about six weeks, and is believed to
continue almost indefinitely.
Susceptibility
Schick Test Toxin CS?SS* W)
To determine susceptibility to DIPHTHERIA.
Dmi <U Ot, injected betimes the 1*tdi of the IKto.
S— H** In peckafea containing ooe hermetically seeded tube of
nndllnwd Dirnmu Toxin, with one IfcCe. vtal of Balis*
Bolntion. lofflcient to nuke at leant fnrtj teeta.
Schick Test Toxin Control
Diluted Diphtheria Toxin, attenuated by
heat, to be used as a control for the
Mulford Schick Test Toxin.
BEND FOB NEW LITER A TUBE
H. K. MULFORD CO.. Philadelphia, D. S. A.
Mentioning The American Pkysician Injures Prompt, Careful Service
A Constructive Marlfet for Buyer and Seller
In summer diarrhea, Intestinal catarrhs, etc.
c
Tannalbin
■ at hourly Interval*.
For Solo by Utmratar* and Sampimm front
MERCK St CO. E. BILHUBER, Inc.
New York St Louia 28 Wait B™dw»y, New York
KtfXeco or "I Calm'
ISl Hi Li Ej IN Ej ^ ^ J ANESTHESIA
/n autonnrticaUy closing tube*. Convenient to cmrji. Easily applied. Uniform rendu.
Widely used for many years. For general anesthesia, useful in minor surgery and dentistry.
Manlactonra Sol. dl.tributor* far tW U. S. A. ud CuxU
FRIES BROS. MERCK & CO.
M R»d. Strwt, Naw York St. Louti NEW YORK
P-^^^"
.7»*f
You can buy with Confidence — See "Service Guarantee to Readers" on page 686
September, 1922]
The American Physician Advertising Service
631
Essential Points
in the
Diet of Growth
1. The food must contain those food accessory sub-
stances known as vitamines, but the presence of
the vitamines is not sufficient in itself.
2. The food must be well balanced, for a deficiency in
one element means the ineffective action of the
other food elements.
3. The vitamine- containing food even though well
balanced must be one that is easily assimilated. It
is a physiological crime to clog the system with
fats that cannot be digested.
VlROL as it reaches the public contains the vita-
mines; it is well balanced, and can be assimilated
in the most delicate conditions. That is why
VlROL is used in more than 2,500 hospitals and
infant clinics.
The presence of vitamines in VIROL as sold to
the public is established by an independent report
by the Bio-Chemical Department of the University
of Cambridge, a copy of which will be sent to any
member of the medical profession on request.
VIROL
Sole Agents for United States
Geo. C Cook & Co., Inc., 59 Bank Street, New York
Mentioning The American Physician Insures Prompt, Careful Service
A Constructive Market for Buyer and Seller
STRENGTH FOR
THE ASTHENIC
Suprarenal insufficiency is one of the marked features of the asthenias.
The blood pressure in these individuals is almost always low and the cir-
culation poor. The activities of other glands of internal secretion are
always impaired. That is why pluriglandular therapy gives better results
than suprarenal substance given alone.
Hormotone
which is a combination of
thyroid (1/10 gr.). entire
pituitary (1/20 gr.), ovary
and testis, promotes oxidation,
increases blood pressure and
enhances metabolism by pro-
ducing suprarenal efficiency.
Dose: One or two tablets
three times daily before meals.
G. W. CARNRICK CO.
419 Canal Street New York, U. S. A.
You can buy with Confidence— See "Service Guarantee to Readers" on page 6f
The Am
encan
Phys
iaan
VmL 27
Smpimmbtr, 1922
Nm. 9
Epidemic Psychic Imbalance
PSYCHOSYNTHESIS NEEDED RATHER THAN PSYCHOANALYSIS
JUST WHICH HORMONE is "hyper" or "hypo"
in the psychic imbalance so current today we do
not know, but we would like to find some material or
tangible thing to blame for a sort of spiritual hypo-
chondriasis that Conan Doyle and others are capital-
izing. The hypochondriac believes himself suffering
from some grave disease, and every so often a spiritual
hypochrondriasis arouses interest in the world of
spooks. Not that people really care very much about
spooks or spirits, for they do not ; but when the indi-
vidual gets out of spiritual balance he rushes off to
the medium for consolation. If his imbalance is
purely physical he holds an experience meeting with
others similarly afflicted, but when his body is all
right and his spirit out of tune he has no material
moorings, hence his interest in spiritism.
After all is said and done, one gets most mortally
little out of a spiritualistic seance; for, whatever
communications with the spirit world one may or may
not encounter in the seance, the messages coming out
of the void are petty and inconsequential, usually too
foolish to influence sensible people. The medium
knows this perfectly well, and he also knows that the
real reason for his seances is the fact that they bring
together groups of persons suffering from spiritual
imbalance, whose interests are not with those gone
beyond, but with themselves.
ScUsk Spiritism
The person with a spiritual screw loose somewhere
is really very much fussed up over something, he
knows not what; and he knows he will be laughed at
if he goes with his troubles to a person whose spiritual
opsonic index is normal. This is a material world,
but the immaterial and intangible is closer to the
surface than we like to realize, and sometimes our
spiritual psyche gets a cramp and we suffer. Yes,
such a person suffers, really and truly suffers, and he
craves consolation. There is a pre-religious phase
to such suffering, just as there is a pre-medical phase
to physical conditions. Sending one of these persons
to a clergyman shocks him just as much as to tele-
phone for the hospital ambulance. He does not want
eut-and-dried religion any more than he wants a
surgical operation. He knows just what the clergy-
man will tell him and he also knows that his condition
is "different" and he wants soothing treatment; he
wants to be "understood," not patronized or reasoned
with. So he goes ostensibly to see the medium and
have a talk with some spook ; but what he really goes
for is to meet a group of companionable people in
the same fix as he is himself. He hopes, by heart-to-
heart talk with them, to get help for himself. After
all, he cannot be blamed for this experience-meeting
attitude, even if he does have to tolerate a medium as
the class leader, as it were.
WkM SUl Wtfof.r Smck PfpU?
Neurologists have long recognized that this prob-
lem exists, oftentimes in epidemic form. So did
Mary Baker Eddy and others realize it. We are not
discussing Saint Eddy now, but the neurologists. As
a matter of fact, Mrs. Eddy developed Christian
Science and the neurologists developed psycho-analy-
sis, and we want to discuss the latter.
Psycho-analysis is "a method of obtaining from
nervous patients against their will, a knowledge of
their past experiences." Now, the stage setting of
the psycho-analyst is semi-spooky with just a dash —
sometimes several liberal helpings — of sex and sex
experiences. Accessories aside, psycho-analysis is a
sort of spiritual or psychic dentistry and one has to
take gas to keep it from being painful; it digs out
old roots and resurrects corpses. No one wants to
see a spiritual corpse, not even their own, hence
psycho-analysis makes the mistake of going back to
the past, whereas the person with a psychic imbalance
wants to attract interest to the present and the
future. Christian Science takes up the present, while
the medium pries into the future, and in the present
worldwide epidemic of psychic imbalance, the Eddyite
and the medium are putting it all over the psycho-
anal vst.
The history of these psychic spasms that sweep the
world is that they usually end up in some sort of
religious manifestation, oftentimes extravagant or
hysterical. Religiously considered, it is to be hoped
that the better educated clergy of today will restrain
the hysterical and extravagant features, when the
next great revival of religion comes. Unfortunately,
religion, as such, can do very little for the present
spiritual or psychic imbalance. Can the physician
634
Epidemic Psychic Imbalance
[The American Phjraciaa
do anything t
Psycho-analysis tears apart and analyzes, princi-
pally the past. This is sometimes useful, but usually
it should be lightly touched upon where there is no
organic disease. An analysis of the present psyche is
more important. No analysis cures ; it simply aids in
diagnosis.
What is needed is something curative, something
upbuilding, that restores, regenerates and recreates,
or re-creates, as one chooses to term it. In other
words, we do not want analysis; we want synthesis.
Hence we coin the word psychosynthesis as what we
mean.
It would take a vast deal of research, study and
clinical observation to develop the full range of
psychosynthesis, and that will not be attempted here;
but it is patent to all that some such advance in the
treatment of psychic imbalance is needed — not only
for treatment, but for prevention. Permit the obser-
vation that it might well be founded on psycho-analy-
sis, simply extending that science in rational direc-
tions, and, at the same time, eliminating from it a
deal of chaff and unnecessary stress upon the sex
factor. Doubtless there are psycho-analysts today
who are gradually doing this very thing.
Immity, Nemreses and Imbalance
Pathologists are explaining insanity more ration-
ally than the alienist and psychiatrist are doing.
Syphilis, tuberculosis, other infections, alcohol and
other toxic irritants, traumatic changes and injuries,
blood-vessel degenerations — these are the things that
cause real insanities. A psychosis is a morbid mental
state without demonstrable organic lesion, and it may
or may not produce a delusion or other legally
accepted proof of insanity. Many psychoses are
entirely curable outside of a hospital for the insane.
A neurosis is, even more completely, a functional dis-
ease of the nerve centers or peripheral nerves. We
have come down the stairs, as it were, and at the
bottom we find psychic imbalance. Reverse the proc-
ess, and we find the patient climbing from an im-
balance to a neurosis or even to a psychosis. So,
then, psychic imbalance is important and must not be
treated lightly, especially when, as exists at the
present, a worldwide epidemic of psychic imbalance
is noted.
Tame to Slew Up
The present recrudescence of spiritism will soon
pass, as such reawakenings have passed before; but
it may be a long time before the present epidemic of
psychic imbalance passes. Viewing its features as
the ultra-neurologist does will accomplish little. The
general practitioner, the sociologist and the more
level-headed clergymen must study the situation
broadly. It is possible some modification of present
religious methods may help; but the main things
needed are social readjustment and clinical study of
each case. Doctor, don't be unsympathetic with your
patients who are running after mediums, science
healers, oriental mystics, religious fanatics or new-
thought cults; they are suffering from the current
psychic imbalance and need your sympathetic help,
not your scorn. Don't turn these people away with
a prescription for bromides or some other drug that
will probably harm them. And don't forget that the
world is full of poor souls who need sympathy.
We Are Rem*** What We Sewed
For years we allowed alcohol to get a terrible bold
on all classes of our people; then a sudden revulsion
against it came, and there are many thousands of
good citizens who are off balance because they do
not get their liquor at all or get it in some poisoned
form. Society is paying for this.
We have abused tobacco, coffee and other caffeine-
bearing drinks, which, used rationally, may do little
harm; but they are used in excess and very irration-
ally and are doing a vast deal of harm. Society is
now beginning to pay for this.
We have allowed our patients to prescribe strong
drugs for themselves, often on our own prescriptions
and against our own better judgment, but more on
their own initiative; and opiates, chloral, synthetic
somnifacients and analgesics, irritating "tonics" and
a world of pharmaceutical trash are disturbing the
national physical and psychic balance. Society is
already paying for this and will pay.
And all the wild agitations, the excesses, the cupid-
ity and self-seeking, the running after strange gods,
the lack of parental and other restraint — these will
all be paid for by society. Today it is pay, pay, pay,
and "the Devil take the hindmost." "Step on the
gas, Kid!" is our national motto. Let's whistle down
brakes! It is up to the medical profession to do it
Who else will!— T. S. B.
Significant New Publication
*The American Medical Press"
"Devoted to the Political and Economic Interest
of the Medical Profession*
It seems to us significant of the growing recogni-
tion of the vital importance of the question of the
future economic status of the rank and file of physi-
cians, that a publication is now started devoted par-
ticularly to this field.
The American Physician has for several years
urged the importance of this problem, and has de-
voted particular attention to arousing the rank and
file of the profession to an earnest and constructive
Phila., September, 1922]
Imwoniiing Against Diphtheria
635
attention to it. If solutions are to be worked out in
the development of modern medical service to meet
modern conditions that will conserve the individual
economic independence of the physician in general
practice, we feel that it will be accomplished only
through the insistence of an enlightened medical pub-
lic opinion that springs from and has its roots firmly
established in the rank and file of the profession.
"The price of liberty is eternal vigilance."
complementary. Constructive work of enduring value
in this field will be built only on that foundation.
C. C. T.
We are glad to welcome a new colleague in this
important work. There is need for every force and
agency that can be enlisted in the constructive service
of this cause. Doctor, as a matter of intelligent self-
interest, you should support every publication giving
earnest, adequate, constructive attention to this vital
problem. Subscription to the American Medical Press
(280 Broadway, New York City) is $2.00 yearly.
The first two issues are decidedly good initial issues
and very promising. As an indication, some of the
titles are : The Menace of Ultra-Specialization in the
Practice of Medicine; Medical Education and the
Future of the Medical Profession; Suggestions for
Operation of a Doctors' Exchange in Communities
of Thirty Thousand or Over; Multiple Voting Privi-
lege in the American Medical Association; The Men-
ace of Foundation Control and Full-Time Medical
Education, etc. Doctor, we believe it will be well
worth your while to send an initial subscription to
this publication. Continuance of subscription to any
publication should depend upon your judgment of
the service rendered.
We should like to add a note that we try to keep
ever in the foreground in every consideration of this
subject. The interest of the public is paramount. The
best interest of the rank and file of the medical pro-
fession will be served only as the best interests of the
rank and file of the public are served. Regardless of
any professional interests, medico-political interests,
commercial interests, any medical journal interests,
interests of any medical society or organization, any
interests of any group large or small, the most ef-
ficient service in the conservation of health must be
made available to the public on a self-respecting basis
at a reasonable cost within the ability of the public
to pay. The first test that every proposition and
every instrumentality must meet is — How Will the
Public Be Served.
This is not a vague, visionary point-of -view ; it is
sound, practical common sense and enlightened self-
interest for the rank and file of the medical profes-
sion.
The American Physician is convinced that the
best interests of the rank and file of the public and
of the rank and file of physicians are mutual and
Immunizing Against Diphtheria
with
Toxin-Antitoxin
O OME PHYSICIANS fear that this modern pro-
*** cedure is dangerous and contend that it is new
and untried, therefore, dangerous. As a matter of
fact, the earliest work along this line, performed on
laboratory animals, was done twenty-five years ago,
and the first work on man in 1913. So, then, it is
not new and has been most carefully worked out be-
fore placing it prominently before the profession as
a clinical resource.
We know that the inoculation of horses with the
toxin in the process of making diphtheria antitoxin
is not dangerous, the horses remaining in good health
except for certain reactions not at all dangerous
under proper technic. But antitoxin, not being of
human origin, while effective therapeutically confers
very brief immunity on human beings. For this
reason the toxin nearly neutralized with antitoxin,
when injected into man, causes the elaboration of an
homologous antitoxin, and thousands of human cases
show that the danger is very slight and confers a
fairly lasting immunity.
It is true that in a child of tender age a slight re-
action occurs in all cases, and a moderate and
occasionally severe reaction in ten per cent, of older
children and adults, this reaction being from protein,
not from the toxin as such. With improvement in
the technic, less horse-serum antitoxin or a concen-
trated one being used, the reaction should become less
marked.
Smm CUmeti Cvmiimtimm*
There is some question whether a completely
neutralized preparation should be used, or one slightly
less than neutralized; but as the toxin-antitoxin tends
to complete neutralization on standing, the recent
practice is to use a preparation not completely
neutralized.
Dr. William H. Park, the able director of the labo-
ratories of the New York City Department of Health,
is the authority for most of the following statements.
Three injections, 1 cc. each, spaced one or two weeks
apart, will cause about 85 per cent, of susceptible
children to develop sufficient antitoxin to produce
protection against diphtheria and give a negative
Schick reaction; but the development is slow, being
from one to six months after using the toxin-anti-
toxin, when it affords protection against diphtheria,
in 90 per cent, of the children, for more than six
years and probably for life.
636
Announcements
[The American Physiciafl
Toxin-antitoxin injections should not be given
within two weeks of an injection of antitoxin, as the
toxin is thus overneutralized and is ineffective in large
degree. Preparations used should not be over three
months old in order to be fully reliable, but older
preparations are not dangerous and do not become
more toxic. The Schick test is a valuable control in
determining the degree of immunity attained, but is
usually omitted in a child under three years of age
and in school work, in which it is often a routine to
give the injections. Toxin-antitoxin injections are
rarely used in children under six months of age, the
tissues of the baby not responding well.
We desire to urge the profession to thoroughly
familiarize themselves with the toxin-antitoxin pro-
cedure, since its value is now fully determined. —
On the opposite page you will find a paper on
"Diphtheria : Control and Prevention," by Dwight M.
Lewis, M.D.
Experimental Innoculation of Human Throats With
Virulent Diphtheria Bacilli
Guthrie, Marshall and Bull (Johns Hopkins Hosp.,
Dec., 1921) — Diphtheria bacilli obtained from the throat
of an otherwise healthy carrier, and proven to be virulent
for guinea pigs, were innoculated into the throats of
eight volunteers. Four of the eight had previously
given a positive Schick test and all four developed
clinical diphtheria. The other four gave negative Schick
tests and none developed the disease after innoculation.
All of those innoculated with the exception of one
who had given a negative Schick test became carriers.
The authors have found that the administration of
antitoxin does not always prevent the carrier state. They
also believe that the guinea pig test can be relied upon
to estimate the virulence of diphtheria bacilli.
Diphtheria bacilli of a virulent type in the throats
of otherwise healthy carriers can produce clinical diph-
theria in susceptible individuals.
Incorporation of The American Society for the
Control of Cancer
On May 15, 1922, the society was incorporated
under the Membership Corporations Law of the State
of New York. This step was taken after the Judiciary
Committee of the Senate had decided against recom-
mending the incorporation by special act of Congress
of the charitable, benevolent ai\d educational organi-
zations, including this society, which had applied for
national charters.
The certificate of incorporation of the society states
that "its operations are to be principally conducted
in the United States of America" and describes its
purposes as follows:
"To collect, collate and disseminate information
concerning the symptoms, diagnosis, treatment and
prevention of cancer; to investigate the conditions
under which cancer is found and to compile statistics
in regard thereto."
Coming
Cancer Therapy; The Proper Co-ordination Between
Surgery, Radium and X-Rays, by Isaac Levin,
M.D.
In his authoritative paper, Dr. Levin states that
it is of the utmost importance not to impede the
correct and scientific progress of the subject by
either an over-enthusiasm over one method or
an unwarranted pessimism over the other. Dr.
Levin believes an individual cancer patient has
a far greater chance for recovery now than
thirty-five years ago, and that the most important
problem today is to obtain a true evaluation of the
three methods of cancer therapy and find a way
for their proper co-ordination.
Pathological Personalities, by Gustav F. Boehme,
Jr., M.D.
It is the author's belief that ours is an age of
increasing insanity and mental defectiveness, the
basic principles of which hinge closely upon
"pathologic personality."
Something undoubtedly must be done; and Dr.
Boehme indicates a large opportunity for the
physician to prevent if possible and to cure where
possible these unhealthy mental states.
Ectopic Pregnancy, by Gilbert I. Winston, M.D.
Few conditions are as dangerous as ectopic ges-
tation. Few conditions require as prompt and
as efficacious attention as does this fatal disease.
The excellent recapitulation herein presented,
together with the cases illustrating the points
dwelt upon in this paper should prove of interest
and value to both physician and surgeon.
Obscure Etiology of Trifacial Neuralgia Complicate*
Satisfactory Treatment, by William A. Lurie,
M.D.
Trifacial neuralgia results from a variety of fac-
tors of imperfectly understood origin. Because
of this obscure etiology the treatment is equally
unsatisfactory. To remedy this, the paper of Dr.
Lurie attempts to unravel the complicated ele-
ments involved and explain matters on logical
and sensible bases. Its practical value, then, is
self-evident.
Gall Bladder Diseases, by G. S. Foster, M.D.
Gall bladder diseases, experience has shown, yield
more readily to surgical than to therapeutic meas-
ures. However, the scalpel must here cut with
caution and care, as is asserted by Dr. Foster in
this short, clear-cut. sensible paper.
Ludwig*s Angina, by Mayer Shoyer, M.D.
When crossing a railroad you stop, look and
listen. When crosssing Ludwig's Angina you do
not, you rush your patient to the surgeon, or
the patient will go to the undertaker as is em-
phasized in this short but illustrious paper of
Dr. Shoyer.
Muscular Tone and Reflex Pain in Diagnosis,
Twenty-ninth Clinic, by A. Mackenzie Forbes,
M. D.
The duties of a diagnostician are similar to those
of a judge. <4In a court of law the evidence is
of the greatest importance. The omission or
addition of one point may change the courts
decision. In a similar way the science of diag-
nosis, the collecting, weighing and properly ad-
judicating the significance of the symptoms is
of the greatest importance."
The following papers
are contributed exclu-
sively to this journal.
Republication is per-
mitted if credited as
follows: AMERICAN
PHYSICIAN, Phila-
delphia.
Original Articles
We are not respon-
sible for the views ex-
pressed by contribm-
tors; but every efort
is made to eliminate
errors by careful edit*
ing, thus helping the
reader.
Diphtheria
Control and Prevention
By Dwight M. Lewis, M.D.
New Haven, Conn.
ion ok Casts
Central — Emrly
A preventable death not prevented is a
stigma on civilization in general and medi-
cine in particular. To correlate internal
and prophylactic medicine, to harmonize epi-
demic experiences and standing facts, read
Dr. Lewis' paper. You mill find it sensible,
instructive and practical. — Editors.
FOR REASON OF theoretical completeness of
measures, not only of control but of prevention
of the disease under consideration, explanation of the
continued general absence of control as shown by the
mortality statistics for 1921, country wide as well as
for varying cities, as compared to immediately pre-
ceding years, deserves the close attention of the gen-
eral practitioner, whether of internal medicine or of
the public health.
The past history of attempted control has rested
primarily on the tremendous success of prophylactic
and curative diphtheria antitoxin, any reasoned lack
of control being a measure of the inability to hos-
pitalize cases or to find the mild missed case. Gen-
erally the present-day viewpoint is that the healthy
carrier has been the predominant missed source for
absence of control. But little less important is the
very general public health teaching yet prevalent in
all centers, that both parent and physician are re-
sponsible for failure to early recognize, report and
<?ure such numbers of cases as would make for control
of the disease. Therein lies the first fallacy of rea-
soned control. The fallacy lies very definitely in the
pathology of the disease. An essentially toxic process
and one predominantly of the younger child (90 per
cent of deaths at the least are frequently in children
under age 5), there is neither complaint, on the
-part of the patient, nor appreciation on the part of
the parent, of a sore throat. In sharp distinction to
the ordinary "follicular tonsillitis" in the same age
group with its immediate prostration, fever and evi-
dent disability on swallowing, diphtheria may only
be appreciable to the parent from the utterly indif-
ferent, even obscure, signs of low fever and general
lassitude, the measure of a slowly increasing toxemia.
It is then fortunately true that parents do not await
a complaint of sore throat or the appreciation by act-
ually seeing a sore throat before calling for medical
attendance. The following recent example is the
usual:
"On a Friday afternoon a young Polish mother
took her 5-year-old boy to the dispensary because
he had a slight fever. A throat culture was taken
and the mother told to report with the child the fol-
lowing morning. At the latter time a positive report
was had, 8,000 units of antitoxin given, and the case
reported to the Board of Health as an emergency case
without medical attendance. The mother refused to
permit hospitalization of the case. No carriers were
found in this family nor in a second family in the
house. On the following Friday, a culture from a
5-year-old boy in a parallel street, one block away,
was positive for diagnosis. The history here was
that the child had been "ailing" for some 5 days,
but that it was only when the boy seemed "sick" on
Wednesday that the family physician was called. The
father of the case rather pertinently asked whether
the father of the first boy mentioned, a peddler, might
not have brought the disease here on a visit he had
made the Saturday previous. Inquiry elicited the
fact that the families knew one another and that
the children had been playing together with other
children in the neighborhood previous to the onset
of the first case. Fortunately at this point the oldest
child in the family, a girl age 7, came in from school,
and the presenting bloody, purulent unilateral nasal
discharge of the girl became the positive epidemiolog-
ical evidence of the cause of both cases. Confirma-
tion was had the following day with a positive
638
Diphtheria Control and Prevention— Lewis
[The
laboratory result"
The usual then presents first, the phase that no
amount of education on "sore throats" can obtain con-
trol through early finding of cases, and secondly that
while control may be said to be had with the discovery
of tlje carrier, yet prevention had not been obtained.
The Cerrier
Discussion may hold then first as to the question
of the carrier, and why, although control may be
obtained, prevention is not obtained. Literature is at
the present time well filled with the numerous city
surveys, showing that upwards of 2 per cent of pop-
ulation are, during "normal" times, healthy carriers,
increasing in percentage with the relating frequency
of the disease. By reason of the showing by virulence
tests that but one in ten of such healthy carriers have
virulent germs in throat or nose, few cities seek
healthy carriers in advance of actual cases, and then
only among contacts of cases, unless for reason of
prevalence, and under such conditions as several in
one school room. The basis of such surveys has been
and is dependent entirely upon systematic, routine
culture reports from nose and throat Except then,
in times of frequency of the disease, it is the usual
that cities try not to find such carriers, necessitating
much social restrictions until virulence can be estab-
lished. The fallacy here lies, as we have shown, in
the initial field work that was done with the diph-
theria carrier, in the absence of appreciation that the
healthy carrier responsible for a case or cases as well
as for further carriers showed a pathological picture
appreciable to the eye. Predominantly nasal, it re-
solved itself into the time-honored, "nasal diph-
theria" (other than being secondary to faucial diph-
theria and as such in one at the time practically
moribund), being frequently a previous recovered
case of the disease, with evident defect of nose,
usually unilateral, and with a pathological discharge.1
Our previous epidemiological supposition that a
healthy carrier was thus diagnostic rather than a
carrier without such pathological evidence, although
with positive laboratory evidence, has since been
borne out in a small number of virulence tests,
positive laboratory cultures from ordinary head
colds and "tonsils" showing negative virulence tests.
In accord are the data of the more extensive results
of hospital carriers, literature showing that the nasal
is the usual and has the irritating characteristic pre-
viously described. It is noteworthy that our survey
based on the pathological manifestations to be seen
by the eye and confirmed by the laboratory, in some
35,000 school children in 1917 by two nurses, gave a
two-tenths per cent, of health carriers.2
Dtpktkerim mmi Memdes — !■— iiafi—
One further factor has obscured the possibility of
obtaining control as practiced by the laboratory dem-
onstration of carriers. That an entity like diphtheria
should in any way be dependent on any other entity
like measles is untenable to a laboratory worker.
It was the historical fact that diphtheria follows
measles and that during and following measles nasal
diphtheria is unusually prevalent, that gave us the
field demonstration of the characteristic healthy diph-
theria carrier.
With the observations that active immunization by
a toxin-antitoxin mixture has, during periods of from
5 to 8 years, given a very material reduction in
the morbidity and mortality among those so protected
as contrasted with those of the same communiticB
who were not immunised, a decided reversal of method
of prevention as well as control, is increasingly ad-
vocated as the solution. Wide application during
times of infrequency of diphtheria, of immunization
of all children under age 6, irrespective of the Schick
test for susceptibility, with immunization of children
over the mentioned age dependent on the susceptibil-
ity test, makes unnecessary any control of the healthy
carrier. During a time of frequency of the disease,
until all contacts have been so immunized, control
may be had by temporary immunization by anti-
toxin.
Imcremeed SmtciptikWty FfcrMfft Other
To the field worker who is as well a student of the
vital statistics of the component parts of not only
the United States, but of the foreign countries who
are constantly contributing added population to this
country, two fundamental facts have been overlooked.
The first is that the method under consideration is
applicable in rural regions or in urban districts where
combat of diphtheria is not a large problem. The
second fundamental (and it explains as well the first
fundamental), is that no consideration is given as to
the relationship of any dependence on other specific
respiratory diseases. It is on record that during
measles, scarlet fever, poliomyelitis and other such
diseases, an increased susceptibility to diphtheria is
shown as evidenced by the positive Schick reaction in
one previously negative. We return then to the ob-
servation made previously that measles frequencies
are factors in immediately succeeding frequencies of
diphtheria through the historical increased "nasal
diphtheria," the latter constituting our healthy car-
riers. That a large measure of prevention may not
be obtained in large cities may then be readily seen.
During measles years the diphtheria carriers, in-
creased in numbers, have increased susceptible mate-
rial among those with, or recovering from, measles.
I have observed that such may be deduced from vital
statistics of communities as well. In an as yet un-
published paper it is shown that during a five-year
respiratory cycle urban cities continue their history
of such previous cycles by having a constant of two
or more times a diphtheria mortality as measles mor-
Phila., September, 1922]
Diphtheria Control and Prevention — Lewis
639
tality. Appreciation of this factor and of those
factors which we have recorded as of race and cli-
matic conditions,8 correlate the exceptions of such
constants in certain urban cities. There results not
only an opportunity of co-ordinating the times of
especial combat from carriers, but of reasonable
estimation of the results of possible decreased mor-
tality as related to the past history of the disease.
9S.
Ermd,c*mm-Tk* "Emdcmic ImluT
Neglect of healthy carriership of the disease may
be provocative of absence of prevention along
other lines than of diphtheria. There is as yet an
unrealized importance in the control of the nasal
streptococcus carrier, who, as we have shown, may
not only resemble pathologically, the nasal diphtheria
carrier, but may, in a single carrier of both organisms,
give rise to separate infections in the same family
in two different age groups.4, 5 A rather defi-
nite explanation of the "epidemic constitution" of
Sydenham and as definite explanation of the replace-
ment of one disease by another of Watt follows. We
also reach an analogy with the current prevention of
typhoid fever. Shall we by vaccination render a
population for a period of years immune to typhoid
fever, or shall we by control of feces and urinary
excretions prevent not only typhoid fever, but in-
fant diarrheas, the dysentaries, hookworm and, as
many epidemiologists suspect, but as yet are statis-
tically unable to prove, an appreciable measure of
prevention in all forms of tuberculosis f The factor
of the specific inicroorganism as the dominant prob-
lem in each specific disease becomes then subordinated
to that factor which may release a multiple number
of such specific microorganisms, causing not only
an interdependence of the respiratory diseases, but
of the filth borne as well.
The public health bookkeeping is, in a measure,
responsible for results in lack of control of the dis-
ease. By reason of the so-called "endemic index" or
its later modification, the median index, an appre-
ciable amount of epidemic frequency of the disease
is present before action may be taken. The reason
for the amount of epidemic frequency present may
be seen in its interrelation with measles.
A corresponding normal year may either be the
comparable one of the previous respiratory cycle, or
yet better, the best previous one on record.
The former is the method of choice when compara-
tive data of cities is sought.
C«*nl mi Prewcmtmm 1« latfitatiMt
There are on record many instances of methods of
control and prevention of the disease in institutions.
The following two instances are related in contrast
to those on record: In 1916 in a tuberculosis sana-
torium with a total of approximately 150 patients
and staff, there occurred simultaneously two cases
of diphtheria. Nose and throat cultures of all pa-
tients and of the staff were sent me for carrier de-
termination. One nasal culture only was positive.
With isolation of the carrier, I advised a twice daily
inspection of nose and throat for the ensuing week
or ten days. There was no further carrier or case
until two weeks later. At that time I was told
over the telephone that there was a further case and
was asked for advice. On inquiry it was stated that
both of the former cases had been returned from
the hospital a few days previously. Advising an
inspection first of these two for nasal discharges or
in the absence of such an inspection of the entire
personnel of the institution with cultures of suspi-
cious nose or throat conditions, I was informed with-
in an hour that one of the two returned cases was
the only individual showing an unusual nasal dis-
charge and that a culture was being sent. With the
isolation of the individual and a finding of a positive
culture, the former procedure of inspection of nose
and throats was continued. During the ensuing two
years there was no further reported case. During
this time an added procedure was advised, namely,
the inspection of the nose and throat of every pa-
tient on admission to the institution.
The second instance was in a local orphan asylum
with a content of approximately 500 individuals. In
January, 1918, there occurred the first case of diph-
theria in many years. I immediately sent a nurse
trained in the finding of carriers to the institution.
There were two typical nasal carriers found, one of
whom was a recently infected one, the other, a more
chronic one, being an orphan recently admitted from
a neighboring city. Cultures were taken from these
two carriers and from upwards of one-half dozen
children who had ordinary head colds, in order to
exclude recent impregnation of the head colds by
the two carriers. Such was not found to be the
fact. Those in charge of the institution were shown
the diagnostic appearance of the carriers, taught to
take cultures, and after being visited twice during
the ensuing ten days for assurance, have controlled
the situation by routine daily inspection of naso-
pharynx of all inmates and of the routine culturing
of all new admissions with isolation until proven to
be free from carriership.
Prt**mti»e Medico* — A Dyimg Art
Not unnoted is the appreciation that the art of
medicine is often a part of the past. The* laboratory
as a reasoned aid to that art, has, to the younger
practitioner, become the controller. The human ele-
ments of the past history, of diagnosis, of treatment,
even of prognosis, whether in a case of pneumonia
or other disease, have become dominated by consid-
eration of the specific etiological micro-organism giv-
640
Diphtheria Control and Prevention — Lewis-
[The American Physician
ing rise to the disease. In no dissimilar fashion there
appears on the horizon its analogy in considering the
art of preventive medicine. The public, safe from
smallpox by reason of vaccination, are warned to
be vaccinated or have smallpox; be vaccinated or
have typhoid fever; already in public health bulle-
tins there is the prediction that in the near future
the public will be told to have diphtheria toxin-anti-
toxin or have the disease. There are some who vision
the future as one of education in such health habits
as will control preventable diseases, including diph-
theria. The fallacy of such apparent medical impos-
sibilities would seem to lie along two directions. The
first is the increasing dominance of educational propa-
ganda logically reasoned by non-medical theorists in
advance of medical demonstration; secondly, the de-
creasing responsibility of the medically trained, not
only those in internal medicine, but those connected
with preventive medicine as well.
IwUrmkUmey W Vindemct—Cmduutn
»
In the consideration of the prevention as well as
the control of diphtheria (and of all other prevent-
able disease as well), heed may well be taken of the
words of Hill-Greenwood in the International Jour-
nal of Public Health in their article, "Relation of
Health to Atmospheric Environment":
"When the inspiration of classical Greek science,
which found its noblest medical expression in the
writings of Hipprocates was spent, clever, unoriginal
minds reduced medicine to a system needing much
study to master and as unreal and useless as the
academic political economy of the earlier Victorian
age. The witch doctor had returned and held sway
for more than 1000 years. The revival of experi-
mental physiology of the sixteenth and seventeenth
centuries and the efforts of such great physicians
as Sydenham removed this incubus. The popular idea
that freedom from disease can be secured by specific
immunization, by this or that ad hoc method, is the
old appeal to the witch doctor clothed in modern
phraseology." Vol. 2, No. 3, pp. 232.
In sum, there is distinct epidemiological and sta-
tistical evidence from vital statistics that preven-
tion of diphtheria may well be at basis dependent on
better field investigation of the carrier. From the
study of typhoid carriers it would seem that "once a
carrier, always a carrier" is rather definitely de-
pendent on relating factors of activation by inter-
current affections, for example, predominantly gall
bladder infections in adult females. Similar con-
sideration may well prove the intermittency and
irregular virulency of the diphtheria carrier and
establish the pathological basis. Consideration of
the carrier leads to the demonstration of pathological
carriers of other specific diseases, explaining the
"epidemic constitution" and replacement of specific
diseases. Results commensurate with those where
action has been taken against typhoid fever would
appear to be even greater in the case of the respir-
atory diseases if the basis is made one primarily of
visible or demonstrable local pathology and secondar-
ily that of bacteriological content. The vicious cir-
cle of interdependence of specific diseases is cut at
any one point. It is essential for prevention that
control be carried to the point of continuous consid-
eration of the carrier before the occurrence of cases.
Finally the proper placement of medical responsi-
bility and an intensification of procedures and methods
in accord with the science of internal medicine and
preventive medicine alike, may be the desired accom-
plishment.
REFERENCES
1. Control of Diphtheria: Lewis, D. M., Journal of the Ameri-
can Medical Association, Vol LXVI, pp. 1535-1536.
2. Study of Diphtheria Carriers: Lewis, D. M., Boston Medical
and Sorsrical Journal, Vol. CLXXVTII. No. 18, pp. 602-606.
3. Application of the Factors Controlling Carriers of Com-
municable Diseases: Lewis, D. M., Interstate Medical Jour-
nal, Vol. XXV. No. 1.
4. Streptococcal Infection Simulating Diphtheria : Lewis. D. M.,
Boston Medical and Surgical Journal, Vol. CLXXIV, No.
23, p. 887.
5. Two Infections Caused by a Single Carrier: Lewis, D. M«
ibid. Vol. CLXXIX, No. 18, pp. 566-658.
The Common Drinking Cup
From Dr. Hermann M. Biggs, New York State
Commissioner of Health
The use of the common drinking cup is undoubtedly
one of the ways in which contagious diseases are
spread, since by its use infection may .be carried
rapidly from mouth to mouth.
While careful people take pains to wash off the
edge of the cup before drinking and thus succeed in
removing some of the saliva of the previous users, it is
a fact, proved by careful experiments, that nothing
short of soap and hot water will remove all of the
germs from the rim of a drinking cup. *
The common drinking cup has been banished from
railroad trains, first-class hotels and many large halls
and public buildings, but it is still to be found in
many public places. With the many cheap paper cups
now available the time has come when the common
drinking cup should be absolutely forbidden in all
public places. Especially should this rule be rigidly
observed in all schools and other places where children
gather, for the poisons causing contagious diseases
common to children, such as measles, scarlet fever,
diphtheria and so forth are spread from mouth to
mouth in saliva, and in coughs and sneezes. Even
in the home careful people will see that separate
glasses are provided for each member of the family.
While on this subject it may not be out of place
to call attention to the lack of proper facilities for
glass washing at many soda fountains and soft drink
parlors, where running water is not available. Par-
ticular reference is made to roadside shacks and
summer resort booths which are in use for only a
short period during the year, In such places a simple
pail of water, without any soap, has been known to
serve for the washing of innumerable glasses during
an entire day. Such places should receive immediate
attention from local health authorities and should be
put out of business if they refuse to conform to
the rules of common sanitary practice and ordinary
decency.
Do not patronize any place where glasses and other
eating and drinking utensils are not absolutely clean.
Better go thirsty than run the risk of taking disease
from some previous customer.
Phila., September, 1922]
The Problem of "Nervous Indigestion" — Niles
641
The Problem of "Nervous Indigestion
99
By Geo. M. Niues, Ph.G., M.D.,
922 Candler Bldg., Atlanta, Ga.
TO THE PHYSICIAN who has honestly endeav-
ored to drink deep from the Pierian spring, this
problem is significant — oft times vexing. To be
just to the patient, to safely eliminate surgical con-
tingencies, to either coax or compel an unstable or
capricious digestive apparatus into furnishing the
body a sufficiency of available nourishment — these are
only a part of the whole problem as it is so fre-
quently presented to the gastroenterologist.
These sufferers come
to us in various forms;
their alimentary tracts
present disturbed secre-
tions, sensation and mo-
tility, while the psychic
relations are generally
the most awry. They
constitute a generous per-
centage of the habitual
invalids who throng the
health resorts and sana-
toria; who patronize the
freak cures and freakier
"cniists"; who subscribe
to the new cults and fads,
and who furnish the pre-
datory fakirs much of
their income.
These fame neurotic types are seldom found in
either the extremes or near-extremes of life, but in
those past the twenties and under the fifties — those
at the age to care for themselves or others. In chil-
dren the digestive organs are less impressionable,
while in those past the prime of life there seems to
be established an immunity; or, on the other hand,
they have learned by experience how to side-step such
habits or articles of food as are injurious.
The Prmdpti Smitrcr*
This "nervous indigestion" is seldom found among
those who earn their bread by manual labor, or among
the uneducated or unrefined. Those who labor with
their brains, whose nerves are tense, votaries of the
"strenuous life," the eager spirits who burn the candle
at both ends — they are the principal sufferers.
Contrary to the reports of some well-posted ob-
servers, who claim to find a majority of these neuroses
in women, my experience has led me to believe that
£ully as many men are affected. While women have
The problems of "nervous indigestion" are
numerous and difficult, chiefly so because of
the organic and neurotic elements combined.
Unless the gastro-enterologist supplements
his medication with common-sense psychol-
ogy, he is doomed to positive failure. The
factors here involved have been happily
solved by Dr. Niles in this delightful paper.
He truly succeeded, to use his expression, in
playing a poor hand remarkably weU. —
Editors.
i_
more time to complain, and seem, in a manner, to
possess more sensitive reflexes, men come more di-
rectly in contact with the issues of life, often flounder-
ing among the shallows and breakers, until they sud-
denly discover digestive disorders cropping out, to
their great discomfort. Under such circumstances
these wide-awake business or professional men begin
to train their analytic powers on their own internal
organs, and before they fully realize the danger of
such a habit they find
themselves taking each
meal, perhaps each
mouthful, in a state of
gastronic introspection.
These patients crave
relief. They are not
posted on vicious circles,
on inhibition, nor on
hormones. They find it
difficult to comprehend
that the epigastrium is
simply acting as a reflex
alarm center for dis-
orders, either material or
psychic, entirely outside
that troublous zone. To
minimize their sufferings
or to admonish them to
"forget it," proves absolutely unsatisfactory to the
patient, and asinine in the physician.
Occasionally we can remove an irritating cause, but
more often such causes as domestic infelicity, erotic
longings, unsatisfied ambition, uncongenial environ-
ment, financial reverses, or carping care, are entirely
beyond our reach.
In one of the inimitable western tales written by
Alfred Henry Lewis occurs the account of the death
and burial of a highly esteemed gambler, on whose
tombstone was inscribed this meaty epitaph: "Life
Is Not in Holding a Good Hand, But in Playing a
Poor Hand Well."
This fitly applies to the problem now under con-
sideration, as well as others in life.
To enter into the niceties of differential diagnosis
in this necessarily brief paper would lead too far
afield, so, passing this phase of the subject, eliminat-
ing as far as possible surgical indications, and being
642
The Problem of "Nervous Indigestion"— Niles
[The American
reasonably certain that no marked anatomic lesions
nor important organic changes are underlying the
outward digestive discomfort, it behooves us to out-
line some general plan calculated to meet and control
the protean symptoms presented from day to day.
The line of treatment embodied in this study may
not stand the test of therapeutic orthodoxy, but it has
served me well in many instances, and, as an old ante-
bellum negro said to me when a lad, that the only
way to learn a thing was by "hard knocks and sudden
jerks/' some very trying experiences have forced me
to evolve certain ideas, which I deem at least worth
a trial.
To begin, if practicable, the patient should receive
a more thorough and painstaking examination than
he has ever had. This serves the double purpose of
placing the physician on a solid basis as to direct and
indirect morbid conditions, while it satisfies the in-
valid that a real interest is being taken.
This examination will in every instance furnish a
cue by which a preliminary treatment may be in-
augurated. Right here let me emphasize that treat-
ment is what the patient desires, and as an integral
part of this treatment some form of medication meets
both an intrinsic and psychic need. Should there be
hyperchlorhydria, and oft-present neurosis, antacids
sufficient to neutralize the excess will win the opening
skirmish and increase the physician's influence. A
hypoacidity will naturally call for HC1, which may
generally be combined to advantage with nux vomica
and pepsin, though pepsin, apart from being a good
vehicle, possesses few of the virtues ascribed to it.
Less than ten drops of the dilute HC1 amounts to
nothing, and more than thirty drops often proves
irritating, so, from twelve to twenty drops, well
diluted, will give the best results. Occasionally we
find achylic stomachs intolerant of any form of acid,
and when this is the case it is useless to push it.
For the almost constant eructations, a combination
of milk of magnesia and milk of asafetida, to which
is added a small quantity of compound spirits of
lavender, tincture of myrrh, or compound tincture of
cardamon, may be given ad libitum. It is well also
to be on the lookout for aerophagia, for, when the
eructations are frequent, explosive and odorless, they
often consist of only swallowed air. When this is the
case the patient should be admonished to keep the
mouth closed while eating and swallowing, avoiding
conversation while food is being masticated.
A point I consider almost the keynote of the treat-
ment is to change the medicine in some way, even
though it be simply a change of appearance, every
few days. These neurotic alimentary tracts must be
kept guessing all the time; for, if they "get on to our
curves," we at once lose a great part of our influence.
I have often added to an alkaline powder of calcined
magnesia and bismuth a little pulverized charcoal or
carmine to the increased satisfaction of the patient
The active and indicated base of the prescription may
remain the same, so long as the adjuvants are fre-
quently varied.
Constipation is often present, and should be man-
aged like constipation complicating any other trouble,
if only the watchword of frequent change is borne in
mind.
The question of gastric lavage is somewhat a del-
icate one, for we occasionally encounter highly strong
people who derive far more harm than good from this
procedure. I might say, as a general principle, that,
when there is a marked excess of stomach mucus, or
a delayed evacuation of the gastric contents, an alka-
line or gently antiseptic lavage at not too frequent
intervals is helpful; while for hypersensitiveness of
the gastric mucosa a lavage containing forty grains
of nitrate of silver to the pint, and followed by plain
water will often yield gratifying results. Routine
lavage, however, is not, in my opinion, advisable.
Faradic electricity has proved satisfactory to me,
though I confess the belief that its influence is mainly
psychic. I use the intra-gastric electrode, if the pa-
tient does not object, or, if the objections are too
strenuous, I apply the large epigastric pad in front
with a smaller pad directly opposite on the back,
administering the current strongly enough to be per-
ceptibly, but not uncpmf ortably, felt.
As to massage, vibratory, and otherwise, the same
may be said.
DiH
Regarding the diet, I have often found the patient
suffering more from errors of omission than commis-
sion. Either reasonably or not, they have tabooed one
article of food after another, until they are ingesting
hardly enough to nourish an infant in arms.
There was recently referred to me a young Cuban,
who had by easy stages trimmed his diet down to a
daily quantity of three glasses of malted milk, ex-
pecting to continue his work on this munificent allow-
ance. On finding the gastric juices present in a
workable quantity, I admonished him to begin eating,
assuring him that if he would eat I would help him
take care of it Heeding my advice he gained ten
pounds in twelve days, ultimately making a perfect
recovery.
So many of these nervous dyspeptics have devel-
oped a sitophobia or morbid fear of food, that all
the persuasive arts of the physician are demanded to
keep them adequately nourished. Acting on the prin-
ciple that ''birds who can sing and won't sing must
be made to sing," when I find present a decent amount
of digestive juices I endeavor with all my might to
force these recalcitrant stomachs and intestines to do
their duty, even though they do it eomplainingly.
For indifferent or finical appetites I use the stom-
achics condurango, calumbo or nux vomica, with com-
Phila., September, 1922]
Varicose Veins — Hammer
643
pound tincture of gentian or cinchona as a base,
changing them constantly, as I have previously indi-
cated. Occasionally, where hyperacidity exists, three
grain doses of orexin, given two hours before meal-
time, will wonderfully cheer up an indifferent stom-
ach.
flJNUrWMn^PJ AMI r9j€mmmwfWJJ
Hydrotherapy is specially valuable in these condi-
tions, aiding, as it does, the emunctories, cleansing the
bodily Augean stables, relaxing the nervous tension,
and adding its quota of psychic uplift
The benefits of hydrotherapy have not been appre-
ciated as they should by the rank and file of the
regular medical profession, and I consider it high
time that we wake up to our opportunities in this
important field, not relinquishing it to others, as we
have to a regrettable extent.
Change of environment, or even of occupation,
should be recommended at times; in fact, there are
certain of these cases where a change, and the more
radical the better, seems the only method by which
the discouraged invalid may be started on the road
to Wellville.
The whole plan of treatment is based on reinforcing
the weakened digestive functions, wherever situated,
pressing every procedure with kindly interest and
sympathetic optimism, keeping the patient as busy as
practicable, heading off doubts and fears, springing,
if possible, some therapeutic surprise at every visit,
encouraging each glimmering ray of hope, providing
ample calories, so that bodily strength may promote
nervous equilibrium, and, without slighting the main
issues, taking cognizance of the countless little inter-
current and irritating ills always present.
This study I submit in the interest of that most
unhappy and misunderstood class of sufferers, trust-
ing that some of my suggestions may aid in restoring
joy to troubled epigastriums, quietude to restless ali-
mentary tracts, and springtime to repining hearts.
Varicose Veins
Rationale of Mineralization in the Treatment of
Cancer
A. Robin reports in writing of silica, lime and mag-
nesia in connection with cancer, that the results of cer-
tain experiments show that cancer fixes these bodies
to a notable extent. Since they doubtless are fixed
only by the connective tissue which is antagonistic to
cancer growth, they may be regarded as assisting the
natural defence.
S. W. Little calls attention to the significance of sud-
den marked increase of skin pigmentations and freck-
ling; such unusual sudden increase in old-age freckling
frequently precedes by several months the appearance
of a cancer, which by no means is always a skin can-
cer— indeed, most frequently not a skin cancer. Often
one observes a rather sudden appearance of old-age
freckling before it is normally due; this also is often
a forerunner of a cancer.
A SUBJECT OF PARAMOUNT IMPORTANCE IN
INDUSTRIAL LIFE
By A. Wissi Hammer, M.D., F.A.C.S.,
218 South Fifteenth Street, Philadelphia
The best results from operative measures
are to be found in eases in which stasis is
well marked and the trunks of the veins are
prominent.
In deciding for or against operation^ the
dictum of Mayo is applicable: "An elastic
bandage is applied from the foot to above
the knee. If this bandage can be worn with
comfort, an operation should give relief."
Discomfort from the bandage would show
that the superficial vessels are necessary to
the circulation- — Editors.
THE PRESENCE of varicose veins is so com-
mon an affection and one that so often incapaci-
tates the individual in the pursuit of his daily occu-
pation, that industrial efficiency is not infrequently
badly handicapped by the existence of this con-
dition. As three times as many men as women are
affected, the subject at once becomes one of para-
mount importance.
Veins are said to be varicosed when they are
permanently dilated, due to changes in their walls.
Systematic writers draw some distinction between the
terms phlebectasis and varix. The former refers to
the cylindrical, fusiform and tortuous dilatations;
the term varix being restricted to the sacculated
forms, in which pouches are formed in the venous
walls. The affection may occur before the twenty-
fifth year, although more than thirty per cent,
occur before the thirtieth year; the remaining two-
thirds of cases appearing after the fortieth year.
In regarding the venous distribution in the lower
extremities, one is impressed with the peculiar hydro-
dynamic influence of gravity in the erect posture, as
in this region there is no perivascular support, for
the saphenous or other superficial veins. The valves
aie weak and often deficient. There is interference
to the return flow through powerful muscular con-
ti actions, all of which factors favor venous stasis and
produce increased venous tension. Hence the likeli-
hood of varicosities in the leg, rectum and along the
course of the spermatic cord, etc. Thus it is that
varicose veins are so common among those whose
occupations require so much standing, especially when
combined with hard labor.
Cmaitfot Fmdort
Among the many causative factors engendering the
644
Varicose Veins — Hammer
[The American Physician
affection, we will merely refer to the possibility of
certain nervous diseases, in which there may be
loss of vasomotor control and in chronic phlebitis,
which produces structural changes in the venous
walls.
In the vicinity of varicose veins changes are ob-
served in the neighboring arteries, they offering a
sclerosed condition. The varicose process also affects
veins in the large nerves, especially the sciatic. The
skin above the ankles is remarkably glossy and offers
a drawn, pale, translucent appearance. Later, this
involved area becomes hard and adherent to the under-
lying subcutaneous tissue, and the chronic hyperemia
leads to a pigmentation, which leaves a dark brown,
permanent stain.
Lymphatic involvement now occurs, causing a sec-
ondary hard edema and this, in association of the
hypertrophied corium, constitutes the so-called, ele-
phantiasis phlebectatica. The bones often undergo
a rarefying process (osteoporotic osteitis), while in
the vicinity of the lower, inner aspect of the leg,
just above the internal malleolus, the varicose ulcer
is seen.
In forty or forty-five per cent, of cases of vari-
cose veins, ulcers are present. These may be on
one or both legs. These ulcers increase in area
without treatment, and they may attain enormous
size. By some authorities it is contended the ulcer
may undergo a malignant degeneration.
The Develop*** of a Varix
A vein under pressure usually dilates more at one
spot than at another, the distension being greatest
back of a valve or near the mouth of a tributary.
The valves become incompetent and the dilatation still
greater. Treves maintains that for the development
of a varix it is necessary that three forces meet — the
blood column above, the valve below, and the force of
the blood current. At this point the vein dilates, and
from this dilatation the blood current is deflected and
causes another dilatation higher up and on the
opposite side of the vessel. The veins not only dilate,
but become longer, therefore, they do not remain
straight but twist and assume a characteristic form.
Some years ago, Delbet showed that varicose veins
that had their origin in the femur, resulted from val-
vular incompetence, and as a consequence, there was
a variation of pressure, favoring the development of
ulcers. He also pointed out that this disturbance of
intravenous pressure more nearly equalled pressure
in the arterioles, thereby arresting capillary circula-
tion and causing congestion; thus greatly lowering
tissue resistance. Incompetent valves also favor ulcer-
ation by establishing a vicious venous circle so well
demonstrated by Trendelenburg. Trendelenburg con-
tended that blood traversing such a circle must suffer
loss of its nutritive elements. He argues that blood
in the saphenous vein instead of passing toward the
center, passes toward the periphery, and that it
empties into veins that connect the superficial with
the deep veins, which then enters the tibial and the
peroneal veins. It then passes from the tibial and the
femoral veins, and some of it leaves the femoral and
again enters the saphenous vein.
Origin W Varices* Ulcer
In the foregoing remarks we touched lightly upon
the subject of varicose ulcer. This may have its origin
in a slight abrasion, blister, or scratch. Its formation
is favored by the patient scratching the itching ede-
matous area. The skin around the affected region is
extremely vulnerable, because of the trophoneurotic
changes. In long neglected cases, the underlying
tissues through lymphatic involvement, contribute to
the sclerosed condition and the thickening of the skin
that naturally results, confers upon the part the ap-
pearance of elephantiasis. The destruction of tissue
often begins at the margin of a congested area and
advances toward the center. When the varicosity
attacks the hemorrhoidal plexus or the pampiniform
plexus, we have hemorrhoids or a varicocele, respec-
tively.
Much judgment is often required in determining the
advisability of operating upon certain cases of vari-
cose veins. While a large proportion of persons thus
affected are fit subjects for the surgeon, there are
many contraindications to the performance of any
radical operation. There are certain associated con-
stitutional affections that render such an operation
one of considerable risk. These constitutional states
include : Diabetes mellitus, purpuric conditions, hem-
ophilia, uncompensated cardiac lesions, arteriosclerosis,
cachectic conditions, etc. But where danger from in-
action is imminent, the surgeon's judgment is put to
test. He has little alternative in cases of rapture,
hemorrhage or septic infection of the varices.
Radical operations are likewise contraindicated in
instances of obliteration of the deeper veins by a pre-
vious thrombophlebitis. Per contra, when it can be
demonstrated that the deeper veins are competent to
return all the venous blood, although they may be
involved in the same process, the removal or ligation
of the superficial veins is indicated.
As a rule, the best results from operative measures
are to be found in cases in which stasis is well marked
and the trunks of the veins are prominent The out-
look for success is not promising in those instances
where a phlebitis has brought about edema, with slight
changes in the veins. However, if the ulceration be
extensive, or the phlebitis recent, the final results of
operation will give better results and shorten con-
valescence if the patient is put to bed some days
before the contemplated operation, with the affected
parts snugly bandaged and elevated.
(Continued on page 662)
Phil*., September, 1922]
Analgesia and Sleep— Dinkelspiel
645
Analgesia and Sleep, Without Narcosis
A STUDY OF A NEW DRUG
By M. R. Dinkelspiel, M.D.,
Wilkes-Barre, Pa.
The narcotic and habit-forming properties
of opium and its derivatives have undoubted-
It/ been the primary cause for stimulating in-
vestigations in the search for a less objection-
able substitute. While many substitutes have
been and are being tried out, and each has
its individual value, none of them has at-
tained that minimum of risk which is the
ultimate goal.
The indomitable spirit of intensive chemical
investigation, which has resulted in a rapid
succession of comparatively recent therapeu-
tic achievements in the field of syphilis, lep-
rosy, local anesthesia, hookworm infestation
and other conditions, wiU no doubt do much
in the future to meet this and the other
problems which still confront our profession.
— Editors.
IT IS A LONG WAY from the now discredited
aphorism of Sydenham to the effect that, "with-
out opium few would be so obdurate as to practice
therapeutics," to a consideration of the narcotics of
the methane series, actively investigated a little over
fifty years ago. Notwithstanding, the use of opium
and its derivatives have since been taught as pre-
senting the best means for treating insomnia due to
pain. This practically covers the fundamental posi-
tion of opium, and especially morphine, embodied in
the voluminous literature on the subject, up to and
including the comparatively brief modern period rep-
resented by the achievements of constructive chemis-
try, which, not content with discovery alone, added
to its inventive potentiality the chemical control of
physiological action. This was made possible, not
only by some of the results achieved, but by dispell-
ing an apparent attitude of therapeutic contentment
in the face of apparent insurmountable difficulties.
This indomitable spirit of intensive chemical inves-
tigation will no doubt do much in the future to meet
the problems presented by cancer, tuberculosis and
pneumonia, and we may now look for their solution
to the combined work of chemists, biologists and
clinicians.
The profession may well display a feeling of ex-
hultation when we contemplate the rapid succes-
sion of comparatively recent therapeutic achieve-
ments in the fields of syphilis, leprosy, local anes-
thesia, hookworm infestation, deranged metabolism
and many other conditions depending for their cure
or alleviation upon the biochemical mastery of the
situation. Those who have labored have also had
their paths made easier by the presentation of a
finished product based upon methods of exactitude
rather than upon empirical experimentation.
The narcotic and habit-forming properties of opium
and its derivatives have undoubtedly been the primary
cause for stimulating investigations in the search
for a less objectionable substitute, with the result of
a rapid succession of brilliant accomplishments, and
even the opening of new and unlooked for fields,
none the less valuable even if they sometimes deviated
from the main road of endeavor. When we con-
sider that since the introduction of chloral by Lieb-
reich in 1869, sulphonal appeared in 1884, trional
and tetranol in 1888, veronal in 1904, proponal in
1905, and finally luminal, together with many others
of varying therapeutic value, we can realize the in-
tensive exploration of this field. The obstacles always
confronting the investigator were toxicity and addic-
tion and the production of untoward symptoms that
would interfere with the therapeutic effect.
Drmgt W tht Methmm
The drugs of the methane series bear considerable
similarity to each other in their general physiological
manifestations, varying from a slight anodyne effect
to sleep, stupor, coma, and, in overdose, death. While
it is true that they each have their individual value,
none of them has attained that minimum of risk which
is the ultimate goal. Therefore, the advent of these
drugs was subjected to the proper reserve with which
the medical profession has met all innovations in
therapeutics, preferring to err in the direction of
omission, rather than of commission, and largely
actuated in its final conclusion by the source and
character of clinical experience and substantiation-
We have therefore arrived at the stage of therapeutic
tolerance and conviction, not by experiencing the fact,
that a drug is efficient for a given purpose, and then
ascertaining why, but by logical reasoning from bio-
chemical premises, where possible, removing previous
errors, correcting erroneous hypotheses and obtaining
the finished superstructure upon the foundation of
experience.
646
Analgesia and Sleep — Dinkelspiel
[The American Phytieiaa
It was therefore with this natural reserve that I
regarded allyl-iso-propyl-barbituric acid chemically
combined with amidopyrin, marketed as allonal, and
concerning whose therapeutic value I have been in-
formed by a paper of Dr. M. A. Burns,1 associate in
nervous and mental diseases in the service of Profes-
sor Francis X. Dercum at the Jefferson Medical Col-
lege, read before the Philadelphia Neurological Soci-
ety, and the interesting and convincing reports con-
tained therein of the cases of Drs. A. C. Messmer,
Leopold Steiglitz, Frank Wright, and others. It is
therefore also opportune to consider this drug as a
substitute for opium as a remedy for producing sleep
due to pain, and at least with a minimum of, if not
exempt from, the two chief obstacles, toxity and
addiction.
Smm C«Mf
My personal experiences, cautiously obtained, have,
in the brief period since the publication of the above
mentioned paper, been limited to four cases, with
results . so striking as to justify more extensive
clinical investigation. One was a case of chronic
inflammatory glaucoma with such severe pain that
morphine failed to produce sleep, and in which one
allonal tablet had a slight effect, two a pronounced
effect, and three produced sleep lasting for seven
hours. The second case was one of cellulitis of the
neck, apparently from deep streptococcic infection
of the tonsil, in which, after two allonal tablets, the
patient obtained the first refreshing night's sleep for
months. The third case is a member of my own
family suffering from obscure though severe pain
referable to the kidney, in whose case morphine has
never been employed, and who has obtained sleep
repeatedly for a whole night after one or two allonal
tablets. The fourth case is one of obscure and very
severe headache, paroxysmal in character, with as
yet undetermined diagnosis, but which has been
markedly relieved at various times by allonal.
The Crmdmd Dewtlopmt* W Sym&etic Hypmotict
From the introduction of the aldehyde derivative
sulphonal, and its congeners, trional and tetranol, to
the appearance of the newer products, there has been
more or less inclination to take advantage of the fact
that molecular changes were necessary for the de-
sired chemical construction sought for, and that this
might be more important than the actual physical
properties of the finished product. The relative
interdependence of the toxicity and absorbability of
the alcohol division, depending not upon their actual
toxicity alone, but upon their solubility by various
fluids of the body, gave much food for thought. In
the case of the methane series it is known that they
are most soluble in eholesterin and lecithin, and
hence the subject of greater affinity by the nerve
cells than they are by the more aqueous media in
the blood, thus tending to accumulate in that structure
of the body upon which they are desired to exert
their effect. We are indebted for this fundamental
conception to Meyer2 and Overton,3 which has
been expressed as the Meyer-Overton Law,4 sub-
stantially as follows : The physiologic-chemical activi-
ties of the hypnotic groups are principally determined
by this theory, which associates the hypnotic effi-
ciency with the lipoid solubility of the narcotics, and
according to which the narcotic potentiality is directly
dependent upon its partition coefficient; that is, its
narcotic property increases with its lipoid solubility.
This can, it is claimed, be proved experimentally by
molecular changes, and has apparently established
the chemical affinity of the cells of the nervous system
as the primary goal for the control of clinieal nar-
cotic potency. The groups, therefore, imparting nar-
cotic properties are potential in that respect, propor-
tionately to the ability of the chemist to regulate their
lipoid solubility, either by substitution or variation of
the individual radicals.
What appeared to be the best group of hypnotics
from which to choose for a basis of further investi-
gation, were the derivatives of barbituric acid, a step
further bringing the investigators to the alkyl-bar-
bituric acids, which according to Tiffeneau,* and
quoted by Burns (1. c), are combinations of marked
hypnotic power and a relatively small lipoid solu-
bility. Should, however, the alkyl-radicals be so
changed as to increase the otherwise small lipoid
solubility, it follows that if this theory is true, that
the hypnotic power of the substances can be in-
creased, the accuracy of which has been shown in a
series of systematic experiences in the domain of
synthetic chemistry.
All this, however, while fundamentally important
in the successive progress of the pharmacology and
chemistry of the hypnotics more recently produced,
failed to incorporate the remaining and long-sought-
for requirement, viz., safely to produce sleep in
affections due to pain, which hitherto almost invari-
ably necessitated the employment of opium or its
derivatives. This was finally undertaken by the
chemical incorporation of an analgesic molecule into
the molecule of allyl-iso-propyl-barbituric acid, thus
making a double salt with amidopyrin, imparting to
it not only the property of producing analgesia, but
likewise accentuating its normal hypnotic power.
Therefore, as mentioned by Burns (L c), allonal b
a synthetic hypnotic which, like morphine, simul-
taneously develops hypnotic and analgesic effects, and
over and above that alkaloid, possesses the advantage
of being relatively feebly toxic.
Allyl-iso-propyl-barbituric acid is a yellowish crys-
tal of bitter taste, very slightly soluble in water,
Phila., September, 1922]
Analgesia and Sleep— Dinkelspiel
647
easily soluble in alcohol, neutral in reaction, and
readily forming soluble salts with the alkaline. It
is a hypnotic of the barbituric acid series which in-
cludes, among others, veronal and luminal. In
small doses it is claimed to act on the central nervous
system, inducing sleep without any noteworthy de-
pression. The desired effect is produced by doses
half as large as those required with the other known
hypnotics of this series, and even when larger doses
are given, unpleasant by-effects are absent.
The primary action of allonal is that of a de-
pressant to the sensory nerves. There is no reported
effect on respiration, nor any apparent depressant
action on the circulation in a state of health. It
has no hemolytic action on the blood, and is elimi-
neted by the kidneys.
The clinical value of this group of drugs in-
cludes: 1, the production of analgesia without
sleep; 2, the production of analgesia and sleep with-
out narcosis; 3, ambulatory treatment for pain of
neuri tides, myalgias, cardiac diseases, sinusitis, etc.;
4, mental excitement in the insane; 5, dysmenorrhea;
6, pain where the cardinal symptoms should not be
masked, as acute abdominal conditions, mastoiditis,
etc.; 7, obstetrics; 8, pain in inoperable cases, in the
moribund, and tabetic crises; 9, pain in iritis, and
glaucoma; 10, drug addiction; 11, before operation;
12, dentistry, to allay nervous excitement; 13, before
or after reactions from intravenous injection; 14,
functional nervous diseases; and 15, as a preliminary
sedative before local anesthesia, and for pain follow-
ing operation under general anesthesia.
Drug Cwmpmr ii— i
In comparing allonal with opium, neither drug has
much influence upon the circulation in small thera-
peutic doses; but unlike morphine, this is not the
case with larger doses of allonal, which does not
appear to have any stimulating effect upon the pneu-
mogastric nerves, peripherally or centrally, nor upon
the cardiac muscle or the cardiac ganglia. This evi-
dently produces a special advantage in the case of
pain in cardiopaths, in whom morphine very fre-
quently increases the blood-pressure without any com-
pensatory assistance on the part of the peripheral
arterial circulation, and easily generates addiction.
In Drug Addiction
An interesting case of melancholia and drug addic-
tion, by Burns (1. c), shows that a woman had
been receiving as much as four grains of morphine
sulphate in twenty-four hours, and where he was
able to withdraw the morphine at once without any
serious results after the administration of allonal,
certainly justifies institutional research in those
cases requiring still larger doses. Likewise in in-
tractable headaches, where the unfortunate victim is
often started on morphine, or where he has been
deluged with coal-tar products, allonal may serve a
double purpose, as its analgesic value does not de-
pend upon a physical addition of amidopyrin, but
as has been previously stated, a synthetic chemical
transfer to the molecule of the allyl-iso-propyl-bar-
bituric acid. The clinical substantiation remains, as
well, that the amount of amidopyrin incorporated in
allonal could in itself hardly subject the patient to
great depression, and in addition it probably causes
the least depression of any in the antipyrine class,
or any drug in which the antipyrine might be
modified by the substitution of the radical NH2 for
hydrogen.
No reports are as yet available regarding its in-
fluence upon convulsions. It probably will be tried
in eclampsia and tetanus after the paroxysms are
under control, and in small doses after severe in-
fantile convulsions. It will certainly be much less
dangerous than chloral, safer than some other hyp-
notics, and more prompt in its action than the
bromides, while in maniacal excitement it ought to
be far safer than hyoscine.
The exploration of the therapeutic field for epi-
lepsy, with the exception of the bromides, manifestly
has been risky, as has also the reinforcement of the
bromides with opium and other powerful drugs.
Phenylethylmalonylurea, marketed as luminal, has
lately been employed to an extensive degree in epi-
lepsy, with considerable success by some, and even
claimed to "act virtually as a specific." In other
instances it has not been found free from danger.
Allonal has not yet entered a prolonged experimental
stage for the treatment of epilepsy, but is deserv-
ing of prompt trial, not only in that disease, but
in all conditions characterized by sudden nervous
explosions, especially if traceable to irritability of
the motor areas in the brain.
So much for a general consideration of this late
and promising hypnotic, possessing the additional
advantage of producing analgesia and sleep without
narcosis. An intensive and separate investigation of
each indication in which morphine was hitherto the
sheet anchor, undoubtedly will be anticipated with
much interest by the profession.
References
L Burns. A new non-narcotic drug which is both hypnotic
and analgesic. New York Medical Journal, April 19, 1922.
2. Meyer. Arch. f. Bsp. Pathologic u. Phorm., xKL, p. 109,
and xlvi., p. 888.
3. Overton. Gotlieb. Brgebniss* der Physiologic, Vol 1, No. 2,
p. 666. Studien u. d. Narkose. Jena, 1901.
4. Meyer-Overton -Law. See Reference No. 5.
5. Tiffeneau. I* regie de Richet et le Coefficient de partage
de Meyer et Overton dans les Hypnotiques du group* de Veronal.
I. Serie Allylee. Comptes rendus des Seances de la Sod*
et£ de Biologic, Seance da 19 Mars 1921, VoL 34, No. 11, p.
640.
6. Burns. (L*c)
648
Diagnosis of Typhoid Fever — Snow
[The American Phyakaaa
The Diagnosis of Typhoid Fever
SOME ORIGINAL ANGLES WITH SPLENDID RfiSUMfi OF STANDARD LABORATORY ASPECTS
By Bruce Snow, M.D.
Assistant to the Staff of Notre Dame Hospital,*
Manchester, N. EL
The paper of Dr. Snow comprises several
interesting features — it reviews typhoid fever
vividly; it presents some original angles, to-
gether with a splendid risumi on the standard
laboratory aspects of this undeniably impor-
tant disease, a disease which, in spite of its
constantly reduced prevalence, is still inter-
mittently pandemic, endemic and epidemic
practically throughout the world. — Editors.
TYPHOID HAS a somewhat varied and incon-
stant course, no one pathognomonic sign by
which it may be recognized. It may simulate several
types of diseases. For these reasons and also because
of the gradual onset with symptoms pointing to the
lungs, the brain, or to an indefinite combination of
organs, the diagnosis is usually not made until some
time has elapsed. Furthermore the disease has
become less frequent; only a few cases are seen
during the year, and as a result the true diagnosis
is often not considered until the commoner diseases
of bronchitis, grippe, headache, epistaxis, nephritis,
etc., are completely eliminated. It is well that from
time to time our memory be refreshed and our at-
tention called to the existence of these diseases which,
though not frequent, still occur in sufficient numbers
and need a correct diagnosis. This is my excuse for
presenting to you today a subject in which I have
no new research to report.
Typhoid is usually considered and treated as an
infection localized in the intestinal tract; it is con-
sidered that the lesion is located in the lymphoid
patches of the intestines and all accompanying lesions
are described as "complications" without any men-
tion of the relationship of these complications to
the original infection. It seems much simpler and
clearer to consider typhoid what it really is, a septi-
cemia. Typhoid is a septicemia with the typhoid
bacillus as the causative factor just as truly as the
more common septicemias, caused by the streptococ-
cus and staphylococcus. As is the case in these latter
'Read at a clinic given by the staff of the Hospital Notre
Dame de Lourdes to the Manchester Medical . Society.
diseases the organism exists in the blood, it is car-
ried all over the body by the blood, it can be secured
in its living state from the blood, and as a hematog-
enous infection it may attack any organ. The tem-
perature chart of typhoid is that of septicemia; it
is the swinging up-and-down temperature — down in
the morning and up in the evening; which is so
characteristic of septicemia. As such, the bacillus
is carried all over the body, affects all the organs,
and can be obtained in the living form from many
sources, from the blood, the urine, the intestinal tract
(chiefly the small intestine), also from the rose spots,
sweat, sputum, spleen, gall bladder and even the
muscles as uterus, heart, and lungs.
Although the tissues of the typhoid patient are,
as it seems, constantly bathed in a weak culture of
the bacillus, some tissues yield to the infection much
more readily than others. Chief of these are the
lymphatic structures as Peyer's patches and the
spleen. In both these structures the first pathology
is a hyperplasia with a great increase in the lymphatic
cells. This compresses the blood-vessels so that the
resultant anemia causes death of the tissue, necrosis,
and slough. Owing to the far richer blood supply in
the spleen, the process there is not so extensive as
in the Peyer's patches, although the spleen always
becomes larger and softer as a result and may even
rupture. In the intestine the shutting off of the
blood supply is more complete, necrosis is more ex-
tensive, and usually the entire patch must slough off
into the intestine before healing can follow. The
resulting ulcers are lengthwise rather than across
the intestine — a fact which explains the absence of
intestinal obstruction from contracture of scar tissue
in healing. The mesenteric lymph glands show the
same process.
The liver is always affected. This organ becomes
hyperemic, swollen, tender and shows small areas
of necrosis throughout. The bacilli are evidently
excreted in the bile and often collect in the gall-
bladder. The kidneys are similarly affected— occa-
sionally the areas of infection going on to abscess
formation. Usually the clinical picture is one of
Phila., September, 1922]
Diagnosis of Typhoid Fever — Snow
649
nephritis of varying intensity. The organisms may
rarely cause an endocarditis. They abound through-
out the gastro-intestinal tract including the mouth —
pharyngeal ulcerations often being seen.
From these few illustrations one sees how far-
reaching is this typhoid septicemia; all organs are
directly involved and abscess formation anywhere in
the body may occur.
Apart from the actual growth and development of
the bacteria there appears to be one other factor of
injury present: I refer to the toxin formation and
the resulting toxemia. The toxin seems to be formed
only by the destruction and decomposition of the
bacilli. It is for this reason that the strong and
husky individual often succumbs while the small and
weak man survives. The powerful man with his
marvelous power for destroying pathogenic bacteria
seems to kill them off in swarms and is, unfortu-
nately, overcome by the resulting toxemia. The
weaker individuals who can only destroy them more
slowly are apparently able to take care of the result-
ing toxin, as it is much less in quantity. The heart
and brain — with the well-known stupor and delirium
— are the organs most affected by the toxin.
SymmimmmUU§y mi Dimgmmu
The typical case is rare in typhoid. The tempera-
ture is gradually increasing for several days; the
high see-saw temperature lasting two or three weeks
followed by a gradual drop. During the first week
one usually has headache, often bronchial symptoms,
sometimes epistaxis and diarrhea. Toward the last
of the week or into the second week one gets rose
spots, large spleen, and torpor. Diarrhea, tympan-
ites, abdominal pain and even perforation or hem-
orrhage may occur at this time. The third week
shows an increase in the severity of the symptoms —
weakness, loss of flesh, diarrhea. At this time, lung
involvement, marked delirium, myocarditis, perfora-
tion, and hemorrhage are the bad signs. In ordinary
cases the fourth week shows the beginning of im-
provement.
In diagnosing, we must always hold in mind the
fact that the 'typical" early signs of typhoid are, as
a rule, not present. Headache, by far the most com-
mon initial symptom— occurred in 74 per cent, of
the cases. On the other hand diarrhea which so
many associate with typhoid occurred only in one-
third while one-sixth were constipated (Osier). The
famous epistaxis was only found in about one-fifth.
With so few striking symptoms early in the disease
it is not surprising that the diagnosis is usually made
rather late. Continued fever, rose spots, and the
laboratory data are most important for diagnostic
purposes.
Am JUbsMifa
In this connection let us consider the story of a
man which is, in many respects, typical. The past
history is unimportant, the man being a healthy
individual without previous sickness. His immediate
family are all living and well, and his habits are
good; being limited to three cups of coffee in the
morning, two cups of tea at night and five cigarettes
during the day. The case appeared to be sporadic,
entirely independent of epidemic or definite source,
as the man had not been outside his town and there
were no similar outbreaks at the time. With the
exception of a little tired feeling towards night after
a full day's work he had been in excellent health.
One morning about three o'clock he woke up with
a cold, chilly feeling. Thinking nothing about it he
got an extra blanket and went to sleep again. On
getting up at six he noticed a headache and dimness,
but as he had been subject to occasional headaches for
years he thought nothing of it. Although he did not
feel well, he kept up and about till noon, hoping that
the trouble would wear away. His appetite was poor
and he ate little, but aside from a headache and a cold
feeling he complained of nothing.
The next day he called in his doctor on account of
the headache. In the presence of fever, headache,
slight cough, and no other striking symptoms a diag-
nosis of grippe was made. At first he was constipated
and never had marked diarrhea. For ten days the
symptoms remained as above, the temperature varied
between 103° and 104° and he stayed in bed under
treatment for grippe.
After two weeks the condition did not seem to be
clearing, a slight cough persisted with diffuse sub-
crepitant rales in the lungs, and at the base of the
right lung appeared some dullness and distant voice
sounds. Also the patient, although not delirious, had
a marked impairment of memory. A consultant was
called in and empyema was diagnosed. However an
exploratory needle failed to show more than a few
drops of fluid. A second consultant was called. In
addition to the findings above mentioned the patient
showed large, irregular and reddish spots over the
entire body and even on his head — these looked almost
like measles and had been considered incidental. The
second consultant thought them atypical rose spots,
a tentative diagnosis of typhoid was made, and nine-
teen days after the onset the patient was sent to the
hospital. Widal proved positive and x-rays showed
nothing of importance in the lungs.
During his sickness the patient felt no pain or
discomfort — simply had no appetite, wanted to sleep,
and had poor memory. Treatment consisted largely
of nursing care, cold baths when temperature exceeded
102°, and a diet of about 55 ounces of milk, V/*
ounces of sherry wine, with occasionally some chicken
broth. Towards the twenty-sixth day in the hospital
or after he had been sick in all six weeks, the tern-
650
Diagnosis of Typhoid Fever — Snow
perature having been normal for several days, his
diet was increased.
The next day the temperature sailed ap and a real
relapse came in. The relapse resembled the original
infection and lasted a bit over two weeks when the
temperature came to normal and stayed there. Since
then he has been on regular diet, has been very
hungry, and has been rapidly gaining strength and
weight. During the sickness he lost thirty -five
pounds, fifteen of which he had regained before
leaving the hospital, and three weeks later he was
within five pounds of his original weight.
The only complication, except the relapse, was a
subperiosteal abscess over the right tibia. Toward
the last of his first infection the patient began to
notice a pain in the leg. At first this took on sharp
exacerbations and later became a dull pain. About
the fortieth day after admission and toward the last
of the relapse his leg began to swell "like a boil." It
was now tender and the pain had become continuous.
The swelling at first small, gradually became larger
and finally was distinctly fluctuant. It was incised,
much pus expressed, and packed with iodine gauze;
good repair followed.
In many ways this is a typical case showing also
the rarer forms of relapse and abscess formation,
The temperature showed the typical septic appear-
ance of low in the morning, and bigb in tbe after-
noon, as well as the typical reduction by lysis. On
tbe fortieth day when the temperature had almost
regained normal there was a peculiar and sudden
rise of five degrees which at once returned to normal;
this was probably due to mental excitement fol-
lowing the receipt of bad business news.
Ubfratary FWnj.
Now for a summary of the laboratory findings.
The Widal was positive (sputum negative for T. B.).
Throughout the disease the urine was acid and showed
a varying amount of albumin, uric acid crystals,
white blood cells, red corpuscles, hyalin casts and
motile bacilli. The phenol sulphonephthalein test
agreed with these findings in showing some moderate
renal involvement, for the results were 15% in one
hour on the 12th day (in the midst of the first sick-
ness) and 45% in two hours on the 54th day. These
results are no more than one would expect and no
further comment is needed. Tbe blood picture on
the 20th day of the disease (11 days after entrance)
showed an extremely slight anemia— 4,920,000 red
cells, and a white count of 5,200. The hemoglobin
was 70% and the differential shows polys 48%, large
mononuclears 23%, small mononuclears 29%, eosino-
philes 0, and basophiles 0, coagulation time 6 minutes.
A bit less than eight -weeks later (54th day) the hemo-
globin remained 70%, the anemia was slightly greater
(4,310,000) and the white count 8,800. Differential
at this time was, polys 63%, small mononuclears 31%,
and large mononuclears 6%. The anemia was not is
great as one would expect from such a protracted
illness — otherwise the findings were normal for the
disease.
Obulttt r«tt— B«illi U W«J «J ExcrriHi
The diazo reaction is obsolete, as is the test belong-
ing to the same group, the Russo.
Early in the disease the best and often only certain
method of diagnosis lies in finding and isolating the
bacilli from the blood stream, or some of the excre-
tions. If search is made in the blood about 1 c.c. is
taken sceptically from a vein and added to 100 e.1
bouillon. This great dilution is necessary to over-
come the natural bactericidal activities of the blood,
for in a greater blood concentration the natural pro-
tective power of the blood would kill the bacteria and
no growth would occur. Naturally this great dilution
in itself is a handicap in obtaining good results. To
overcome this, where greater accuracy in technique is
possible, killed typhoid bacilli or the filtrate from
typhoid cultures after autolysis are added to the blood
drawn. These take up the specific amboceptors of
the blood and prevent the bactericidal action. In
these cases the blood need be added to only 10 c.t
bouillon. If typhoid bacilli are present (as they cm
be found in 70% by this refined technique), after
24 to 48 hours there is a diffuse turbidity in tbe
bouillon. If sterilo the blood corpuscles fall to tbe
bottom while the supernatant liquid remains dear;
Phili. September, 1922]
Diagnosis of Typhoid Fever — Snow
and if streptococci are present the blood is usually
laked owing to hemolysis. Id cases where feces, urine,
etc., an examined, plating on endomedium is usually
done {10 gms meat extract, 10 gnu peptone, 5
NaCl, 5 ce. of 10% alcoholic solution f uchsin, and
25 c.c. 10% solution sodium sulphite.) On this me-
dium typhoid colonies are colorless while colon bacilli
appear red.
Sptitt TaU—Tk, Wiid
Among the specific tests which depend on anaphy-
laxis or agglutination of the definite bacillus are the
Bordet-Gengou, the Chantemesse, and the more com-
mon Widal.
The Bordet-Gengou test is bio-cbemieal and rests
Mass., is a valuable, efficient and simple process. It
is more recent and is fast becoming popular. The
only equipment necessary is 10 test tubes about 1 cm.
in diameter with a test tube rack; a 1 c.c. pipet
graduated in tenths and a water bath. The reagents
used are serum from the patient,' normal salt solution,
and an antigen which may be a bouillon culture of
living organisms, a suspension of killed bacilli, or the
usual typhoid vaccine — in the latter case one must
bear in mind the possibility of the antigen containing
also the para-typhoid organisms. The test is carried
out as follows:
The ten tubes are placed in the rack : in the last
9 of these % c.c. of saline is placed, using the pipet
to measure. In the first tube one places 0.9 c.c. saline
and 0.1 c.c patient's serum which are carefully mixed.
This gives 1:10 dilution. After mixing, 0.5 c.c of the
mixture is put in tube 2 and thoroughly mixed, after
which 0.5 c.c. from tube 2 is placed in tube 3. This
process is continued through tube 9, but none is
placed in tube 10, which is used as a control. After
this process has been performed each tube contains
0.5 c.c. of a mixture of patient's serum and salt
solution, the concentration varying from 1 :10 in the
first tube, 1:20 in the 2nd; 1:40 in the 3rd, down to
1:2560 in the 9th. Now to each tube, including the
control, add % c.c. of antigen, that is killed typhoid
on the complement fixation principle, discovered by
Bordet and Gengou-and imaginatively explained by
Ehrlich. Although accurate, this is a complicated
method and on this account is rarely used.
The Widal is the most convenient accurate test and
therefore the most widely used. Of this there are two
forms : the microscopic and macroscopic. In the past
the microscopic method, where a few drops of live
typhoid bacilli and patient's serum are mixed in
various concentrations and observed under the mi-
croscope, has been most popular. The common dilu-
tions used are 1:10 and 1:50, and in positive cases
agglutination takes place in the weaker dilution within
an hour. Normal blood serum will often agglutinate
the 1:10 dilution.
The following macroscopic method used by Dr.
Dwight O'Hura in a recent epidemic in Waltham,
bacilli. This doubles the dilution and gives 1 c.c. in
each tube — the concentrations now being half the pre-
vious strength, or 1:20, 1:40, 1:80, 1:160, 1:320, and
652
Diagnosis of Typhoid Fever — Snow
[The American Physician
so on to tube 9, which is 1:5120. These are then
placed on a water bath at 40 to 45 degrees C. for two
hours when agglutination takes place in positive cases.
Agglutination is shown by flake-like masses settling
to the bottom leaving a clear supernatant liquid, while
the negative ones remain cloudy.
The advantages claimed by the macroscopic method
are: 1, it eliminates the use of living cultures; 2, it
is more accurate; 3, it gives greater precision of dilu-
tion with more sharply denned end-point; 4, it gives
quantitative titre readings.
Let us consider each of these factors by itself. The
elimination of living cultures is a great blessing, as
such cultures are not only dangerous but they are hard
to obtain. The suspension of dead bacilli may be
shipped from distant sources and may be kept on hand
as stock. This makes the Widal available in many
places where before it could not be used.
Acemrmcy W the TtaU
Next as to accuracy. By the microscopic method
only two dilutions are common: 1:10 and 1:50, and
of these the 11 : 10 agglutination is often present in
normal serum. Hence, microscopically only one con-
centration for typhoid is commonly used. Macro-
scopically a great variety of dilutions is present
and the concentrations giving agglutination can be
recorded and measured. Furthermore the end-point
is more definite and there is less chance of error, for
microscopically it is often uncertain whether there is
agglutination or merely a chance grouping together
of the bacilli. With the macroscopic method, how-
ever, there is no uncertainty; it is the difference be-
tween a precipitate and a suspension.
As to the dead cultures vb. living culture. Inas-
much as the bacilli take a passive and not an active
part in the phenomenon of agglutination the dead
organisms are as effective as the living. Agglutina-
tion per se does not kill the bacilli and densely agglu-
tinated clumps of bacilli will grow. The degree of
motility cannot be considered as an indication of
agglutination for this varies more with the individual
culture and the temperature under which the test is
made than it does upon agglutination ; loss of motility
is not an evidence of agglutination.
The last two advantages are directed to the same
conclusion, namely, to make a qualitative test quanti-
tative. By this method we not only say we have a
positive Widal, but we can also say agglutination oc-
curs between 1:160 and 1:1280, for example. This is
important not only in studying the course of the dis-
ease, but even in diagnosis, a fact which is not gener-
ally appreciated. As an illustration, let me cite a
patient seen by a noted physician during the Spanish
War. This patient had a positive Widal and was diag-
nosed as typhoid. Later it was determined that he had
malaria, but having had typhoid years before, his
serum still contained typhoid antibodies. When we
consider that these antibodies may stay in the blood
for an indefinite time after the disease itself or even
after prophylactic vaccination and when we consider
that during the past war typhoid vaccination was
nearly universal, we must not be surprised to find
positive Widals quite common among the population
regardless of health or sickness. In other words, a
positive Widal is not conclusive evidence of typhoid
any more than a negative Widal rules out typhoid.
A positive Widal means simply that the patient has
come across the typhoid bacillus; this may be as a
present disease or it may have been some time in the
past. But, and this is where the macroscopic method
is valuable ; a change in titre shows that the encounter
with typhoid is present and the body is straggling
with the disease right now. For instance, on one
examination, agglutination may occur between 1:80
and 1 :320, while a week later it will agglutinate up
to 1:1280, this person definitely has the disease, for
he has more antibodies than before.
Another very puzzling phenomenon is the serum
which agglutinates in weak dilutions, but which will
not agglutinate in strong ones. It is possible for a
serum to agglutinate between 1 :80 and 1 :640, but not
to agglutinate at all in 1:10 to 1:60 dilutions. A
serum of this kind under the microscopic method of
1:50 dilution would be classed as negative, whereas
the more extensive macroscopic method would make
it positive and give us the diagnosis.
The time of appearance of the positive Widal varies,
but is usually not found early in the disease. One
does not expect it until the second or third week,
and in some cases it is not found until after the
fourth week of the disease. Hence a negative Widal
early in the sickness does not mean that the patient
16 free from typhoid. Early in the disease when the
Widal first becomes positive, one expects low titre
reading, the higher titres coming usually between the
fourth and eighth weeks, after which they decline
again.
Now as to prognosis. Although it is felt that a case
showing a rising titre is favorable while one showing
a fall in titre is of bad prognosis, this cannot be
strictly followed. The test tube never can attain
accuracy in dealing with the intricacies of human cell?.
It has been found that less than half of the cases can
be prognosticated by such means. The reason for this
is that many factors other than that of agglutination
enter into the disease of typhoid. Chief among these
is toxemia; and agglutination does not measure the
damage done by the toxins on the heart or kidneys.
As in surgery, one is apt to consider an operation
"surgically successful" when the patient seems to rally
from the knife only to die of a complication the next
week. Similarly, one is apt to think that if the ability
to agglutinate the bacilli increases the patient should
get well. So he should, but often the toxins have in
the meanwhile so injured the heart and other organs
that he cannot survive. A serious illness is a com-
plicated affair and the improvement in one respect
does not necessarily mean improvement in them alL
Fhila., September, 1922]
Obstetrical Conditions in Rural Communities — Shoyer
653
Can Obstetrical Conditions Be Improved
IN
Rural Communities?
By Mayer Shoyer, M.D.,
Soldier, Kansas.
The country practitioner is forced by
conditions to be a really resourceful ob-
stetrician. In the cities, where hospitals and
specialists abound, the general practitioner
usually attends so few obstetrical cases that
he never becomes really skilled.
We believe in modern obstetrical teaching
and practice, as set forth in modern text-
books. In necessarily modified form, thou-
sands of country practitioners are living
up to these teachings. The propaganda, Dr.
Shoyer condemns is a gratuitous libel against
the hard-working country doctor, who could
give points to ninety per cent, of the city
practitioners who attend an occasional ob-
stetrical case. — Editors.
SHOULD the above title read "Do we dare do
obstetrical work in rural communities f" If we
would believe some of the articles we read in the
popular monthly magazines, some of the magazines
that are not so popular, and some of the so-called
magazines that have absolutely no license to exist,
and once in a while in an ultra-scientific medical
journal, that it is nearly impossible to carry to a
successful issue labor cases in the country, we must
answer, we dare not do it. Their articles nearly
demand a hospital and obstetrical specialist unless
one would lay himself liable to a criminal prosecution.
Some articles are written to swing public opinion so
that the expectant mother will want to avail herself
of a hospital and a specialist; others are written by
natural born fanatics and by others for self -profit.
Some are written by nurses who really are very nice
writers, but very poor obstetricians.
As far as the rural practitioner is concerned, I
believe many of them would welcome a central
hospital (county) and turn over all obstetrical work
to some one man, provided he was a real specialist
and experienced as such. There are many so-called
obstetrical specialists in large cities, who take any
and all kinds of other work and couldn't do a
Cesarean section, a pubiotomy or other surgical
work. But in an emergency, when the patient can-
not be taken to the county hospital on account of an
eclampsia or hemorrhage, the man specializing in
obstetrics should respond to these calls, irrespective
of the distance, especially in January or February,
when old Fahrenheit is down below zero. I say, for
my own part, bring on your specialist for the country
work; but will the fees of the specialist be as low
as the country practitioner has to accept f I'll say
they're not.
Wh* Unpens U the Cky
Are all women living in the larger cities delivered
by obstetric specialists and in the hospital f Why
of course not. Do any cases in the cities ever die
from accidents incident to labor f As yet, I haven't
heard of the abandonment of their last resting places.
So I take it for granted that they do have some
deaths in the large medical centers, the same as they
do in the rural communities.
Certainly obstetrical conditions can be improved
in country practice; it can also be improved in city
practice. But, oh, the educational campaign it will
take!
Isn't it wonderful the lot of words that a non-
medical magazine writer can put together and then
say nothing f The majority would convey the idea
to all women who live in the country or smaller
towns and do not have the care of a specialist in this
particular line, that they are truly up against it and
disaster will follow, certain invalidism; many will die
from puerperal infection; they will go through life
with perineal tears that have not been repaired, and
the remainder will be condemned to a living hell.
Maybe so, but it would be a "heads I win, tails you
lose" bet that only a small porportion of city dwellers
have the care of obstetric surgeons and another small
proportion go to hospitals. Some obstetricians who
have written articles in monthly magazines on this
subject have what may well be called "one-track
minds." They are brilliant theoretically in their
specialty ; they are generally your city society doctor ;
if anything goes wrong they call a real working
physician in consultation. Put them in country
practice, depending on their own resources, meeting
654
Obstetrical Conditions in Rural Communities — Shoyer
[The American Physician
all branches of practice and frequently under adverse
conditions, and they would soon fall by the wayside.
Do you really think that civilization has advanced
as regards obstetrical technique for the rank and file
of women beyond that of twenty years agof Witness
the midwives, chiropractors, voodooism, mental heal-
ing, and goodness knows what else. What is the
answer T Education; and this doesn't mean by a few
wise fat old ladies and fanatically inclined men re-
formers who are ever ready to reform the world, but
by sane, able, and broad-minded persons. Every
community must be supplied with such persons and
education started; until then no progress will have
been made.
Perfect technic cannot be carried out in rural
practice, except in a few instances. Practically all
of our cases of obstetrics are seen for the first time
when the hurry call is made; quite a few are entire
strangers. A few put themselves in the care of their
family physician in the early months; the majority
do not. Some lay writers would convey the idea that
all expectant mothers in the cities are given pelvic
measurements, urine examinations, blood-pressure
readings, and if so unfortunate as to have to be
delivered in their own home, the room to be used
must be fumigated and all woodwork and furnishings
scrubbed with soap and water, the patient bathed
and shaved, and the presenting parts made surgically
clean. But I don't believe it, do youf
A real obstetric specialist, in private and hospital
practice, on high-class patients, may do so; real
obstetric specialists are fully prepared to handle this
class of practice and their compensation is commen-
surate with their efforts. But they also handle their
non-pay hospital practice in the same way; they are
the real specialists — they do not pretend, but deliver
the goods.
Am Ammkemmf Netted
The day may come when the masses will awaken
to the fact that obstetrical work demands as careful
attention to all details as does general surgery. I
will venture to say that if all country doctors would
insist on shaving or clipping the pubic region and
making preliminary measurements, the patient would
not allow it, or we would lose that family and their
neighbors. We would be "putting on." Unless all
practitioners insisted, it would be obstetrical suicide
for the exceptional one who did. Is it not a factt
I know one doctor who has quite a reputation as an
obstetrician. Whyf Because of the fact that he
does not expose the woman, but delivers under the
sheet or blanket, doesn't use gloves, and always washes
and dresses the baby. This is frequently called to
our attention, because it makes a great hit with the
mothers; but of the one who uses a sterile gown and
gloves, and prepares his patient, you hear nothing.
You don't believe itf Well it is all too true in most
small towns. Investigate your own community and
see.
A country doctor works under disadvantages. A
long trip to the country; frequently the patient is
seen for the first time and all kinds of things turn up,
from persistent occiput posterior to transverse pres-
entations; occasionally no help can be obtained. The
responsibility is too heavy and many country doctors
break under the strain. In sparsely settled communi-
ties it is a dog's life and no wonder that as soon as a
country practitioner has accumulated a little of this
world's goods he wants to move to a city. Right now,
all over the country, the small towns are losing their
physicians. I know of one large city nearby where
all the surgeons and other busy men refuse to take
obstetrical work, except for their very best friends or
for high fees; they claim it takes too much of their
time and interferes with their night's rest.
A British writer states that a forceps delivery
must never be conducted in unsanitary surroundings.
What does he meant Does he refer to the London
hospitals and White Chapel district or to the com-
paratively clean rural homes of America T
He also states that the evacuation of large pieces
of placenta and efficient antiseptic irrigation of the
uterus should be practiced in the early stages of
infection of the placental site. Who is so negligent
as to leave large pieces of placenta T Surely not the
obstetrical specialist; we know it wouldn't be a
country practitioner. Also, what is the efficient anti-
septic that he uses to irrigate the uterus to clear up
infections of the placental sitef Is there not some
danger connected with uterine irrigations, and is it
used daily, and in what manner does this efficient
antiseptic kill these little germs T Are they trained
bacteria and die to order or is this only a figment of
his imagination T
OhtUtricd ActmdkUt
The disagreeable features of a country practice are
well illustrated by the following : #
Woman, age 34; first pregnancy. In the seven and
one-half month called to find out why her face and
legs were swollen. The sp. gr. of the urine was 1001
and the blood-pressure was 180. She was plainly told
what to expect She was put in bed, given skimmed
milk diet, sweats, and magnesia sulphate ordered, and
if no results in ten days to bring on labor was
advised. As they would not consent to having any-
thing done at the end of that time, I dismissed the
case, telling the husband I would not assume the
responsibilities if the ease was allowed to go on. In
sixteen days from the time she called at my office^ she
was delivered by a friend of mine and had a very
easy time, yet the blood-pressure was 180 and plenty
of albumin. So you can imagine how I stand with
Phila., September, 1922]
Obstetrical Conditions in Rural Communities — Shoyer
655
that family and their immediate friends? But who
would have thought it? I certainly was bluffed out,
and have lost that immediate vicinity for the simple
reason that the neighbors do not understand why I
wanted to bring on labor except to grandstand. The
only thing that would have saved my face would have
been the death of the patient. Well, such is life!
No one realizes more than the rural practitioner
the great obstacles in the way of rural obstetrical
practice. It is fierce. Do all city men doing obstet-
rical work take their cases to a hospital? Do you ever
get an emergency call to the house for say, eclampsia,
or postpartum hemorrhage, or what not? If so,
what do you do first? Do you shave the patient, have
all the woodwork washed, rugs moistened, walls wiped,
or do you get busy with the patient?
The fees for obstetrical work in rural practice is
somewhat lower than city pricey. Yet the work in
country practice is more strenuous, especially in the
winter months, with the long cold drives, long hours
of waiting, and in the face of difficulties "all by your
lonesome."
Just last year we were up against it. Two eclamp-
sias, a right shoulder presentation, a bad left occiput
posterior and a breech presentation in which the head
was extracted with difficulty. Everyone in the country
knows when a woman is going to have a baby and if
anything goes wrong "you get yours." You are
censured right and left ; there must be no pathological
cases in a country doctor's practice. The same old
saying, if they had had some one else, everything
would have been 0. K. A new man in a location,
losing a case of this kind or having some other bad
results, might as* well pack up and leave. "He is a
dead one."
Eleven years ago a recent graduate of my acquaint-
ance had the misfortune to lose two new mothers
from erysipelas; he had been attending at that time
a case of erysipelas. Of course, there was absolutely
no excuse for such criminal negligence. He lost what
practice he had and moved away. But an old timer
in another town lost two or three cases from the same
cause, and there was very little comment It makes
a difference how long you have been located. In a
large city you don't know your next-door neighbor;
they do not rush over to offer assistance. They don't
even know your wife had a baby.
Wkmt It the Be* Tk* Happens la the Cmrtry
In country practice, about the best one can do
would be about as follows: (I wish the editor would
write on this subject, as he has enjoyed ( ?) both city
and country practice.)
The woman is supposed to have taken a bath. If
she has not done so, one of the women present will
attend to that function. The presenting parts are
covered with a bichloride pack 1-2000 or painted
with iodine 3*4 per cent, or picric acid 6 per cent.,
and then a large sterile or boiled cloth. The patient's
gown and sheets are freshly laundered or ironed with
a hot iron. Under the patient is put a large sterilized
parchment paper. Boiled rubber gloves used, clean
gown or coat, umbilical tapes in tubes or envelopes.
Gloves boiled each time an examination is made.
After the child is delivered and the cord tied and cut,
the parts are covered with a sterile pad, and after
delivery of the placenta another sterile pad. When
toilet has been completed, another sterile pad and
binder; also binder to the breasts. No visitors allowed
for six or seven days. Normal eases in bed ten days ;
operative ones two weeks. It is not practicable to
repair cervical tears in country practice, but carefully
repair perineal ones.
If you will keep your hands in good condition, and
by that I mean never get your hands contaminated
with pus from abscesses or venereal diseases, and if
you do not attend obstetrical cases when you are in
active attendance on erysipelas, scarlet fever, small
pox, etc., you will have a better mortality and mor-
bidity record at the end of twenty years than a man
of the same caliber in a large city.
Remember the writers who were sent to Germany
by the magazines a few years ago to report twilight
sleep as conducted at the Freiberg clinic; they had no
scientific knowledge of what they saw or were writing
about and jumped at the conclusion that all suffering
was to be abolished in the expectant mother; but what
a fizzle it has been! True, properly conducted it is
worth while, but the manner in which it was presented
to the public was quackery. How many asphyxiated
babies did you have?
Are the majority of modern women pathological as
regards labor? As society becomes more cultured and
the human race more pampered and raised as a hot-
house plant, will pathological labor increase?
An Editorial N*U
We shiver over what we used to do and wonder
how in the world we ever "got away with it." But
we did, without a single maternal death. Surgical
or rubber gloves were never used, carbolic acid was
about the only antiseptic then commonly available;
yet thirty years ago we had plenty of hot water and
soap, understood the mechanism of labor, and it was
a disgrace to any average doctor not to know how to
use the forceps and meet all kinds of obstetrical
emergencies right on the spot with the help of a
neighbor woman. The average physician had several
cases every month, often four or five in a week, and
he became very skilled. We have done craniotomies,
versions, etc., in the backwoods, and nearly lived with
the patients for two or three days to pull them
through. There was not a hospital nearer than sixty
miles and not a trained nurse in the county. While
656
Pellagra and the Negro of the South — Nason
[The American Physacua
conditions are better now, and modern technic has very
much reduced the dangers encountered, to this day the
really resourceful obstetricians are country practi-
tioners. In the cities, where hospitals and specialists
abound, the general practitioner usually attends so
few obstetrical cases that he never becomes really
skilled, and many practice for years without ever
doing a high forceps delivery. No wonder there is
much poor obstetrics.
Yet we believe in modern obstetrical teaching and
practice, as set forth in modern text-books. In
necessarily modified form, thousands of country prac-
titioners are living up to these teachings. The prop-
aganda Dr. Shoyer condemns is a gratuitous libel
against the hard-working country doctor, who could
give points to ninety per cent, of the city practitioners
who attend an occasional obstetrical case. — T. S. B.
Pellagra
and
The Negro of the South
By A. L. Nason, M.D.
Darling, Miss.
THE NEGRO race as a whole, is the poorer one
and must look mostly to the white man for
teaching and better care. Negro schools are being
made good and in accordance with progress in
civilization. We find the average negro careless and
indifferent, as the height of his ambition is for some-
thing to eat, a place to "stay," as he calls it, and he
will get all the sleep he wants irregularly; conse-
quently, he is a man without system, taking every-
thing opposite to the whites; he is going to church
when the whites are returning, eats the first meal of
the day "way up in the morning,,, etc. He is ill
concerned about what he eats, just so it's something
and enough to satisfy his hunger. He usually tears
out the screens in his home — "too hot," and lets in
the flies and mosquitoes and thus subjects himaplf to
filth and disease, regardless of teachings or his better
knowledge. Most negroes are careless about raising
vegetables and have only a small early spring garden,
thus losing the major part of the vegetable vitamines.
The negro has a powerful resistance, due to his
having lived so close to nature, with its constant ex-
posures, and thus acquires a great degree of im-
munity to many diseases; but his small variety and
sameness of diet over long periods "gets" him sooner
or later, and when his vital forces give way and his
superstitions (which ignorant people of any race
possess) supervene, then is he in a predicament, and
since the past two unprecedented years, we find him
a victim of nutritional diseases, chief of which is
pellagra.
Pellagra is chiefly a nutritional disease no matter
what the cause, whether from lack of diet, common
worms and uncinariasis, etc, or wilful lack or ig-
norance in the balance of the daily diet, for thus it
resolves itself into an alimentary, a skin and mucous
membrane trouble from denutrition and a general
physio-chemical imbalance of the body chemistry and
is akin to if not quite the same as berri-berri and
other kindred nutritional troubles and the treatment
is accordingly.
Now the chief diet of the negro and poor whites
is what is commonly called "sow-belly" — the cheapest
hog meat — compound lard, poor molasses, meal and
flour, the latter of the self-rising variety, some
sugar and a great deal of rice. Some do not have all
I have mentioned. Read the above list again and
note what is left out .and you can readily join me in
the common conclusion that pellagra is undoubtedly
a nutritional disease complicated, at times, with in-
fected bowels from worms, etc They all have one or
more sorry dogs to the family, hence the worms
included in their filthy regime
Do the wealthy of both races ever have pellagra?
Sure! But inquire into his or her dietary and yon
will find it unbalanced, and they leave out important
articles with the explanation, "I don't care for or
love' it."
How would you treat pellagra T Just as I have
done successfully for ten years. Examine the feces
for any kind of infection, and treat it, and feed the
patient a balanced diet. I try to leave out, for awhile,
what he has been eating and give him a balanced
ration of what he has not been eating and give him
chlorin and iron and arsenic. Ton find the pellagra
chlorin-free and hydrochloric acid is needed in diges-
tion. I give it all the time in heroic doses, with an
initial clean out, and also give plenty of iron. Under
this treatment the diarrhea, ptyalism, sore mouth and
skin rapidly disappear. One to two ounces of
Epsom salts usually promptly stops the diarrhea. If
patients have ascarus lumbricoides, santonine in
heroic doses promptly cures the patient if repeated
once in six days; as long as you see a worm, save
the consequent anemia, which is as promptly relieved
by the iron and arsenic, if deficient in red blood
corpuscles. If there is uncinariasis, the once-per-
week dose of sixty to ninety grains of thymol, until
the ova are no longer in the stools, will promptly
cure that. If from amebiasis (I had one such), treat
with emetine, and the accompanying anemia as be-
fore, and your patients get well promptly and re-
main well until infected again, which is rarely, but
when it is strictly nutritional, you have the worst
of it.
(Continued on page 664)
Efficient Organization of Medical Practice
WhUo surgery, tho specialties, hospitals, people are to bo served, tho primary im- ordinatod in constructive co-operation with
institutional medicine, public health work, portance of tho function of tho General tho essential service of tho Family Physician,
industrial modicino, etc., hove their definite Practionor must bo recognised. Other divi- This is an integral purpose of Tho American
functions, if tho best health interests of tho sions of medical service must be properly co- Physician.
We Are Tagged, Gagged, Nagged and Dragged
TAGGING PEOPLE is an old game; it is now
being carried to the ultimate. Babies get mixed
in the lying-in ward and hence necklaces with plain
and lettered beads are now duly strung with Smith,
Martin and other names thus spelled out, and one
is firmly fastened around the neck of the babe be-
fore the cord is tied, so that Baby Smith does not
get mixed with Baby Martin. Thus we come into
the world labeled, and we are labeled all along the
way until the silver name plate adorns the coffin.
There seems to have been a special penchant for
tagging the doctor* — not a 'tag day" once in a while,
but every day he is a marked man, a fair and easy
mark only too often. But it is our own fault. Long
whiskers, silver stains on the fingers, a long-tailed
coat, and a smell of rhubarb and iodoform used to
be the distinguishing labels; now it is a thermometer
case sticking up, the outline of a hypodermic case
next to it, special insignia on the automobile, and
a characteristic mannerism. We are not as well
labeled as is the clergyman, but nearly the whole
breed of us are unmistakable in a crowd.
Doctor, did it ever occur to you that it does not
pay to be tagged ? You enter a restaurant, "Doctor"
sticking out all over, and it costs you fifty cents more
to get out than if you were plain "Mister." You
are in the theater, on the street, on a train, and
some handy guy is wanted for free service; you are
labeled and so you are "It." You register at a
hotel with M.D. after your name, and the clerk
assigns you to a four-dollar room and you do not
have the nerve to tell him that your limit is two-
fifty. So it is all along the line, the sum total of
"sugar" you pay out for your label being hun-
dreds of dollars a year. The preacher's label saves
him money; your's costs you a lot. Doctors are
supposed to be rich and free with their money.
Next time you go to the A. M. A. meeting make
a study of the dress, manner and general get-up of
the "Big" men you meet there. Most of them
look like business men with just a tinge of sporti-
ness in their tailoring, and they are just as detached
from medicine and professionalism in their talk and
manner as can be. They are only too glad to get
away from passing out free opinions, posing and
being imposed upon. It is awfully tiresome to one
to be always on display. Doctor, perhaps you do
not realize what a relief it would be to you to
be plain "Mister" except when definitely on duty.
Do you remember how tired of your uniform you
became while in the armyf The supposed advertis-
ing value of always looking like a doctor, always
talking like one, and always being taken for one, is
grossly exaggerated. One gets very little practice
in that way, and the strain of acting up to the part
is greater than you imagine until after you learn
how much fun it is to be just a plain man among
men, for men are a pretty good lot after all.
Dom't Say It With Drmgt
Doctors gag themselves; consequently they are
gagged. The florists' slogan, "Say it with Flowers,"
means that the other fellow is to say it in that way,
at so much per; the florist gets off his line of talk
in the advertising pages, where lots of people hear
his message. If he talked flowers to every chance
person he meets he would be regarded as a pest.
He must get awfully tired of roses and violets any-
way. We doctors are so painfully ethical that it
is wicked to get the other fellow to say it with
drugs and the lancet, and we lecture them when
they do. Consequently, we must "talk shop" in sea-
son and out of season. It is funny to get chummy
with a group of good chaps in the smoking com-
partment of a Pullman, who are very fraternal with
you until you fairly itch to let it out some way that
you are a physician, when the talk drifts right away
from you to the other quiet fellow who chances to
make some bright remark on some topic of the day
and who does not care a whoop whether they know
him as a banker or not. Doctors don't know how
to talk without putting a pill in it, but they ought
to learn how — it would help a lot and they would
not be regarded as "pills" themselves.
658
Tagged, Gagged, Nagged and Dragged
[The American Phyacun
We so doctor our talk and drug our opinions that
we are not supposed to have worth-while opinions on
anything but medicine; hence, our views as citizens
and men-of-the-world are discounted in advance and
we are sort of out of it. Doctor, forget it! Mix in
as a plain "Mister" and you will be surprised at the
friends you make. There is no occasion so to pro-
fessionalize our work and our talk that we are
gagged by the big world full of amateurs. The
medical profession would get further if we simply
forgot our work soon as we have washed our hands
and closed our office doors and went out as men
among men.
Mdtmg m Bmmmu •/ B*mg MmrrM
"Love is of men's lives a thing a part; 'tis women's
whole existence." Just watch the career of the man
whose main business in life is being a married man,
for his wife nags the life out of him. She has
forced him to the feminine view of love being the
whole career, and it is not natural to a man, no
difference how good a husband he may be. The
result is that "Maggie" brings up "Father" with
a club, which is bad for both of them.
Being married to medicine, having no other inter-
ests, means that you will be nagged all your life.
People get the idea that the doctor is so married to
his profession that he is a sort of monastic so far
as other interests in life are concerned; and, oh,
how they do work him! What is money to himf
What is restf What is social lifef What is in-
dependence T It is nag, nag, nag — twenty-four hours
of every day, Sunday included. What is "Doc" for
anyway T
It would be a means of grace and a good religious
exercise to swear at some of these naggers once in
a while. Once the worm turns he is more respected.
There is a tendency now in medicine, since it has
become more of a public affair, to nag the whole
collective profession. It was bad enough to nag
poor "Doc," who stood for it, poor fish, but it is
worse to think it one's community duty to nag
the whole darned profession, and that is exactly
what a lot of people are trying to do. As per usual,
it is our own fault We have spoiled the public.
The remedy is obvious.
Simn md TrmeUrs
"Hitch your wagon to a star" is good advice if
you have a strong wagon built for speed. Plows are
strong, but not built for speed and are dragged.
One mule and a six-inch plow may be good enough
for one-man farming, but nowadays it is the gang
plow and a tractor in big farming. Both kinds of
plows are* dragged — don't forget that. One-man
medicine seems to be going out of style, and gang
practice in the form of group clinics is coming in.
It is "Hail, hail, the gang's all here; what the H
do we care now!" That is what the crowd pushing
health insurance thought if they could get the whole
medical gang hitched to their machine. If we are
simply to be tools, like plows, it makes little differ-
ence whether a mule or a tractor drags us, for we
will be dragged separately and collectively.
So our plan is to make our wagons strong and
speedy and hitch them to a star, not to a political
tractor. If we go star-riding a tin Lizzie medical
organization will not be strong enough; we will
need a machine that is just as strong as the political
machine. Do you get itf Doctor, elaborate the
idea yourself. Unless we do something along this
line we will certainly be dragged, and it will be
our own fault
Never attempt to rupture, a prostatic abscess by
massage per rectum. If the abscess points towards
the urethra it may rupture into it, and although
no immediate harm is done and relief is prompt,
cicatricial contraction, with resultant stricture forma-
tion, may occur later. Should it point towards the
rectum, it may rupture there, and a disagreeable,
painful condition, with a purulent discharge from
the rectum may ensue. If it points towards the peri-
neum it may rupture into it and a perineal abscess
will develop, causing needless suffering and delay
and necessitating operation later. If it points to-
wards the peritoneal cavity and should rupture into
it, peritonitis and death may result Therefore,
when a diagnosis of abscess of the prostate is made,
it should be opened and drained without delay.—
George Livermore, M.D., U. and C. Review.
Vincent's Angina and Intestinal Spirillosis
Bouchet and Lcroux (Le Progrte Mid.) relates a case
as follows: A man, aged 25, first suffered from pyor-
rhea alveolaris, upon which there developed an ordinary
case of Vincent's angina. This was in April, and in the
following May there followed an attack of acute enter-
itis.
One year later there was a second attack of angina,
after the patient was treated with salvarsan ; since which
he has remained free from all symptoms.
The authors cannot demonstrate that the intestinal
trouble was due to the exciters of Vincent's disease, but
this sequence is highly probable.
We know now to a certainty that this affection is a
pure spirillosis, the fu si- form bacillus playing no role in
causation. The spirilla as a class have been suspected
before of the ability to cause enteritis. There are mem-
bers which dwell in the intestine as harmless sapro-
phytes which are probably capable of becoming patho-
genic at times. While the authors use the term spirillum
in a general sense they clearly refer to Vincent's spiril-
lum, while at the same time the existence of other forms
is sometimes implied. A description of the spirilla of
angina and those found in the stools of subjects with
enteric diseases shows both conformity and divergence.
The germ found in the mouth appears to agree with
the so-called buccal and dental spirochete, while there
were two distinct forms in the intestine, one of which
conformed to the buccal spirochete. One faction of
bacteriologists state that the spirilla of the mouth are
multiform, indicating either different species or varieties,
and the same may be said of the intestinal forms. Others
definitely separate the dental from Vincent's spirochete.
Despite the confusion in detail there is no doubt that
banal spirochetes are able to set up a considerable variety
of lesions under certain circumstances.
PhiU., September, 1922]
Beat Currtat Medical Thought
659
Best Current Medical Thought
Acute Abdominal Conditions in Children Due to
Errors in Diet*
A large percentage of all cases of gastrointestinal
diseases in children are caused by errors in diet; this
is particularly true during the summer months, when
the heat and humidity of our climate will cause foods,
which on other conditions are perfectly suitable, to
be indigestible to the individual infant or child, caus-
ing conditions varying from acute gastric indigestion
to acute gastroenteritis.
. In infants the cause must be found before the con-
dition can be cured. If breast-fed, the quality of the
milk must be determined and the health of the mother
must be looked into; while if bottle-fed, the question
of the fat, sugar and proteid content must be studied
to find which one is at fault. It will be found that
the fats, in summer, cause more disturbance than the
sugar or proteid, as a rule; in some cases which have
not been under the care of a physician it will be found
that the sugars have been much too great in amount
and are the cause of the upset. Again, the quantity
at times plays an important part, as the stomach is
overfilled and by the motility being impaired the con-
tents are not so quickly passed out and some remains
there until the next feeding takes place; this also may
happen when the feedings are too close together.
In older children overfeeding itself plays an im-
portant part, particularly in the acute gastric :>nd in-
testinal indigestions; while indigestible foods, such as
cake, candy and pastry, are important factors. Over-
ripe fruit will in many instances be found to be at
the bottom of the trouble. Bad milk which has been
pasteurized or sterilized still retains the toxins from
the bacteria which it contained before treatment and
these will at times cause trouble, while unpasteurized
milk which is unclean contains many bacteria which
may be pathogenic and set up an acute inflammation.
The symptoms produced by these errors in diet vary
in intensity, but give the same general picture. As a
rule, tye gastric condition first presents more or less
offensive breath, coated tongue, fever, slight at first,
becoming higher as the disease progresses, until in
the gastroenteric forms it will reach 103° F. or over.
Pallor associated with nausea and followed by vomit-
ing, which may occur only once or twice or at times
will be continuous for some hours or days. Thirst is
present in all of these conditions and where the vomit-
ing is continuous is one of the most distressing symp-
toms. Prostration varies greatly, according to the
acuteness and length of the attack. Abdominal pain
is present in all cases to a greater or less extent, de-
pending much as to whether there is an acute inflamma-
tion or a simple irritation. Constipation for at least
twenty-four hours is the most frequent condition, though
•Abstract (Roster and Medical Digest, July, 1922) of paper
read by Theodore Le BoutiUier, of Philadelphia, before the
Northern Medical Association of Philadelphia.
there are cases in which diarrhea is present from the
start In the intestinal form of these diseases diarrhea
always takes place sooner or later and varies much
in the number and character of the stools; in a gen-
eral way the number of stools will be from five to
twenty in twenty-four hours and the character changes
from containing undigested food at first to liquid or
frothy, greenish yellow in color and containing much
or little mucus.
The prognosis depends upon the condition of the
patient when the disease starts, how long the trouble
has progressed before active treatment has been started,
the care with which the treatment is carried out and
the type of infection which is present; in other words
the more healthy the patient has been before the at-
tack, the shorter the time before the treatment is started,
the better will be the prognosis.
The general principles of treatment are the same
for all conditions. Wash out the stomach, either by
means of the stomach tube or by giving a large
amount of salt or soda bicarbonate water by mouth to
cause vomiting, which will clear out any food remain-
ing there; this to be followed by a dose of castor
bil (1-4 dr.) or calomel 1 gr. in divided doses or in
one dose, or in some of the older children a dram
of magnesium sulphate in a glass of hot water. An
enema should now be given so that the lower intes-
tine will be cleared out. Following these measures
rest of the gastro-intestinal tract is essential. No food
should be given for at least twenty-four hours ; if there
is little or no vomiting, water in small quantities (Vz-\
oz.) every half hour or so, or tea (1 dr. to the quart
of water, brought to the boil and no sugar added)
can be given hourly. For the pain a hot-water bottle,
mustard paste applied to the abdomen or a hot mustard
pack will be found useful; while in older children if
the pain be gastric, small doses of phenacetin and bis-
muth subnitrate at times give relief. In the intestinal
cases with diarrhea the same treatment should be car-
ried out. The starvation period should not be con-
tinued for too long a time or the resistance of the
child will be so lowered from lack of nourishment
that it will be very hard to build it up again. For
infants the start of feeding should be with a weak
mixture of fat-free milk and no sugar added; at times
a clear vegetable soup may be used as the diluent,
as it contains considerable of the water-soluble vita-
mines. Sugar is gradually added to the mixture, if
the condition has not been due to sugar in the first
place; then a little whole milk is added and in time
takes the place of all the fat-free milk. It is well
not to add cream to the mixture until the baby has
entirely recovered.
In older children cut out all milk for some days,
letting clear meat and vegetable soup take its place;
follow this by the cereals, green vegetables and light
puddings, gradually getting back to the regular diet
660
Best Current Medical Thought
[The American Physician
in from a week to ten days.
As far as drugs are concerned they are of little
value except in occasional cases. The diarrhea is, as
a rule, controlled by the cleaning out of the gastro-
intestinal tract and the rest which follows. At times
the bismuth preparations may be of use, but they are
apt to be abused and more often cause harm, particu-
larly if used too early. The same is true of the opium
preparations. If there is much fermentation, the Bacil-
lus bulgaricus or Bacillus acidophilus are of use.
Cyclic or recurrent vomiting is due, I believe, to
errors in diet, as it has been found that by testing the
child with the food proteins and removing from its
diet any food that shows even a partial reaction the
case can be cured in a short time; in fact, many cases
that have been so treated have not had any return at-
tack, and two children who were allowed to eat some
of the forbidden foods had an attack within three
days.
The Nature and Cause of Old Age Enlargement
of the Prostate
Kenneth M*. Walker (British Medical Journal) con-
cludes in reviewing the various theories to account for
old-age enlargement that it is impossible to explain it
by any theory of chronic inflammation. Although en-
largement may reproduce conditions favorable to the
development of a neoplasm, the enlargement itself does
not come into the category of true tumors. The con-
dition is in the nature of a fibro-epitheiial degeneration
which finds its analogy in the female in serocystic disease
of the breast. This degeneration may be regarded as
an accident occurring in the progress of involution of
the genital tract. The cause that determines the onset
of the condition is unknown, although it is not improb-
ably connected with a loss of endocrine balance during
this period. The writer's observations indicate that in-
jections of extract of prostate in the human being do
not produce any response in the way of alteration of
blood pressure, respiration, etc. He has used both auto-
lysit and commercial preparations of prostatic extract
for this purpose and has never obtained a reaction that
could be appreciated clinically. Incidentally, he mentions
that he has found that prostatic extract, when employed
as a therapeutic measure, is occasionally of use during
the early phases of enlargement, but of little benefit in
the later. Answers received to a questionnaire inquir-
ing into the incidence of prostatic enlargement in the
various countries of the world brings out the fact that
prostatic enlargement shows a definite distribution that
is anthropological rather than geographical in character.
It very rarely occurs among Mongolians or Negroes.
Generally speaking, enlargement is commoner among
meat eaters and those leading the sedentary lives of
cities than among vegetarians and frugal livers.
The Indications for Operation in the Treatment
of Injuries Involving the Brain
Donald Munro (Boston Medical and Surgical Jour-
nal) states that the indications for operation in injuries
involving the brain are three: Compound fracture of
the skull, depressed fracture of the skull, and a rise
in the intra-cranial cerebrospinal fluid pressure. Pa-
tients who have received an injury to the brain do not
develop symptoms and do not die from the fracture which
may or may not be present in the bones of the head.
They do develop symptoms and they do die as a
result of the increase in intra-cranial pressure which
accompanies the fracture, or which not infrequently is
present in the absence of any fracture. The intra-
cranial cerebrospinal fluid pressure depends on the re-
lation between the secretory powers of the choroid plexus
and the absorptive powers of the cerebral venous cir-
culation. All cases that have received or are sus-
pected of having received an injury to the brain, no
matter how slight, should, as soon as they have recov-
ered from their surgical shock, have the pressure of
their cerebrospinal fluid measured; and the treatment
should be based primarily upon this finding alone. Ii
the intra-cranial pressure is measured, the symptoms and
signs, such as pulse, blood pressure, respiratory rate, and
mental state, commonly used as indications governing
diagnosis, treatment, and prognosis, need not and should
not be regarded in any other light than as confirmatory
evidence.
Effects of Faulty Foods on Endocrine Glands
Robert McCarrison (New York Medical Journal)
observed in feeding experiments in animals that mal-
nutrition, whether rising from complete starvation, from
the incomplete starvation due to avitaminosis, or from
starvation resulting from deficiency of proteins and
calories, gives rise to enlargement of the adrenal glands
and sometimes of the pituitary body with an atrophy
of all other endocrine structures. The functional per-
fection of the adrenal glands is dependent upon the
balance of the food and the quantity and quality of its
vita mines.
Faulty food permits the entrance into the blood of
a stream of intestinal bacteria, which, acting on the
thyroid, may cause congestion of the organ, desquamma-
tion of its acinar cells, and distorting of its normal
acinar structure.
It is possible by the examination of the thyroid alone,
with but a small percentage of error, to distinguish be-
tween those deficiently fed animals that have suffered
from septicemic states in consequence of food faults
and those which have not.
C. F. Hoover says, "I have been unable to see any
justification for amputation of part of the thyroid gland
as a direct treatment for Graves' disease."
Where there is a clinical suspicion of syphilis, but
with the blood returning a negative Wassermann, pro-
ceed on the assumption of syphilis, at least to the
point of giving a dose of salvarsan, or a short course
of mercury and iodine. The information gained from
a therapeutic test may remove all doubt. It does it
more often than we think.
A syphilitic with evidence pointing to cerebro-
spinal involvement should be protected from worry and
unusual mental strain. Also, patients with cerebro-spinal
syphilis, as far as possible, should not occupy positions
of great responsibility or involving the welfare of
others. For instance, no patient of this type should
be permitted to serve as an engine driver.
Many syphilitic patients are careless in follov/ing in-
structions as to systematic dosage. This particularly
holds good after the disappearance of all lesions. In
view of this lack of faithfulness when treatment is put
into their own hands, it may be advisable to resort
to the intravenous or intramuscular administration of
mercury. This secures exactness of dosage and con-
stant supervision of treatment, highly important factors
m success in the treatment of the case.— Urologic
and Cutaneous Review.
September, 1922]
The American Physician Advertising Service
661
Sluggish Bowel Action in Childhood
is usually due to errors in feeding. Subjecting these fundamentals to the cus-
tomary careful correction,
INTEROL
may be administered coincidentally to relieve the immediate condition.
This pure, tasteless and odorless mineral oil — notably free
from the greasiness common to such products — has proved
of exceptional value as a safe and dependable means of
moving the bowels of young children, and this without the
griping, straining and after-constipation by which the use
of castor oil and other drastic cathartics is so frequently
attended.
The constantly growing number of physicians who prefer
INTEROL to any other media in the routine management
of constipation in early life is its own best endorsement.
Sample and Inter ol brochure on request
Dosage in Children
Begin with a half to
one teaspoonful, 3 times
a day before meals. In-
crease or decrease dose
until one good movement
is obtained daily. Then
gradually decrease to the
point where a small dose
at bedtime will maintain
this result.
Drug and Chemical Corporation
2413 Third Ave. New York City
Manufacturers of
Oraseptink — Internal and External Antiseptic, Wash, Spray and Douche.
Adacco Salt — Effervescent Saline Laxative and Uric Acid Solvent
Velocen — "The Doctor's Hand-maid and Household Emolient."
Is it ever safe to take anything for granted?
Take dropsy for example. Regardless of the underlying
cause — cardiac valvular lesions with loss of compensation,
chronic Bright'* disease, Post Scarlatinal Nephritis, or what
not— effusion of fluid into the tissues means increased cardiac
burden, augmented circulatory stasis, resultant renal irritation
and increased absorption of toxic waste. More than a mere
diuretic is required.
ANASARCIN TABLETS act upon the heart and strengthen its
action and regulate its rhythm.
ANASARCIN TABLETS help to overcome circulatory stasis
and so bring about absorption of
effused fluid.
ANASARCIN TABLETS increase elimination of urinary solids
as well as fluids.
Such action ia demonstrable. Why not convince yourself by trial?
Sample and literature on request.
The Anasarcin Co. Winchester, Tenn.
Mentioning The American Physician Insures Prompt, Careful Service
662
Varicose Vena — Hammer
[The
Pfcysda
Varicose Veins — Hammer
Continued from page 644
The operative procedures for the cure of varicose
veins are numerous and important. They include the
ligature of varicose trunks; linear section of the
varicose trunks between ligatures, with or without in-
clusion of collateral tracts by circumferential incisions ;
open resection of varicose trunks and secondary trib-
utaries; subcutaneous resection.
The first of these procedures, or ligature of the
varicose trunks, is inseparably connected with Tren-
delenburg's name. According to the Trendelenburg
theory, the valves in the saphenous become incom-
petent because of the high central pressure. The veins
of the leg distend, because they are incapable of sup-
porting so great a column of blood and, finally, the
blood begins to flow in the wrong direction in the
saphenous vein, establishing a so-called vicious circle.
His first operation, about the year 1890, consisted
in division of the long saphenous at the junction of
the lower and middle third of the thigh. Later he
modified this by placing two or more ligatures on the
saphenous, one above the level of the internal condyle,
the other below the knee. The vein is attacked through
a short incision at right angles to its course and
divided between ligatures near the saphenous opening.
The operation may be accomplished by local anesthesia.
Sckeit'i JfcffcW
One of the most valuable procedures is the method
of Schede, when the vein cannot be readily removed;
the object sought being to force the superficial venous
circulation from the unsupported subcutaneous veins
into the deep muscular trunks when these are not
obstructed by previous disease. This operation con-
sists in a circular incision completely around the leg
at the junction of the upper and middle third, the
incision reaching to the deep fascia. Bleeding points
are ligated and the edges of the incision .stitched
together. Moreschi has utilized this principle in the
treatment of varicose ulcers. He makes two circum-
ferential incisions; the first of these 4 cm. (13-5
inches) above the ulcer, the other 1 cm. (2-5 of an
inch) above the malleoli. The principle of this oper-
ation is that the skin in the immediate vicinity of
the ulcer and between the two parallel incisions is
completely undermined and detached by subcutaneous
dissection, thus destroying the varices over an area
within the limits of the cross-section.
Resection, partial or complete, was suggested by
Madelung in 1884, systematized by Schwartz in
France, in 1888, greatly perfected by Terrier and
Alglave in 1892, and has been improved upon through
the labors of Ledderhose who, in addition to extirpa-
tion of the veins, makes a series of longitudinal
incisions along the inner aspect of the leg from the
knee to the malleolus, in the hope of intercepting and
obliterating all the tributaries lying between the knee
and the ankle.
The subcutaneous method is the operation of choice
among many of the best surgeons and the procedure
introduced to the notice of the profession by G. E
Mayo,* of stripping the vein by means of a metal
ring on a carrier, may be briefly described as follows:
"The long saphenous vein is isolated and divided
near the saphenous opening, and the proximal end
ligated. The distal end is then mobilized as much as
possible by means of a long artery forceps of the
Murphy type, and the ring of the stripper introduced
over the end of the vein. By means of combined gentle
traction on the vein with forceps, moderate forcing
of the instrument along its course, and with the skin
supported by the spread-out hands of an assistant,
being particularly careful when the larger branches
of the saphenous are encountered, it is possible in
most instances to strip the vein down the entire length
of the instrument. By forcibly pressing the ring out-
ward against the skin and incising carefully on it, the
vein can be picked up and brought out through the
small button-hole incision, and the stripper withdrawn
through the first incision. ... If the saphenous
breaks high up, the stripper is discarded and the
trunk picked up through a small incision in the lower
third of the thigh and there ligated. ... A
spiral incision extending from a point close to the
anterior border of the tibia, continued backward and
downward to a point about the middle of the calf,
divides all the main branches of the long saphenous
at this level . . . The second incision is made
about three inches above the internal malleolus, and
of sufficient length to pick up all the superficial veins
in that vicinity." Further improvements in the tech-
nic have been made by W. Wayne Babcock, of Phila-
delphia. While Mayo's method appears the simplest,
it is not adapted to chronic cases in which the main
trunk of the vein remains very tortuous, forming a
series of adherent, friable veins, intimately blended
with the skin.
Wkm !• OptreU
In deciding whether an operation should be per-
formed or not, the dictum of Mayo is applicable:
"An elastic bandage is applied from the foot to aboTe
the knee. If this bandage can be worn with comfort,
an operation should give relief. If the bandage
causes discomfort, it is probable that the superficial
vessels are necessary to the circulation of the limb."
Statistical studies of operations on varicose veins
are of marked interest. Some years since in a hug6
• Balfour, D. C, Minnesota, Journal lancet, 1916, XXXVL
September, 1922] The American Physician Advertising Service 653
The Foetus as
a Mineral Parasite
IT has been definitely established that during gestation the
* foetus acts as a mineral parasite.
If the mother's diet during these eventful months is defi-
cient in mineral salts imperatively demanded for the develop-
ment of the mineral structure of the child, the deficiency is
made up at the expense of the mother's tissues.
This brings about a corresponding loss of vitality both for
the mother and for her prospective offspring.
It is for this reason that a liberal quantity of Grape-Nuts
with milk or cream will be found of value in the diet of
expectant mothers; to provide an adequate mineral content
in the mother's blood during the period of utero-gestation,
and also an adequate mineral content in her milk during the
subsequent period of lactation.
The high food value of Grape-Nuts is shown by the fact
that Grape-Nuts contains 95.25% of solids, including 1 1 .88%
of protein; 78.76% of carbohydrates (of which 48.24% is
soluble, as dextrin, reducing sugars, etc.) and 2.27% of
mineral salts. *
These salts include:
Potassium chloride .... 4.55% Calcium phosphates .... 5.42%
Sodium chloride 34.33% Magnesium phosphates. . 24.20%
Calcium sulphate 1 .96% Iron phosphate 0.62%
Potassium phosphates. . 22.67% Silica 2.02%
Grape-Nuts with milk or cream is well suited for supply-
ing the elements required by the developing child; it is ad-
mittedly a good all-round food for the mother.
Samples of Grape-Nuts, for individual
and clinical test, will be sent on request
to any physician who will write for
them.
Postum Cereal Company, Inc.
Battle Creek, Michigan, U.S.A.
Mentioning The American Physician Insures Prompt, Careful Service
664
Pellagra — Nason
[Phfladdptit
number of cases at the Halsted clinic, 79 per cent,
were cured or greatly improved. Goerlich, in an
exhaustive series of cases numbering nearly 1500,
reported by 42 operators, found 65 to 85 per cent,
cured after ligature of the internal saphenous.
Of 256 patients at the Mayo Clinic, statistically
studied and reported by D. C. Balfour, from January
first, 1909, to January first, 1914, inclusive, letters
were received from 161. In 68 patients the condition
was associated with varicose ulcer, in 93 there was no
ulcer. Thirty-nine of the sixty-eight patients (57.4
per cent.) had the ulcer cured, the veins disappeared,
there was no swelling of the feet, and they were able
to pursue their daily labors without pain. Sixteen
patients (23.6 per cent.) reported great improvement,
the ulcer having healed in the majority, but with some
minor complaint, as swelling or pain after a day's
work. In thirteen patients (19 per cent.) the results
were definitely unsatisfactory. The ulcer had either
failed to heal, or there had been periods of complete
healing, followed by pain and swelling sufficient to
make the prolonged upright posture uncomfortable.
Cmu€$ •/ Ftuhtre
Among the causes of failure after operation are
want of good judgment in the selection of cases and
the fault of not applying the best suited operation
for the particular cases under consideraton, also lack
of proper care after operation. In old varicose veins
where the ulcer has remained untreated or improperly
treated over a period of years, with chronic congestion
and inability to exercise the muscles properly, there
is a strong predisposition to flat foot, with the asso-
ciated breaking down of the plantar arch and the
resultant pain and disability.
Relapses are more common after the single linear
division of the veins than after their complete extirpa-
tion. Alglave and Terrier report after an extensive
experience with the disease, as well as from the reports
of many others, that relapse may occur, and in no
small percentage of cases, after extensive and complete
resection. The causes of relapses of this kind are to
be found under the following conditions:
1. Secondary dilatation of small superficial venules
of the ligated vein, which enlarge and unite with the
deep muscular veins through anastomotic branches.
2. The regeneration of veins, which is of frequent
occurrence. 3. After ligation, direct end-to-end ven-
ous communication through the scar.
Although strict asepsis is the best safeguard against
post-operative phlebitis, nevertheless, there is always
a risk of the development of embolism in the hands
of the most careful and of the most skilled surgeon.
These emboli, sterile as they are, are discharged from
the proximal side of the ligature to the saphenous, or
from the remains of the extirpated venules, and
coursing along the deep anastomotic trunks are swept
into the general circulation, lodging in the lung as a
pulmonary embolism.
Pellagra — Nason
(Continued from page 65/6)
The strictly nutritional type is hard to cure, but
easily mended, provided finances are not in the way;
but they are in the way these times for about nine
months in the year, when they return each spring to
the planter's ration of poor sorghum, "sow-beUy,"
compound lard, poor meals and self -rising flours as
the principal diets. While this trouble is menacing
the progress of the farmers, they are beginning to
wake up and are using a more mixed diet. The worst
cases are generally those who are trying to carry
themselves and not buy on credit; they are literally
starving themselves without knowing it.
You will recall that the government, about 1907-8
or 9, tried out the nutritional experiment in the
Mississippi State Penitentiary with twelve men, and
seven developed all symptoms of the disease as re-
ported, and they gave the twelve their liberty for
submitting to the experiment.
Diet
If the proper changes in diet are made and they
are treated correctly, 95 per cent, will recover, but
when the anemia becomes pernicious, as we so often
find it, then we are up against the inevitable.
I have treated pellagrians from eight months old to
sixty-five years of age. The sixty-five-year-old ones
died, and the eight-months-old ones got well promptly.
I use the word promptly in both cases ; the reason is
evident.
I find old cases returning earlier this year, who
have returned to the unbalanced diet as before, and
I have to teach them over again. It seems they are
untaught and unteachable. Some return at three or
four-year intervals and when I ask, "What are you
eating f" they tell the same old story.
Why so much pellagra in the South T Because it's
"The Land of the Mule, the Negro and Cotton," as a
whole, and the people eat what they can buy, and
scantily at that, and the sameness of the diet
Now, again, where fresh milk and butter, peas,
beans, potatoes, fruits and vegetables abound in
families, and they eat them there is no pellagra, ex-
cept of the infected variety. Our hilly and freestone
water country once was heavily infecte^with hook-
worms, and there you would see all the pictures you
commonly see in literature; but since our state-wide
and nation-wide clean up, we do not see so much of it
in severe stages, while more is reported because of
the physician's better knowledge of the disease. It
was mostly among the whites; they are more easily
educated and, therefore, take the necessary precau-
tions to prevent reinfection, but in the course of time
they, too, will forget, and in a few years we shall
see the same episode repeat itself.
"The poor ye have with you always"; so also will
we have pellagra.
September, 1922]
The American Physician Advertising Service
665
KELLOGGS BRAN
fit
stubborn cases
of am s tipation
In a natural, easy way, Kellogg's Bran, cooked
and krumbled, induces better peristaltic action.
When two tablespoonfuls are eaten each day,
permanent relief can be confidently anticipated
in mild cases. Kellogg's Bran will be found par-
ticularly valuable in chronic, old-age and bed-
ridden cases, when two tablespoonfuls in some
form should be taken with each meal.
Kellogg's Bran is delicious. It should not be
confounded with common brans which become so
irksome for patients to eat Kellogg's Bran has
a nut-like flavor and krumbled crispness that
appeals to the most fastidious appetite. It may
be eaten as a cereal, sprinkled on other cereals
or used in countless ways in baking and cooking,
are printed on each package.
We are anxious that physicians should test
Kellogg's Bran to personally know how good it is
and to know the results that can be expected.
Kindly mail a post card today to Kellogg Toasted
Corn Flake Co., Battle Creek, Mich., and a full-
size package will be promptly mailed you.
WVUCONSTIMnON
IRAN
^■UflTTOUT
An Analysis of
KmUogg'* BRAN
cooked and
kmmblad
Aside from its regu-
latory value, Kellogg's
Bran command! atten-
tion at one of the most
valuable foods known.
Read this analysia:
Moisture 2.50
MINERALSALTS S.41
Protein 118
Pat 2.8
Crude Fiber 8.9
Carbo-hydrates 61.6
Calories 1480.46
(per pound)
^
!£*.
die original BRAS '-cooked and humbled
Mentioning The American Physician Insures Prompt, Careful Service
I 'Book VjeMevus |
Doctors— Entre Nous
By Tames Bayard Clark. 66 pages. Publishers, The
Medical Times, 95 Nassau St., New York City.
Postpaid on receipt of $1.00.
In this little book are three stories. The striking
feature of these stories is the combination of quiet
whimsical humor and peculiar force. One is carried on
a high tide of amusement to a sudden and surprising
With a keen blade indeed the author pierces the shin-
ing armor of the profession and lays bare to all an easy
view of some of its usually obscure faults and weak'
This book should be read by every medical man where
the English language is understood. We doubt if the
medical profession would care to have it read too gener-
ally by the laity.
Such wit and vigor has never before been applied at
once to the medical profession.
Adventures in Endocrinology
By Henry R. Harrower, M.D., Director of the Har-
rower Laboratory, Glendale, California; The
Literary Department of the Harrower Laboratory,
1922. Cloth, pp. 159, price $1.00.
This little volume recounts in a very interesting way
the get-together, in the study of the internal s
which led to the publishing of Endocrinology and,
later, the adventures of Dr. Harrower in trying to
promote endocrine therapy for physicians other than
those who specialized in endocrinology. He has been
severely criticized for making this effort. However,
he has no resentment and is philosophical over these
attacks.
His object in writing this book is to collate some of
the attacks — to show to what lengths narrow prejudice
will drive man — and then to let the reader draw his
own unbiased conclusions.
He says : "I have had every reason to believe that
I have been and am still right fundamentally, and have
always attempted to pass my judgment with as many
as possible of the facts before me. I shall be very
glad if any reader, who may be interested and has
any additional facts to submit, will give me proof,
either unpublished or with the reference, to disprore
my attitude, as it will be outlined in the following
chapters."
This statement, along with his dedication {"To my
esteemed colleague, George H. Simmons, who. by his
opposition through twelve years, has stimulated me
more than many a well-wishing friend"), goes to show
that Dr. Harrower, without a doubt, wants the truth
to prevail.
EQU1SETENE IS BETTER
) No Infection: (3) Many time* teMile
math of bono
■ ■month: (7) Can
,1. .Send 1 1. 20 for
2*0 foot.
■ of enteroptomlm, aalteroptoeil, floating
and poet-operati™ enr"" i.j--
It relieves draaafas «
helplvl fa many .
The Obstetrical "Shoe Horn"
Anetocrfcally Correct at Ke(arda
Sin and Shape
Where the foetal head ensagee
^S. bo readily deflected
^®). canal. Eliminate, hou
XQbncI danger to moths
The new Johnaen Kolbnan Dlla
very •imple and •eUafactory urethra
and catheter combined. It will
leork of die S10.00 Kollman Initrnm
coeta Ton only S 12.50.
Huston Bros. Co.
or i«
dlla
101 =
"Full supply for thirty
•e» at only a nickel
each. Send u» $1.50 and
■hip at once pre-
* paid. You will aay that
'Nevarsalip' ia your beat
obitetrical technique. The) only
ound cord that will not slip, will not cut
nd will always hold."
aid
Atlas American Bid* ., Chicago, DL
You can buy with Confidence — See "Service Guarantee t
September, 1922] The American Physician Advertising Service 667
ANNOUNCING
A n.w NON-NARCOTIC Drug
Ttoche
B
which is both
HYPNOTIC ^ANALGESIC
AMONAL which is administered orally in tablet'
form, is a prompt, efficient sedative, hypnotic
and analgesic .capable of Controlling
pain and producing steep inthe
many conditions in which Morphine and other
narcotics have hitherto been the only recourse
Supplies and Literature will be
E
famished on request
TheHoffMAIW-lAROOltCHCHICAtWoeKS
New York
i
Mentioning The American Physician Insures Prompt, Careful Service
668
Helpful Pond*
[Philadelphia
Ringworm and Its Successful Treatment
By John P. Turner, M.D., Medical Inspector of Public
Schools, Philadelphia, Pa. Illustrated by eight
half-tone engravings. F. A. Davis Company,
Publishers, Philadelphia, 1921. $1.00.
A brief and satisfactory review of the subject of
ringworm — its history, pathology, diagnosis and treat-
ment.
A Compend on Bacteriology
By Robert L. Pitfield, M.D., Pathologist to the German-
town Hospital, etc Fourth edition, copiously illus-
trated. Cloth, 295 pages. P. Blakiston's Son & Co.,
Philadelphia. Price, $2.00 net.
This little book covers bacteriology, the pathogenic
protoxea and the elements of immunology, giving the
essential data in such form as to be useful to the
student and as a review for the practitioner. Having
reached a fourth edition testifies to the merits of this
abridged compilation.
Radiant Light and Heat Effective
The following interesting case was reported by Dr.
F. S. Holladay, of Los Angeles (Amer. Journ. Electro-
therapeutics, Apr., 1921): "This case was a woman,
age 35, who had been treated by an eye specialist for
gonorrheal ophthalmia and was becoming worse.
With the specialist's permission, I gave her one long
treatment of radiant light and heat as warm as she
could stand it. She returned next day and the puru-
lent discharge had lightened. In four days the dis-
charge had stopped and she made a very quick recov-
ery. I asked the specialist to see the eye, and he
was very much astonished, as I was. The condition
was verified microscopically ."
In all conditions where radiant light and heat is
indicated you will find Thermolite Light and Heat
Applicator a scientifically designed and well-made
appliance. It reflects a flood of penetrating light
and heat m parallel rays — no focal spots to born or
blister. You will find the Thermolite a practice
builder ; its use is indicated in many of the more com-
monly encountered conditions.
For interesting and instructive literature, address:
H. G. McFaddin & Co., 34 Warren Street, New York.
A Handy Reference Book
With the thought that many physicians would wel-
come a reference book in which were gathered the
essential facts regarding the more important thera-
peutic agents supplied under the Merck label, the
current number of Merck's Abstracts reviews in brief
form a number of important specialties, giving the
composition, dosage, principal uses, etc
Among the interesting preparations which are de-
scribed may be mentioned Numoquin, which is re-
ported to be actually specific for the pneumococcus;
Eucupin, which is described as Isoamylhydrocupreine
and has a very high bactericidal power, a 1 : 16000 so-
lution being capable of destroying streptococci; Vuzin
Dihydrochloride, another powerful bactericide having
an elective action for Gram-positive cocci; Choleval
a colloidal silver preparation with a protective col-
loid sodium cholate for use in the treatment of
gonorrhea; Propytal, which is stated to have about
twice the hypnotic effect of Barbital; and Skiabaryt a
special preparation of barium sulphate "for X-ray
diagnosis," which not only can be instantly pre-
pared when needed, but which forms a stable sus-
pension which will not settle for several hours.
Merck's Abstracts will be sent without cost to
(continued one leaf over.)
000000000000000
@Pil. Cascara Compound — Robins®
A, MILD, 1 GR— STRONG, 4 GRS. £^
^^ It is the failure of the secretory function of the bowel, together ^?
with a poor bile secretion, which, in nine cases out of ten, isftw
responsible for constipation. #Ct
Most cathartics altogether overlook this factor and address \9
©themselves solely to a stimulation of the musculature. Some even'^5^
inhibit intestinal secretion. The result is a rapid, unsatisfactory \£
bowel movement, followed by paralytic reaction.
e
Pil. Cascara Comp. (Robins) is a rational therapeutic formula,
@
e which promotes a natural flow of secretions, which is, in turn, the/Sn
e physiologic stimulant of peristalsis. Thus a normal evacuation is^g^
produced, without subsequent inhibition. WWW
©Samples and descriptive literature on request ^fc^
A. H. ROBINS COMPANY Richmond, Virginia f#W
000000000000000
You can buy with Confidence — See "Service Guarantee to Readers" on page 686
September, 1922] The American Physician Advertising Service 669
'!■
If you have not received your copy of
the last Breon's Medical Gleanings, a magazine
devoted to Intravenous Therapeutics, write to
the nearest Breon Branch and a copy will be
sent to you at once.
GEO. A. BREON & COMPANY
New York Kansas City
Chicago Atlanta
Pioneers in Intravenous Therapy
1 1
Mentioning The American Physician Insures Prompt, Careful Service
Hdpful PoinU
/ sr
f 300
GF
NO. M7« OFHCI AP-
PLICATOR
Reflector 12" dlam.
Stand ad] a stable from
high. Coniumei 3TS watts
... 120 Tolti A. C. or D. C. CoTen
300 square Inches 36" from reflector.
FinUh, OllTe and Nickel. Price com-
plete with stand (30.00 each.
NO. MM HAND APPLICATOR
Same design as 0670 only 8" dlam.
ttauumes 200 watts, 120 volts A. C.
_. D. C Hade of Aluminum, weight
IS o*. Finish, Black and Nickel.
Price complete without stand 110.00
.each. Folding Stand onlj for No.
0S40, WOO each.
Write for interesting and Instructive literature
H. O. MeFADDIN * CO.
M Wama Btraet, New York
Maktri «f tiohti*t dtvicti lima iSjf
American Physician readers and copies may be bad
by addressing the publishers, Merck & Co., 45 Park
Place, New York.
A Very Special Offer
Clinicians have found that Dr. R. B. Waite's Ami-
septic Local Anaesthetic is assimilated readily by the
blood, is safe and effective in use.
This month a very special offer is made to Ameri-
can physicians in order that you may test it out in
your own work. Send just 25 cents to pay cost of
packing and shipping, and the manufacturers will
send you a $1 box of hermetically sealed ampules.
This excellent product is sold in both bottles and
ampules, but you will find that the individual am-
pules please patients. Send just 25 cents to Tilt
Antidolor Mfg. Co., 32 Main Street, Springville, N. Y.
Get Your Copy
Have you received your copy of the last Breon'i
Medical Gleanings? This is an interesting magazine
devoted to intravenous therapeutics and will be seat
to American Physician readers on request. Address:
Geo. H. Breon & Co. at the branch nearest yon.
New York, Atlanta, Chicago or Kansas City.
Management of Acnte Gonorrhea
In the management of acute cases of gonorrhea
three important objectives should be kept in mind:
to alleviate pain, to promote diuresis, and to protect
the membrane of the urethra, especially the posterior
The entire urinary tract should be influenced by
means of proper internal medication; local injections
alone are not sufficient.
This is the rationale of Gonosan, manufactured by
Riedet & Co., Inc., 104-114 South Fourth Street,
Brooklyn, N. Y.
A Rational Therapeutic Formula
It is the failure of the secretory function of the
bowel, together with a poor bile secretion, which.
in nine cases out of ten, is responsible for constipa-
tion.
In many cases cathartics altogether overlook this
factor and address themselves solely to a stimulation
of the musculature, and some even inhibit intestinal
secretion.
Pil. Cascara Comp. (Robins) is a rational thera-
peutic formula, which promotes a natural flow of
secretions, which, in turn, the physiologic stimulant
of peristalsis. Thus a normal evacuation is produced,
without subsequent inhibition. Samples and descrip-
tive literature will be sent to Amebican Physician
readers, on request. Address: A. H. Robins Com-
pany, Richmond, Va.
Aids to Digestion
The salivary glands are not immune to the effects
of constitutional conditions accompanying or follow-
ing acute infections or other general disorders, nerv-
ous or glandular. They are not always HP to par,
yet the whole chain of digestive processes is linked
with their proper functioning. Let the patient go
beyond the capacity of the ptyalin -producing glands
in his choice of foods or in his desire to "build np."
and he starts a vicious circle of indigestion that may
have more serious consequences than his former con-
dition. Hence the call for a diastatic ferment that
can be taken with the food to supplement the de-
fective ptyalin secretion. Parke, Davis & Company
(Continued one leaf over)
You can buy with Confidence— See "Service Guarantee to Readers" on page 686
September, 1922] The American P/iytician Advertising Service
100 TABLETS FREE
ACTIVE CATHARTICS OR PURGATIVES THAT PRODUCE A WATERY
STOOL DO NOT GIVE GOOD RESULTS IN
Habitual Constipation
as the digestive secretions are earned off and a period of constipation follows until
the secretions again accumulate and the natural process of digestion and assimila-
tion is resumed.
A mild tonic laxative gives the best result and you can obtain this with Caacara
Coatp. Tableta (Killgore's), as they stimulate the secretions, give an easy natural
movement without griping and do not become ineffective by continued use.
Dose: One or two tablets at night.
100 Tablet* and Formula Sent to Phytjriang on Request
CHARLES KILLGORE
Manufacturing Chemist Established 1874
55 WEST THIRD ST, COR. WEST BROADWAY NEW YORK
Tested Organotherapeutic Formulas in a
New and Better Package
Harrow« "S.nitnbleU" -n,,, Harrower Pluriglandu-
lar Formula! are now supplied
i* friable tablets. Each do*o
is individually wrapped in par-
affined paper — air-tight and
moi*tu re-proof. "SAN1T AB-
LETS" have the aams for-
mula*, liat number* and prices
i* the correaponding Harrower
capiula*. Thi* new form pre-
vent* fraudulent substitution.
u the Harrower "SANITAB-
LETS" cannot be counter-
feited.
5. T. Adreno-Spei-mm Co.
THE HARROWER LABORATORY
Home Office: Boa 68, Glendale, California
NEW YORK. SI Park Flue BALTIMORE, 4 E. Redwood St.
CHICAGO, 1« N. La Sail* St. KANSAS CITY. MO., Til K. C Llf. Bid,.
DENVER. S21 Central Savins* Bank B,J- swwri iim nae «■ p».-i hi—i.
DAL
Mentioning The American Physician Insures Prompt, Cartful Service
672
Hdpful Points
[Philadelphia
Operative
Surgery
Special course in general
surgery, operative
technique and gynecologic
surgery given to physicians
of both sexes. Enrollment
limited to THREE.
First its isantship-- No cadayer or dog -work
For particulars address,
DR. MAX THOREK
AMERICAN HOSPITAL
846.856 Irring Park Bouleyard, CHICAGO
Long Distance Phonas
Laka Viaw 0152-0163-0154-0155
fr
P
NQosalvarsan
(Ncoarsphcnaminc-Mclz)
is unsurpassed in reliability,
trypanocidal efficiency and
ease of administration.
Neosalvarsan is manu-
factured by the process
used in preparing the orig-
inal Ehrlich product and
offers the physician the
ideal means for treating
the luetic.
KMtETZ HBORWMIES, fm
OneSfoentySfoo Hudson JW#,Afr*>Kf*.
fe=
have been supplying such a product for many years,
and of late its diastatic activity has been increased
100 per cent. The name of this product is Taka-
Diastase. The product itself is supplied in powder,
tablet and capsule form, and as a liquid; also in
combination with tonics and other digestive agents.
Samples of Taka-Diastase, together with literature,
are offered by the manufacturers, Parke, Davis & Co.
Detroit, Mich.
Active Vitamines in Virol
The remarkable results obtained by the use of
Virol in infant feeding, for delicate children, and
expectant and nursing mothers, is shown by the
fact that more than 2,500 hospitals, infant clinics and
maternity centers are regularly using this preparation.
The marked improvement in growth and develop-
ment brought about by its administration is due to:
the presence of the vitamines in their active state, the
well-balanced nature of this food, and the ease with
which it is assimilated in the most delicate conditions
of the intestinal tract. •
In view of the extent to which Virol is used in
public health work in Great Britain, the Bio-Chemical
Laboratory of the University of Cambridge recently
conducted an exhaustive investigation to determine
whether the vitamines known to be present in the
raw materials from which Virol was manufactured,
were present in their active state in the manufactured
Virol as sold to the public. The report which fully
proves the presence of the vitamines in Virol will be
sent to American Physician readers, on request Ad-
dress : Geo. C. Cook & Co., Inc., 59 Bank Street, New
York.
Leader of Mulf ord Amazon Expedition Tells of
Locating Rare Medicinal Plants
An absorbing story of the successful search for
strange narcotics and new drugs which may prove
of invaluable aid in the treatment of human diseases,
and the determining of the botanical sources of both
the genuine and spurious forms of certain drugs
already partially known, was told by Dr. H. II.
Rusby at a recent dinner given to the returned mem-
bers of the Mulf ord Biological Exploration by the
H. K. Mulford Company, at the Manufacturers' Club,
I hiladelphia.
Originally planned only as a personal testimonial
to Dr. Rusby and his associates, who had carried out
the work of the expedition with so much enthusiasm
and in spite of dangers and discouragements, it de-
veloped into one of the most significant gatherings
of scientists.
In addition to the guests of honor, there were
present some fifty men, leaders in medicine, phar-
macy, botany, zoology, as well as captains of industry.
Milton Campbell, president of the H. K. Mulford
Co., who presided, reviewed the history of the ex-
ploration, its inception in Dr. Rusby's mind, the pres-
entation of the plans to the Mulford Company, and
why the Mulford Company availed itself of the op-
portunity to support such an enterprise. He pointed
out that, throughout its existence, the Mulford Com-
pany had contributed, so far as lay within its power,
toward the advancement of the professional side of
pharmacy, and had done its best to disseminate in-
formation concerning pharmaceutical and biological
products. In this exploration the company had s^n
and grasped the opportunity to make another con-
tribution to this end. The fact that it had volun-
tarily relinquished any control over the results, which
(Continued one leaf over)
You can buy with Confidence — See "Service Guarantee to Readers" on page 686
The American Physician Advertising Servio
vtwq
^=
New and Important
from our Biologic Laboratories
A Safe, Efficient and Convenient Product for Non-Specific
Therapy
Lactigen — a milk protein solution for intramus-
cular injections. Prepared from the milk of
tuberculin-tested cows, sterilized while still
fresh. Supplied in 5-Cc. ampules.
Lactigen answers the most exacting require*
menu of protein therapy as successfully prac-
ticed in Europe by Bruch, Muller, Forster and
many other physicians of note, and now attract-
ing wide interest in medical centers abroad.
Good, even remarkable, clinical success, is re-
ported in the treatment of —
Artnritu, neuriti», Soft chancres, nicer*,
Hemorrhagic diatnati*, purpura Fanincoloiu, ana, harps*.,
Epididymiti*, bnba, Chronic ibicnui, ale.
Stimulates leucocytosis. Mobilizes the defensive
forces (antibodies) of the body. Lactigen in-
creases the red blood count when deficient.
Doctor, try Lactigen in your next case of anemia
or arthritis and report results.
Net Price: per box of 6 ampules, $1.20
St* that fur drnrr,iit '• ttiekwl wffli Cslttirona fir -oar prsseribiBg eemiiriM.
THE ABBOTT LABORATORIES
San Francisco
Par Prlcw In Canada, Apply to Our Canadian Branch, BT Colbcrn. St., Tor.
Jt
Mentioning The American Physician Insurer Prompt, Careful Service
674
Helpful Points
[Philadelphia
il
Often Overlooked
ADHERENCE to some
J\ pet theory of baby feed-
ing may blind a physi-
cian to its fallacies, or bias
his viewpoint so that they
are overlooked.
Physicians who insist upon
die home modification of
cow's milk sometimes fail to
consider the inability of the
average mother to follow
properly a complicated for-
mula. They overlook the pro-
bability that the purest milk
may sour in hot weather, be-
come tainted by other food in
a refrigerator, or be contam-
inated through carelessness.
You can eliminate these dan-
gers for your patients by
prescribing a food of pro-
tected purity which is easily
prepared by the most inex-
perienced mother and which
can be kept pure under the
most trying conditions.
NESTLE'S MILK FOOD
is pure cow's milk modified
by the addition of malt, cer-
eals, and sugar and then
reduced to powder form. It
is milk, free from pathogenic
bacteria, in a form which is
easily prepared and readily
digested.
Send for free nmples to Nettle'i
Food Company, Nettle Building,
New York City, or 112 Market
Street, San Francisco.
NESTLES
MILK
FOOD
are to be freely donated to science, has resulted in
the heartiest co-operation on the part of government
bureaus, colleges and institutions of learning.
No Stomachic Rebellion
You will not encounter stomachic rebellion if you
use Benzylets — gelatine globules, each carrying fire
minims of medicinally pure benzyl benzoate.
Benzylets are manufactured by Sharpe & Dohme
and can be had in boxes of 24. They are non-
narcotic, non-toxic, analgesic — antispasmodic in pain
and spasm of unstriped muscles.
A New Non-Narcotic Drag
Allonal, a new non-narcotic drug, is both hypnotic
and analgesic. It is administered orally in tablet
form and is a prompt, efficient sedative, hypnotic and
analgesic, capable of controlling pain and producing
sleep in the many conditions in which morphine and
other narcotics have hitherto been used.
Supplies and literature will be furnished to
American Physician readers on request. Address:
The Hoffman- La Roche Chemical Works, New York
City.
Course in Operative Surgery Open
A special course in general surgery, operative tech-
nique and gynecologic surgery is open to three physi-
cians—either sex. There is no cadaver or dog-work—
the nature of the work is first assistantship. For
particulars address: Dr. Max Thorek, American Hos-
pital, 846-856 Irving Park Boulevard, Chicago.
For Mother and Child
It is of the utmost importance that the expectant
mother have an adequate supply of the vitally neces-
sary mineral salts in her diet during the period of
utero-gestation and lactation. The foetus acts as a
mineral parasite; if the mother's diet is deficient in
mineral salts imperatively demanded for the develop-
ment of the mineral structure of the child, the defi-
ciency is made up at the expense of the mother's tis-
sues. This brings about a corresponding loss of
vitality, both for the mother and her prospective
offspring.
For this reason a liberal quantity of Grape-Nuts
with milk or cream will be found a valuable part of
the diet of the expectant mother, because of its
content of mineral salts as well as its high food
value.
Samples of Grape-Nuts for individual and clinical
test will be sent to American Physician readers. Ad-
dress Postum Cereal Company, Inc., Battle Creek,
Mich.
For Diabetics
Lister's Diabetic Flour offers a strictly starch-free
flour from which can be made bread, muffins, pastry,
etc. With this you can lessen the distressing features
of diabetes and know that your patient will not be
getting any starch. This flour is put up in convenient
form, one box for each day — a month's supply of
30 boxes $4.85. Order from or write for further
information to: Lister Bros., Inc., 405 Lexington
Avenue, New York City.
Its Formula Shows Its Value
A glance at the formula of Pneumo-Phthysine will
at once suggest its mode of action and the numerous
indications for its clinical application: Guaiacol, 2.6;
(Continued one leaf over)
You can buy with Confidence— See "Service Guarantee to Readers" on page 686
The American Physician Advertising Service
Liquid Petrolatum
in Dyschezia
Liquid petrolatum has distinct value In the treatment of dyschezia (rectal con*
stipation) , particularly following surgery. An authority of international note
points out that the effect of the anaesthetic and traumatum often cause an
unavoidable dliturfiance of nerve plexi and induce an obstinate variety of
constipation. He state* that liquid petrolatum It the logical at well a* the
effective treatment, since it prevent* drying omt of the feces, help* re-establish
normal regular defecation, absorbs and removes toxins.
NUJOL offers unsurpassed
advantages of viscosity,
purity and suitability in all con-
ditions of intestinal stasis.
The viscosity and specific grav-
ity of Nujol were fixed upon
after exhaustive research and
clinical test, in which many con-
sistencies were tried, ranging
from a thin fluid to a jelly. The
viscosity of Nujol is closely
adapted to human requirements
and is in accord with the opinion
of leading medical authorities.
That the value of Nujol to the
medical profession is generally
recognized is attested by its use
by physicians and in hospitals
the world over.
Sample and authoritative litera-
ture dealing with general and
specific uses of Nujol will be
sent gratis upon request
Djachewle— A, dilated
ampulla of rectum; B, fay-
pertrophiad rectal valve;
C, eigmoid.
■nun "Di'eoaeo* of tho ZVgee-
tiro Orgeat,"
by Chas. D. Aaron,
Se.D.,M,D. F-AC.P.
For Constipation
Nujol
A Lubricant; not a Laxative
A NORMAL COLON
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
You Can Depend on
ENESOL
(Salicyluiiuale of Mticury)
to cause a rapid disappear-
ance of the Syphilitic mani-
festations.
Owing to its low toxicity ( 70
times less than Bin iodide of
Hg. ) it can be given in much
larger doses than other mer-
curials.
Complete absence of pain
and no local irritation make
it the ideal mercury-arsenic
combination for intravenous
or intramuscular use.
Wrilt for tampla, IHaalatt and
E. Fougera & Co., Inc.
! l-vn ■.. FPA-.I i '
formalin, 2.6; creosote, 13.02; quinine, 2.6; methyl
salicylate, 2.6; glycerine 2nd aluminum silicate <js.
1(100 parts; aromatic and antiseptic oils qs.
The antibacterial properties of all the drugs con-
tained in Pneumo-Phthysine are well established;
in addition, guaiacol and quinine tend to reduce fever
temperature; methyl salicylate lessens pain, and qui-
nine also promotes healing. Pneumo-Phthysine is in-
dicated in all localized and painful inflammatory con-
ditions. For further information address: Pneumo-
Phthysine Chemical Co., Chicago, III.
TAUROCOL COMPOUND TABLETS
"\=
THE PAUL PLESSNER CO.
J3
Yeast Has Definite Value
When appetite cannot be stimulated by exercise,
as is often the case with invalids, and yet the appe-
tite must be increased, more food ingested and the
plane of metabolism raised, yeast has very definite
Many foods fail in such a situation because the
vit amine they contain is associated with substances
rich in calories. Yeast offers a means of furnishing
a relatively large quantity of the water-soluble vita-
mine, together with a comparatively small propor-
tion of calories. Good appetite is necessary to the
liberal consumption and complete digestion and ab-
sorption of food, which, together with prompt evacua-
tion of undigested residue from the intestine, is ab-
solutely essential to health and vigor. Yeast will aid
this complete process.
A recently published brochure on the therapy of
yeast and its manufacture, physiology and chemistry,
will be sent to you on request. Turn to page 623 and
send in the coupon.
A Complete Milk Food
Nestle's Milk Food is pure cow's milk modified by
the addition of malt, cereals and sugar and then re-
duced to powder form. It is milk, free from patho-
genic bacteria, in a form which is easily prepared and
readily digested.
By prescribing Nestle's Milk Food you can avoid
the danger of failure to follow a complicated formula
in modifying cow's milk in the home, and the danger
of the use of sour milk or milk tainted by contact with
foods in the refrigerator, or other contamination. It
offers a food of protected purity which is easily pre-
pared by the most inexperienced mother and which
can be kept pure under the most trying conditions.
Samples will be sent gladly to American Pbtsiciaii
readers. Address: Nestle's Food Company, Settle
Building, New York City, or 112 Market Street, San
Francisco.
Drug Addiction Can Be Cured
Drug addiction is one of the most troublesome con-
ditions which confront the physician. The great ma-
jority of physicians have not been able to get suc-
cessful results in these cases, and yet, as a matter
of humanity, we cannot turn the victims away with-
out the best we are able to give them.
Dr. Chas. H. Quayle has made a study of the
treatment of drug addictions and alcoholism, and i;
able to get gratifying results in most cases. His treat-
ment is painless and supportive, rather than depres-
sant. No nervous period is experienced. Physi-
cians can send patients to Dr. Quayle's sanitarium,
or in cases where home treatment is desired Dr.
Quayle furnishes his treatment for the physician to
use at home.
Write to Dr. Chas. H. Quayle, Dept. 505. Madison
Ohio, tot full particulars.
(Continued one leaf over)
i buy with Confidence — See "Service Guarantee to Readers" c
September, 1922]
The Americn Physician Advertising Service
677
Had Infantile Paralysis
— now plays ball, roller skates and swims
This child would have been a hopeless, helpless cripple for life
if the family physician had not fitted him with a Philo Burt
Spinal Appliance. Here is what the doctor says:
A Typical Case
'Enclosing cheek for wsrk don* sn
jacket for Alrah Bend. The work
is well done and no to jour osaal
standard of excellence. Toa were
especially prompt and joar charge,
too. Is most rratifjriitffly reasonable:
I thank 70a. I placed the Philo
Bart Appliance on Alrah last Jane
and torether with the exercises yon
sot-rested •■»* the treatments he
receired here at the office, I feel
thoroojrhly justified in Hsvln* pat
it on him. The canratare itself b
impossible of correction, beftnft* an
extreme lateral earratare from In-
fantile Paralysis, the apex of the
earratare beta* under the scapola.
Since wearln* the Appliance I hare
retten him tradaally to playing;
ball, roller skatinjr, and harta*
reached the matare ace of twelre,
he is now a Boy Scoot and a mem-
ber of the Y. If. C. A., where he is
tsJdnjr swtmmins; lessons. The Ap-
pliance tires him rood support and
at the same time allows him to be
more acthre and be like the other
boys who hare rood backs. I shall
feel ae hesitancy in plaeinr yaur
appliance whore it is in any decree
indicated.'*
WE MAKE THE PHILO BURT APPLIANCE
ORDER FOR ANY CASE AND SEND IT ON
The Appliance lifts the weight off the spine and
corrects any deflection in the vertebrae. It does
not chafe nor irritate ; weirhs ounces where other
supports weigh pounds and is easily adjusted to
meet improved conditions where the spine is
straightening and the body is resuming its normal
shape and form. It can be taken off in a moment
for bath, massage, relaxation or examination and
put on again just as quickly. Does not show
TO
30 Day Trial
through the clothing. We are anxious to co-operate
with local physicians, and will send without charge
our Physicians' Portfolio of letters from doctors
who know by experience. Let us explain our plan
of hearty co-operation with the physician in charge.
We guarantee perfect fitting from your measure-
ments and refund money paid us if either doctor
or patient is dissatisfied at the end of 30 days.
PHILO BURT CO., 115-18 Odd Fellows Temple
Jamestown, N. Y.
TO REDUCE HIGH BLOOD PRESSURE
without disturbing digestion, or irritating the kidneys, and to maintain
vascular tension at a safe margin, as well as to strengthen and sustain the
heart.
Pulvoids Natrium Compound
is rapidly increasing in use among progressive physicians.
Send for free special booklet on Hypertension and how to treat it.
Salvarols Suppositories
Rectal
require no technique and obtain
action and results equal or superior
to arsphenamine intravenously in-
jected.
Pulvoids Aurazyme
No. 418
in conjunction with other indicated
measures secure satisfactory results
in diabetes mellitus. A trial will
convince.
Interesting literature, case reports, price lists and our little periodical, "Drug
Products," will be sent to any physician, gratis, on request.
THE DRUG PRODUCTS CO-, Inc.
150 MEADOW STREET LONG ISLAND CITY, N. Y.
Mentioning The American Physician Insures Prompt, Careful Service
Hdpjul Points
Pluto Water
lias been iucccu fully employee]
and endorsed by the Medical
Profession as a uric acid sol-
vent and »lim!n»ring agent in
renal disorders; prompt, safe
and efficient and well retained
by the mott delicate stomach.
Many practitioners direct con-
valescent patients to the spring
for rest and complete treat'
Rwk LU Sprit* hW U
Franch Lick I"i
« STORM «
Binder and Abdominal Supporter
For Men, Women and Children
For Ptouj, Hernia, Obesity. Pregnancy,
Relaxed Sacro-lliae Articulation.. High
and Low Operation!, etc
Ask }<* 36 paf Dettripltet Folder
(Catherine L. Storm, M. D.
1701 Diamond St.
Philadelphia, Pa.
Rational Procedure in Infantile Diarrhea
A rational procedure in summer diarrhea for infants
of any age is to give the following mixture: Mcllin';
Pood, 4 level tablespoonfuls, and water (boiled, then
cooled), 16 fluid ounces. Of this give one to three
ounces every hour or two, according to the age
of the baby, continuing until stools lessen in num-
ber and improve in character.
Each ounce of this mixture has a fuel value of 62
calories and furnishes immediately available nutri-
tion well suited to spare the body protein, to pre-
vent a rapid loss of weight, to resist the activity of
putrefactive bacteria and to favor a retention of fluids
and salts in the body tissues.
When stools have lessened in number and improved
in character, milk, preferably skimmed, may be sub-
stituted for water — one ounce each day — until regu-
lar proportions of milk and water, adapted to the
age of the baby, are reached.
Pluriglandular Formulas
The Harrower Pluriglandular Formulas are now
supplied as friable tablets. Each dose is individually
wrapped in paraffined paper — air-tight and moisture-
"Sani tab lets" have the same formulas, list num-
bers and prices as corresponding Harrower capsules.
You will find S. T. Adreno-Spermin Co. (Harrower)
indicated in asthenia, low blood-pressure, snboxida-
tion, subnormal temperature and other conditions re-
quiring adrenal support.
For further information address the home office,
The Harrower Laboratory, Box 68, Glendale, Calif.
A Reconstructive, Tonic and Restorative
Injection Clin (strychno-phosporsine) is a recon-
structive, tonic and restorative. It supplies thera-
peutically active phosphorus, arsenic and strychnine—
for intramuscular or subcutaneous injection. Sold Id
boxes of 6 and 12 ampoules, also in solution for
Literature and samples will be sent to Amekjcas
Physician readers, on request. Address: E. Fou-
gera & Co., Inc., 90-92 Beekman Street New York
City.
In Treating Asthenia
Suprarenal insufficiency is one of the marked fea-
tures of the asthenias. The blood pressure in these
individuals is almost always low and the circulation
poor. The activities of other glands of internal secre-
tion are always impaired. That is why pluriglandular
therapy gives better results than suprarenal substance
given alone.
Hormotone is a combination of thyroid (1/10 gr.).
entire pituitary (1/20 gr.) ovary and testis, and pro-
motes oxidation, increases blood pressure and enhances
metabolism by producing suprarenal efficiency.
For further information address: G. W. Carnrick
Company. 419 Canal Street New York
(Helpful Hints continued one leaf over)
Woodlaum
Maternity Home
A Miictlr priTate and
for unmarried M u . .
nancy and confinement, with beat medical
care, nnrnnj and protection. Abomefaond
for the infant by adoption if A * ""
publicity aroided. Price* reaeo
particulara, nricca and tenna, ad
WOODUWK, OWEGO, Tlo*a Co. H. *
You can buy with Confidence— See "Service Guarantee to Readers"
September. 1922) The American Physician Ajhertumg Service
The Nurse's Comfort
— next to that of the patient — is always to he kept in mind and
should be provided for.
Take alcoholic massage for instance.
Some (most) "rubbing alcohols" have a repelling odor,
equally distasteful to the patient and the nurse.
Not so with "Alkolave."
It has the clean, pleasing odor of grain alcohol; it is grain
alcohol specially denatured.
Salutary externally— poisonous internally.
In 4-oz. and pts. only; at most good drug stores.
Particular physicians prescribe it. Do you?
"ALKOLAVE"
Sharp & Dohme
Ask a fair number of fellow practitioners:
"What is your preferred prescription in Hem-
orrhoids?"
And note how many unhesitatingly reply:
"Anusol Suppositories."
Ample Trial Quantity and Information on
Genuine Anusol Suppositories
from
SCHEREMG & GLATZ, Inc.
ISO Maiden Lane NEW YORK
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
(PhiUddpiiu
Isotonic
Bacteriologists always find that
ANTISEPTIC
LOCAL ANAESTHETIC
is assimilated readily by the blood.
Sold in bottles and ampules. The
ampules are hermetically scaled — won't
deteriorate — will keep indefinitely. Are
ready to use. The individual ampules
please patients.
$1.00 box for 25c
THE ANTIDOLOK MFG. CO.
32 Mud Street, Springvill*, N. Y.
In Childhood
Thoughtful physicians appreciate the benefits from
wearing O'Sullivan's Heels, in childhood. The light,
springy step, the delightful resiliency, and the avoid-
ance of shock and jar, naturally mean much to lilt
active boy or girl.
The child who wears OSultivan"s Heels will be
happier and healthier, the structures of the feet will
be strengthened, the gait and carriage improved and
a marked decrease of nervous irritation or excessive
fatigue will result. Thus O'Sullivan's Heels have
come to fill a definite place in the hygiene of child-
Pure Supply of Salicylate Assured
R. W. Proctor, secretary of the Wm. S. Merrill Com-
pany, after presiding as chairman of the Scientific Sec-
tion of the American Drug Manufacturing Associa-
tion, recently held in New York City, went up ir;.o
Connecticut to supervise the construction of another
birch oil distillery. The Merrell Company already has
several of these distilling plants in Connecticut, where
they distill the birch oil which they use in the manu-
facture of the true, natural salicylate. They have had
to distill their own oil to make sure of obtaining a
product which is undoubtedly genuine, for in their
experience it has been practically impossible to obtain
pure, natural oil in the open market
Physiological Effect of Alkalol
t is to be regretted that the average doctor does
devote more time to a study of the histology
well as the pathology of mucous membranes, be-
ise in such event he would realize to a greater
ent facts which would enable him to get belter
nits from his treatment of irritation or inflam-
tion of these structures. A mucous membrane im-
:s that it is a secreting membrane that the secretion
poured out by its cells forms, when in normal condi-
tion, the best antiseptic solution that can possibly
that particular mucous membrane. Irri-
ither in a suppression
ir a hypersecretion, or
it the mucous mem brine
of such conditions the first
clean off the mucous sur-
Pli
tation or inflammati
or deficiency of such
catarrb. In either
surfers. In the treati
indication is naturally
(Continued one leaf over)
MORPHINE
Drug Addiction*
Treated by the "Q&xyU ffAtthol"
Atafe andeuy way. Reiuio guanumed-
Timbmm k Mini™ ana nipponiM, inWrhm
depw—nt. No namxH pmod bhoibL I
•Uo (iimiih a I iarx TMml for rMdiu »
dh in tnaii&g ■ddim « bam*, who far nhau
For fiUt prrtitxiantidrra
DR. QUAYLE SANITARIUM
OwR Quark MJ)., M^id Di™a«
Dept 505
You can buy with Confidence— See -'Service Guarantee to Readers" on page 6
Stpttmh*!-, i«2] The American Physician Advertising Service
/^TESTOGAN THELYGAN^s
For Men For Women
Formula of Dr. /ic-oii Block
After seven years' clinical experience these products stand as proven specifics.
INDICATED IN SEXUAL IMPOTENCE AND INSUFFICIENCY
OF THE SEXUAL HORMONES
They contain SEXUAL HORMONES, i. e., the hormones of
the reproductive glands and of the glands of internal
Special Indications for Testogan: Special Indications for Thelygan:
Sexual infantilism and eunuchoidism in the Infantile sterility. Underdeveloped mam-
i t_ -. j i ~t mae, etc. Frigidity. Sexual disturbances m
male. Impotence and sexual weakness. obfs'jty and 0?her metabolic disorders. Cli-
Climacterium virile. Neurasthenia, hypo- macteric symptoms, amenorrhea, neurasthe-
Chondria. nia, hypochondria, dysmenorrhea.
FimUM in TABLETS lor Internal bm, and in AMPOULES, far Intraflutaal Inaction.
Taataau ud Tbc-l/tan Tablata, 40 In a box, S1.7S. Taataau Amawilaa, 13 la a box. »1-W
Tbalraan Amnaulaa, 20 to a box, M.0O
EXTENSIVE LITERATURE ON REQUEST.
CAVENDISH CHEMICAL CORPORATION
Sole Agents.
296 Panrl Street Established 1905 Nnw York
To ALLEVIATE PAIN, to PROMOTE DIURESIS
and to PROTECT the membrane of the urethra, especially
THE POSTERIOR PORTION— these are the important
object! of the treatment of acute casca of Gonorrhea.
This it die rationale of GOHOSAN.
RIEDEL & CO., Inc.
104-114 Sooth Fourth St. Brooklyn, N. Y.
ABETIC FLOUR
jtarch-free. Produces Bread.
Muffins. Pastry that makes the
distressing features
TEi
Grow
Less and
Less ■
Lnteri prepared caiein Diabetic Flour — self rising. A month'i Mipply of 30 boxei $4.85
LISTER BROS. lie. 405 Lexington Avenue, New York City
Mentioning The American Physician Insures Prompt, Careful Service
Hdpful Points
A Stand-By in
Uterine Troubles
VIBURNO
(BEACH)
The best evidence of this ia the
repeat orders received from physi-
cians and druggists.
Nervine-Tonic and Anocongest-
ive, with calmative and corrective
action on the bladder. Employed
with much satisfaction in ovarian
congestion and congestive dysmenor-
rhea; weak pregnancy and deficient
lactation; menopause and its phe-
nomena, including hallucinations, hot
flushes, etc.; nervous and menstrual
derangements after "flu," and the
troubles of adolescent girls. Sterility
often responds after 2 or 3 bottles if
no lesion exists.
Unliko similar product., VIBURNO
Domi
(undiliitod) U.S.
Pol ijlii 11 t
THE VIBURNO COMPANY
116 lflaiaoa La**, Now York
Sal Hepatica
THE
STANDARD SALINE
LAXATIVE
Bristol-Myers Co.
NEW YORK
face by using something that will not overstimaUtc
the cells and further irritate them. This done, how-
ever, there remains the most important part of the
treatment, a part which is commonly neglected or
omitted by many physicians. The mucous mem-
brane cells when irritated or inflamed are unable 10
elaborate the normal constituents of their secretion.
They become depleted of certain physiological salts-
They either become lazy or over-active. Their blood
supply is altered and in the majority of cases the
tissue surrounding them becomes relaxed or loses
tone. The ordinary antiseptic solution does not
remedy these difficulties. On the other hand, Alkalol
meets the various indications present because it was
conceived and worked out to accomplish certain
definite actions and effects. Chief among these is
the fact that it feeds the depleted cell with salts to
help itself to get back to its normal secretory func-
tion. Its alkalinity has been carefully adjusted and
its proper salinity worked out so that the solution as
used does not overstimulate or unduly deplete. Its
specific gravity is purposely made hypotonic in order
to reverse abnormal, osmotic outflow. In addition
to which, Alkalol is soothing and healing to a degree
and produces what is best known as a "freshening''
action and effect upon mucous membranes.
A request to the Alkalol Company, Taunton, Mass..
will bring a sample of this product, together with
interesting literature, etc. Write for it.
Dr. Clarence Martin says : Do not use cocaine in a
traumatized urethra. Dangerous absorption is too
marked a possibility.
SRrFFITH'S COMPOUND MKTUHE
of CnmiT, Stilling!*, ate
A Powerful Alterative— Composed of Guaiac,
Stilling, Prickly Abo, Turkey Cora, Colehicum.
Bluet Cohosh, Sanapsrilla. Salicylates of the Alka-
lies, Iodide ot Potassa and other well known reme-
by all patients suffering from Rheumatism. Coot.
Lumbago, Neuralgia, Sciatica, etc
Proserin* it for "That Stubborn Cue"
To Physicians only — we will upon request, acrid a
regular eight ounce bottle ($l.2s size), for trial,
upon receipt of 25 cents for express charges,
Griffith'*. Rhewntk Remedy Coatpu
Nowburgh, Now York
POND'S
Extract
Foot Soreness
EEstte.'Vi
il than a liberal
o-ingency rapidly
i buy with Confidence — See "Service Guarantee to Readers" on page 686
September. 1922] The American Physician Advertising Service
T? VERY DAY doctors are advising a rest, a trip to a sanitarium, a visit to
■*-'a specialist, an operation — anything to get rid of their old, stubborn cases of
Prostatic Disease and Impotence
to ray nothing of the laiiifaction of having turn a hard fight.
offer nothing but promises and frequently five (em.
YOU CAN GET RESULTS
in many of these an If you will try SUPPOS. PROSTANS thoroughly in one or two cases you will surely
convince yourar.li and will thereafter kitp tht buiinrti xou'vt bttn turning away.
There is nothio. aecrel aboul Supfos. Prcitans— [of mula with each box.
If .tier a fair clinical te*t you feel Ibat the results do not more than meet alt your expectations, we hereby
agree to refund your money upon request This offer places the burden of proof upon us «r our own expense.
Remember, Doctor, (bat your immediate order means a dear laving of M to you. Il seem* a duty to
Fill out tbe coupon now. Sincerely,
REGENT DRUG COMPANY
Thii Con
REGENT DRUG COMPANY.
3152 Woodward Ave., Detroit, Micb.
1 enclose $5.00. (end me six boxes of
Snppoa. Ptoatani (worth $9.00) alio
the above book and "Successful Prosta-
tic Therapy" — free.
1 u Will, Fit
1 It 0*1. Send Today.
The Borates ol Prt.nl Raau Upea Us.
Mentioning The American Physician Insures Prompt, Lareful Server
684
Helpful Points
[Philadelphia
Amenorrhoea
Dysmenorrhoea
and other disturbances of the
menstrual function call for the
t*ue active principle of Parsley :
APIOLINE
(Chapoteaut)
It Secures Results
by acting directly upon the uterine
nerve endings and producing ovarian
hyperemia, but without disturbing
gastric or renal functions.
Aroid impure or unreliable substitute*.
Prescribe original vials of 24 capsules.
Laboratory of
Dr. Ph. Chapelle, New York-Paris
Physician* sample and literature on request to
E. Fougera oV Co., Inc., American Agents
90 Baekmaa Stmt, Now York
Canada; Lyman* Limited, Montreal
A FS A T ^C0* tooh ).
*" CJixJ-/ Diacctyl Methylene-disalicylic Acid.
UNQUESTIONABLE REMEDY FOR RHEUMATKM.
Price, 75 cents per Box.
AN
BEFSAL
QbHmOu
Dibcnzyldictbylmcthylenedisalicylic Dip-
yruvic (Cinchoninic) Acid. AN EFFICI-
ENT AGENT FOR THE DESTRUCTION OF THE RHEUMATIC
POISON AND A SOLVENT OF URATIC DEPOSITS.
Price, $1.00 per Box.
CREASEP
CuHmOioIs
Diacet Benzylidenedibenzyldiethyl
MethylenediiododiRUaiacol. Contains
25% of Iodine. VALUABLE ALTERATIVE AND ANTISEPTIC.
ESPECIALLY USEFUL IN INFLUENZA, PNEUMONIA, BRON-
CHITIS AND PULMONARY TUBERCULOSIS.
Price, $1.00 per Box.
IODOMER
(ICioHiOOsHg
Mercury-Diiododiaryl. Holds
25% Mercury and 20% Iodine in
organic combination susceptible of circulating in fluids of body to react
on the spirochetes of syphilis. AN ALTERATIVE OF MARKED
VALUE. Price, $1.00 per Box.
CmH«N«0*
PYR-AZO-PHEN j>xj~
Benzol Methylene Disalicylic Dicinchoninic Acid. FOR NEURITIS
OF GOUTY ORIGIN AND FOR RHEUMATISM AND GOUT.
Price, $1.00 per Box.
ARS AMINE
AsCwHn04)«
DIARYL-DIARSONATE.
CHEMICALLY ANALO-
GOUS TO SALVARSAN. BUT CAPABLE OF ADMINISTRA-
TION VIA THE STOMACH. Price, $1.00 per Box of 30
Capsules of 2>£ Grains Each.
DR. S. LEWIS SUMMERS
Produow of
Synthetic Organic Chemical Compounds
Fort Washington, Penna.
I
These Advertising Pages are
A Constructive Market
Plmee Where Yarn Cem Deed WXk
We beUeee the rwhi Idmi
mseMtotke
op {Mel reemwe*
We
utmb
Our Advertising Standards
Advertisements must give honest service to our
readers and their patients is the basic principle for these
standards and for the conduct of The America*
Physician's advertising pages.
Our attitude in applying these standards is not one
of narrow technicality but of practical service.
Advertisements of the following classes are not
acceptable for the pages of The American Physician:
Fraudulent pharmaceuticals; those making dishonest
claims.
Pharmaceuticals charging excessive price; price not
warranted by content and by trade conditions.
Pharmaceuticals and other mixtures for internal use
and containing narcotics or other habit-inducing drags
in quantities sufficient to promote their improper repeti-
tion on prescription (chloral-bearing proprietaries, etc).
Potent pharmaceuticals which justly merit profes-
sional disapproval because of their lay advertising or
manifestly unethical exploitation.
Financial advertisements that claim returns not com-
patible with conservative investment. Only conserva-
tive investments are advertised.
Further
Advertising copy is subject to revision by the editorial
staff. .
The American Physician agrees heartily with the
principles of the Council on Pharmacy and Chemistry
of the American Medical Association and we exclude
from our advertising pages such pharmaceutical prod-
ucts as they have definitely shown to be unworthy of
professional confidence and the manufacturers of which
have not removed the cause of objection; but we do
not accept such findings as are based on academic data
without due recognition of general clinical experience.
Concerning formulae, The American Physioax is
urging pharmaceutical manufacturers to give full thera-
peutic data regarding formulae, stating quantitatively
active medicinal content, in order that physicians may
intelligently prescribe. We do not accept advertising of
secret pharmaceuticals.
But We do not Decline
Advertising of original drugs, compounds or PreP*rati2P'.J5l
tated in current editions of the U. S. Pharmacopoeia or >*S2.
Formulary (except habit-inducing preparations); new PJ°™2
that seem to be honest and valuable, but which nave not Deea
reported upon by the Council on Pharmacy and C^^*"^'^
similar products whose manufacturers have not yet submitted"*
same to them for approval or rejection. We use our own rear
ment in these cases, but will always consider proper cnarfw
against this class of remedies.
Preparations containing a limited number of drug* in
(Continued one leaf over)
You can buy with Confidence— See "Service Guarantee to Readers" on page 686
September, 1922] The American Physician Advertising Service
A glance at the formula of PNEUMO-PHTHYS1NE
will at once suggest its mode of action, as also the numer-
ous indications for its clinical application. The anti-
bacterial properties of all the drugs contained in
PNEUMO-PHTHYSINE are well established. In addition,
guaiacol and quinine tend to reduce fever temperature;
methyl salicylate lessens pain; quinine also promotes
healing.
PNEUMO-PHTHYSINE is indicated in all localized
and painful inflammatory conditions.
The (act that all the active drug* contained in PNEUMO-PHTHYSINE are readily
abiorbed through the akin; that they are taken up into the circulation and exert their
characteristic effect*, both locally and aytc statically, will be diicuued in detail in the
Fall, 1922, iuue of Enderrnic Medication, which will probably appear early in September.
A'k for your copy no*-
Pneumo-Phthysine Chemical Co. Chicago. 111.
Mentioning Tht American Physician Insures Prompt, Careful Service
Helpful Points
Used the World Over
Marvel Whirling Spray
MARVEL COMPANY
2E W. 45th Street New York
Oar Advertising Staidardi
ICoitlinnld avtr from pr tctdixg pant]
lure and in such form ■■ may parallel a prescription writs bji
qualified physician who is seeling in the proprietary foia fkji*
pharmacy in place of in exlemport prescription.
dosage, provided these drugs have a real place in medical butt
ture and are well defined in materia media, since nan; ftot-
aands of physicians esteem them despite pharmacologic dm
Service Guarantee to Readers
IF YOU HAVE ANY UNSATISFACTORY
DEALING WITH AN ADVERTISER IN THE
AMERICAN PHYSICIAN, WRITE US THE
PARTICULARS AT ONCE.
WE WILL IMMEDIATELY TAKE THE MAT-
TER UP WITH THE ADVERTISER AND SEE
THAT THE ADVERTISER EITHER MAKES
GOOD, OR HIS ADVERTISEMENT IS ELIMI-
NATED FROM THE AMERICAN PHYSICIAN'S
PAGES.
WhyAlkalol?
Because, instead of overstimulating mucous membrane cells,
relaxing tissue and lowering vascular tone, ALKALOL "feeds" depleted
cells with physiologically necessary salts, tones up relaxed tissue,
restores vascular balance.
Hence, in irritated or inflamed conditions of the eye, nose, throat,
mouth, urethra, bladder, vagina, rectum, as well as of the skin,
ALKALOL
brings prompt relief by its soothing and healing properties, and,
in addition, assists natural forces to bring about a return to normal, by
helping the cells to help themselves.
ALKALOL secures results un-
obtainable by other medicine.
PROVE IT
by sending for sample
THE ALKALOL COMPANY
and "Reason Why" literature.
Taunton, Maw.
You can buy with confidence— See "Service Guarantee to Readers" top of this page-
September, 1922]
The American Physician Advertising Service
687
Outing hfection.
Summer Uses
ofDioxogen
A» an Antiseptic
For cuts, lacerations, abra-
sions, and all open wounds.
As a Lotion
For ivy poisoning, sunburn,
chafes, and skin irritations.
As a Spray and Gargle
For colds, sore throat, eye
infections and as a mouth
cleanser.
As a Compress
For strains, sprains, contus-
ions and swollen muscles.
As an Internal Remedy
For gastro - intestinal ills,
diarrhea, etc, from changes
in food and water.
As a Water Purifier
For routine addition to all
drinking water used from
brooks, springs and wells.
Many a physician has
saved an outing from
ending badly by his
advice to carry a supply
of Dfoxogen in the first
aid kit
Directions
Locally — A teaspoonf ul of
Dioxogen to five to eight of
water makes an ideal anti-
septic lotion.
Infernally — One half to a
teaspoonful of Dioxogen
well diluted, stops fermenta-
tion, gastric irritation and
pain at once.
are complications that— like specters at
the feast— always stand ready to spoil the
annual vacation that means so much to
those who live and work in the city.
Simple cuts or abrasions, the bites or
stings of insects, a severe sunburn, derm*
iritis from poisonous shrubs, are all apt
to lead to graver conditions, if neglected
or improperly treated.
Medical men who have learned from
many gratifying experiences how service-
able
Dioxo
is, as a non-toxic, non-irritating but tho-
roughly dependable antiseptic, have no
difficulty in promptly relieving the
immediate effects of these emergency
afflictions of the vacationist and prevent-
ing the development of infection.
The large amount of pure uncontaminated oxy-
gen— nature's own antiseptic — which Dioxogen brings
directly to the point of injury, in its most active form
enables the practitioner to accomplish results in the
direction both of healing and of prophylaxis that can-
not be expected from germicidal measures of a toxic
or irritating character.
At no time of the year does the physician find
the special advantages of Dioxogen a greater source of
satisfaction than during the Summer and Fall months.
A bottle on the surgical dressing table or in the doc-
tor's bag is a bulwark against the many simple but
none the less dangerous emergencies that are prone
to occur throughout the outdoor season.
The Oakland Chemical Co*
59 Fourth Arrauc, New York City
Mentioning The American Physician Insures Prompt, Careful Service
A Notable Contribution to Dlagnoti, and Tnahnttf. (page 709)
Emit Recognition the
Vital Factor in Ectopic Pregnancy
DIFFICULT DIAGNOSIS CONSTITUTES A PROBLEM REQUIRING THE PHYSICIANS KEENEST ARtUTY
0*1*722)
radiological Personalities
(peg' 7 1 8)
What Does Group Practice Mean to the Genera! Physician?
(peg* 705)
Have High Educational Standards Become a Danger?
{page 730)
Full Content, on Page 694
$2.00 The Year "Most Widely Circulated Medical Monthly " 50c The Copy
I 420 Walnut St, Phllxklphim, U. 3. A. 1
A ComtrucHee Market far Buyer and Seller
Rheumatism
Gout
Neuralgia
Neuritis
Sciatica
Lumbago
Migraine
The best of patients
may become the
worst of impatients
if kept Buffering while a "painful" search is
made for the "why's and wherefore's."
First relieve promptly and aafely with
ATOPHAN, then make it part of whatever
is your favorite scheme of treatment.
Genuine ATOPHAN is manufactured at our
Blcomfield, N. J., plant by a special process,
precluding the possibility of even traces of
irritating empyreumatic admixtures.
Complimentary Trial Pac^afe and Information from
Schering & Glatz, Inc.
ISO Kbiden Una NEW YORK
REDUCED PRICES
0.45
0.3
0.15
DIARSENOL
SODIUM DIARSENOL
0.45
0.3
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Orders for 50 ampoules — 10% discount.
Discount on larger quantiliet an request
iirienol i*d Sod!uVDU»"non™inid*. "They'iriu n_ .. , _r.
nouni you nave been paying for arienicali of any brand Id the puL
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r solubility, lability. I
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DIARSENOL COMPANY, Inc.
n buy with Confidence— See "Service Guarantee to Rtaderf on page 758
October, 1922]
The American Physician Advertising Service
691
WILLIAM SCHEPPEGRELL, A. M., M. D.
Says: —
President American Hayfever Prevention Association.
Chief of Hayfever Clinic, Charity Hospital, New Orleans,
"IF the patient applies for treatment during
* an attack of hayfever, the pollen extracts
are usually ineffective, and a vaccine should
be used, these being injected at intervals of
one or two days until the severity of the attack
subsides."*
The Vaccine used by Dr. Scheppegrell is practically iden-
tical with Sherman's No. 36 which is being extensively
used in the prophylaxis and treatment of Hayfever.
* From Dr. William Scheppegrell's new book on Hayferer and Asthma
Lea & Febiger, Publishers
Bacteriological Laboratories of
G. H. SHERMAN, M.D.
DETROIT, MICH.
The combination of tonics and stimulants ex-
plains the clinical results obtained in the
treatment of nervous disorders by the use of
FELLOWS' COMPOUND SYRUP
OF HYPOPHOSPHITES
"A true stabilizer of shaken nerves?
U contains the ••mineral foods". Sodium, Potassium, Calcium, Manganese,
Iron and Phosphorous, and the stimulating agents, Quinine and Strychnine.
Samples and Literature sent upon request.
FELLOWS MEDICAL MANUFACTURING CO., Inc.
26
•r Street, New York, N. Y.
Vol. 27, No. JO, Published monthly— The Taylors; C. C. Taylor, Publisher; Mrs. J. J. Taxlor, Ed. Mgr. Entered as
second-class matter Feb. 13, 1896, at the post office at Philadelphia. Pa., under Act of March ?, iHtq. Continuing
the Characteristic Service of, The Medical Council, "Most ll'idelv Circulated Medical Monthly* established in 1896.
COPYRIGHT 1922, by The Taylors, Publishers, 410 Walnut St., Pluadclphia, U. S. A.' All rights reserved.
MEDiCAL C0MC;L
692
A Constructive Market for Buyer and Seller
LOESERS INTRAVENOUS SOLUTIONS
HAVE MADE
iriTRAVENOUS MEDICATIOK
\x
A SAFE PRACTICAL
^vOPMCE TECMhlC
ACCEPTED
BY THE
COUNCIL
LOESER'S INTRAVENOUS SOLUTION
OF
MERCURY OXYCYAN1DE, 8 Mgs.
A sterile, stable solution in nonsohible glass ampoules, 5cc con-
taining • mgs. ( % grain) of Mercury Oxycyanide.
LOESER'S INTRAVENOUS SOLUTION
OF
MERCURY OXYCYANIDE, 1 2 Mgs.
A sterile, stable solution in nonsohible glass ampoules, 5cc con-
taining 12 mgs. ( *4 grain) of Mercury Oxycyanide.
We offer these solutions to the medical profession
as a means of carrying on intensive mercurial treat-
ment of syphilis.
The objections to the intramuscular method lack
of uniform absorption, irritation, induration and
abscesses, are overcome by the intravenous admin-
istration.
The superiority of these solutions of Mercury
Oxycyanide over the intravenous administration of
the so-called acid salts of mercury, bichloride,
biniodide, etc., is due to the fact that they are less
apt to cause irritation of the veins, a common fault
of most soluble mercury compounds.
Clinical Reports, Reprints, Price List
and
"The Journal of Intravenous Therapy'*
Sent to any physician on request.
New York Intravenous Laboratory
100 WEST 21ST STREET
NEW YORK, N. Y.
Producing Ethical Intravenous
Solutions for the Medical
Profession Exclusively.
ENHMVt*
You can buy with Confidence — See "Service Guarantee to Readers" on page 758
October, 1922)
The American Phytician Advertising Service
693
il-
iac
mi
]■[
]■[
]■[
li C. H. Boehringer Son
"Ingelheim
ff
Cadechol
( Camphor-choleinic
acid)
Indicated in disturbances of
the circulation and heart in-
sufficiency due to auricular
and valvular defects.
Perichol
( Camphor-choleinic
acid and papaverin)
Efficacious Cadechol com-
bination especially indicated
in the treatment of Angina
pectoris.
Alpha — Lobeline
Incomparable stimulant in
subnormal respiration due to
accidents and diseases.
Laudanon
Universally accepted stand-
ard for morphine medica-
tion during long periods
without danger of habit
formation.
Laudanon
Scopolamine
Unexcelled analgesic in labor
and famous hypnotic in deep
X-ray treatment.
Laudanon — Atropin
Indispensable sedative in
overcoming hypersensibility
and tendency to vomit in
senility.
Specialties obtainable through
Ernst Bischoff Co-, Inc., 85 West Broadway, New York, N. Y.
!■[
]■[
]■[
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Mentioning The American Physician Insures Prompt, Careful Service
694
Contents
Copyright, JpM. by The Toyhrt. All right* reserve*.
Editorials
What Does Group Practice Mean to the General
Physician ? 706
Help Us Get the Facts on Group Practice 706
Original Articles
Cancer Therapy; the Proper Co-ordination Between
Surgery, Radium and the X-Rays.
By Isaac Levin, M.D 709
A notable contribution to tbe diagnosis and treatment
of cancer by means of a group-clinic management of
the cases. Herein is shown how thousands of cancer
cases can be relieved, and most early cases saved by a
combined method of treatment along scientific and
rational lines.
Pathological Personalities.
By Gustav F. Boehme, Jr., M.D 718
It is the author's belief that ours is an age of increasing
insanity and mental defectiveness, the basic principles
of which hinge closely upon "pathologic personality.'*
Something undoubtedly must be done, and Dr. Boehme
indicates a large opportunity for the physician to pre-
vent if possible and to cure where possible these un-
healthy mental states.
Ectopic Pregnancy.
By Gilbert I. Winston. M.D 722
Few conditions are as dangerous as ectopic gestation.
Few conditions require as prompt and as efflcaciooi
attention as does this fatal disease. The excellent it-
capitulation herein presented, together with the cues
illustrating the points dwelt upon in this paper, should
prove of interest and value to both physician and
surgeon.
Gall Bladder Diseases.
By G. S. Foster, M.D 727
Gall bladder diseases, experience has shown, yield more
readily to surgical than to therapeutic measures. How-
ever, the scalpel must here cut with caution and care,
as Is asserted by Dr. Foster in this short, clear-cot,
sensible paper.
Obscure Etiology of Trifacial Neuralgia.
By William A. Lurle, M.D 721
Trifacial neuralgia results from a variety of factors
of imperfectly understood origin. Because of this ob-
scure etiology, the treatment is equally unsatisfactory.
To remedy this, the paper of Dr. Lurie attempts to
unravel the complicated elements involved and to ex-
plain matters on logical and sensible bases. Its prac-
tical value, then, is self-evident.
(Content* continued on paf 696)
Chinosol
"A POWERFUL ANTISEPTIC, SOMEWHAT STRONGER IN
THIS RESPECT THAN MERCURIC CHLORIDE AND CONSID-
ERABLY STRONGER THAN PHENOL."
(COUNCIL ON PHARM. AND CHEM. A. M. A.>
««
ASEPTIKONS (supVpAo^,NtAoLr,es
producing complete antisepsis
But
Non-poisonous, Non-irritating and No injury to membranes
Indicated in cervicitis, leucorrhea,
specific and non-specific vulvo-vaginitis, in all cases
where complete vaginal antisepsis is desired.
PARMELE PHARMACAL CO., 47-49 WE9T STREET, NEWYOWU
You can buy with Confidence — See "Service Guarantee to Readers? on page 758
October, 1922)
The American Phjfncian Advertising Service
695
IN THE ANNALS OF MEDICINE
and BIOCHEMISTRY
they tell of the value of
YEAST THERAPY
A prominent pro-
fessor of therapeu-
tics ana doctor of
medicine writes:
A professor in a
Seat American
nhersity writes:
A noted professor
and author of well-
known text booh
says:
Is an antiseptic — increases resistance to
certain infections — has laxative effect —
checks fermentation* "Yeast is more or less
of a gastrointestinal antiseptic, increases the move-
ments of the bowels, cleans a coated tongue, stimu-
lates the production of white corpuscles, and often
seems to aid in combating various streptococcic and
staphylococcic infections. Hence it is a valuable
treatment for septicemia and for boils and car-
buncles.
''Besides the laxative effect of yeast, it has the
ability to change the flora in the intestine and to
more or less check fermentation. It should be much
more frequently given in illness in which there is
intestinal disturbance, especially if it is associated
with constipation.,,
Rich in B-vitamin — beneficial effects* "The
claim made for their use (yeast cakes) rests on a per-
fectly firm basis, they are rich in "B" vitamin, the
proteins of the yeast cake are of good quality and
the cake contains no ingredients poisonous to man.
Many people are reporting beneficial effects from
their use."
Food value of yeast — protein valuable. "The
food value of yeast does not rest alone upon the
vitamin present. The protein of the yeast is itself a
very satisfactory type of protein so far as the
nutrition of mammals is concerned. It is
made use of in the tissues of man to as
great an extent as is the protein of
milk or meat, two of our most
»>
New brochure on yeast therapy
sent on physician's request
staple foods.
Send for free copy of the new
brochure on Yeast Therapy.
Use coupon, addressing THE
Flbischmann Com-
pany, Dept. S-IO 701
Washington Street, x a
New York. N. Y.
C«BMnr
Dept. S-10
701 Washing-
ton St. ,New York
Please send me free
copy of the bro-
chure on yeast based on
the published findings of
distinguished investigators.
Name
Street
City State
Mentioning The American Physician Insures Prompt, Careful Service
A Cmtlructiot Market for Buyer arul Seller
Contents — «wj«m »
a High Educational Standard* B
Acuta Epidemic Encephalitis (Lethargic Encephalitis) .73*
The Heart— Old and New View* 78
Self-Mastery Through Conscious Auto- Suggestion 731
The Alton (Starvation) Treatment of Diabetes— With i
Series of Graduated Diets 7*J
Dloeaaoa of the Dlgeotlvo Organ*— With Special Refer-
ence to Their Diagnosis and Treatment 7«
The Submucous Rooectlon of the Nasal Swptum 7«
What to Do In Case of Poisoning 7*
New Prices on
Merz Santal Comp.
Capsules
DISPENSING PHYSICIANS CAN BUY
OF US DIRECT
10 Minim Elastic Capsule*, box of 100
Ala* box** *l IS and a**** of S4
5 Minim Perles bottle of 36
5 " " bottle of BOO
5 " " bottle of 1000
Unsurpassed for happy effect in Urethritis,
Cystitis, Prostatic Troubles, difficult mic-
turition, etc.
PRICES AND SAMPLES UPON APPLICATION
THE MERZ CAPSULE CO.
DETROIT, MICH.
You can buy with Confidence — See
Monty Back Guarantee to Suhtcribtn
Tm« Abtojcab PariKtiaH Is , , .„. ^,_ --., --
purpose— to nee the snml araeainaaar the cAkitnuy pnio**!
I sod imtrtttU of
■ rsslly a*j*/>l in the problen:
»""»» or entenjlrment in a*? Mr with titktr.
If say subscriber, at ») «■■>, feds that Ta
pBTHtiin is oat (inns Bin /oil awasare ("pressed
l( he mil write □• we will c)utT~j*Uj rrfaad,™
""■ money be paid far Ik* yrm/t f»iim>ii»,
oared eleven issoes.
Tbi Ahiucak Pnrstcun seeks nly sanated, tetereaes
SmbtriptJom Cawtfana
Practically all of oar subscribers, u a matter of ami
tiri subscription Is be continued, to avoid nissuur "*
_ nast luffly back unn), sod to be billed when subsrri,
due (yearly in advsace, unless, sf course, paid shesd to lafO
""where this is -at the •ubscriber's desire it is rorr/aU;
However, if for sny reason subscription is continued ■
koI desired, if notificstioa is sent frumfllj apon rtrt
inscription bill, it will be discontinued (at once, of a
ith no charts for the copies seat sfter cxpirstioa.
TBI Akuioh Piiiiciai does Ml distribute MauMf est
■ee copies of any kind. ,
Srr&ecriBCian Price
Fifty cents s copy current issue (back Issues 11.00 • r*fj~
ost issues not avsunble): tl.00 far One Year; fl.OO to Tvti
ears (S1.S0 a Tear): |J0O for Four Years <H-» U"1
tlfj.OO for Ten Years (only 11.00 1 a rear).
This is for Domestic postage — U. 5. sad psssssawas, can
Mexico. Canada sad Foreifn. Wc aaa>n#a*J sack yesi.
Iran aA csstwHiateaiiou and m*kt a» fundi aryaWr t»-
Thr Anurinm Pkyiida*.
tie Wtlnni Strni. PluUJtlfhU, D. S. A.
Service Guarantee to RtaAtrf on page 758
October, 1922]
The American Physician Advertising Service
697
In January, 1917
THE BACILLUS ACIDOPHILUS
was introduced and made available to the medical profession for the
first time through
Bacid Preparations
which were created solely to make possible the therapeutic use of this
antiputrefactive organism, the Normal Habitat of which is the Human
Intestine in health.
Bacid Preparations
Tablets— Capsules — Liquid Cultures
do not now and never have contained the
B. bulgaricus— either Type A or Type B
Literature — Bibliography— en request
Guaranteed and Manufactured ONLY by
The Arlington Chemical Company, Yonkers, N. Y.
3BBF3QFRr=?FRF=?BF=lF3r=3BBBB^MB
COMPLETE LIST OF
PROTEOGENS
feS-ForTdratoat.
pV.4-ForrkyFewra»il
lk.S-For
not dot to
lfe.7-For
lh.t-For.Pe
sot the apiMK type.
fet-For Staple Goto*.
Mo.*-A-For Exophthalmic
Ik. It-For SypUa.
Ho. 11— For GoMolieB.
ftV tt-For Ptaeaaoa* tad kv
Ho. IS— For Pyordaa.
Ha.l4-ForDU»am,
Clinical Experience
is after all, the deciding factor in determin-
ing the worth of any remedy, and a tabu-
lation of reports from physicians all over
the world shows that
PROTEOGENS
hare been used with favorable results m
67% of the cases treated.
If you have a case with any of the diooaiet
listed, that is not responding to ordinary
treatment, remember the Proteogens can be
relied upon for beneficial results in almost
seven cases out of ten.
Your patients expect you to use every pos-
sible means to effect a cure, and because of
the high percentage of favorable results ob-
tained, it is to your advantage to use the
Proteogen treatment regularly in your
vr e have some interesting literature on the
Protein Therapy and the use of Proteogens.
Shall we send it to you?
-p tt fl p p p g
THIWUS.
o o p o=g
COMPACT
Mentioning The American Physician Insures Prompt, Careful Service
A Corutructkfe Market for Bauer and Seller
-MORE AUTHORITATIVE KVIOENCEE
CONGESTIVE
DYSMENORRHEA
This painful condition it readily
relievable by. proper medication Ac-
knowledged gynecological author itiei
HAYDEN-S VIBURNUM COMPOUND
./ iwumtbl, «i» in Ikt tr.am.nl of
DYSMENORRHEA
P. H. Davenport, AB, M.D., of
Harvard, in his lest book on "Dii-
qk! of Women," page 144' (herewith
reproduced) referring to various rem-
edies for the relict of congested
dysmenorrhea, suits "That HayoWi
Virbumum Compound 11 the rout ef-
fectual remedy in its class."
There are many imitation! and sub-
stitutes for Haydn's Viburnum Com-
pound. We shall be glad to send you
a sample of the original product aa
compounded by Dr Hayden, and
which was so effectively used by Dr
Davenport and Dr Sims.
A card will bring you literature and
sample of the original H. V C
HEW YORK PHARMACEUTICAL CO.
Bedford Springs. Bedford. Mats
batUa ■
with hot w^er. cm- sponsjio-piline wrung* nut tn hot
will nnT infrequently hma wcry soothing eflcct
Hot, itiamlating drinks are popularly iiippoaod to
* . red lavender, and pep-
duet in Lot water for Sve of tfH limn.
pnuible. the ui
You can buy with Confidence— See "Service Guarantee to Readers" on page 758
The American Physician Advertising Service
A Dependable Antiluetic
WHEN spirochetes become arsenic-fast— tolerant of arsenic so
that, temporarily at least, no further impression can be made
on them with Salvarsan or its derivatives— mercury becomes the
sheet-anchor of antisyphilitic treatment.
In the short time since our Chemical Research Department devel-
oped MercuTOsal, trustworthy evidence has accumulated to justify
the conviction that this new synthetic compound is a dependable
antiluetic, well adapted for administration by the intravenous or by
the intramuscular route.
Clinical improvement following Mercurosal injections has been
observed to come rapidly. In. many cases, too, the sudden dis-
appearance of a seemingly persistent Wassermann reaction has been
clearly attributable to the Mercurosal treatment.
Low toxicity. Relatively high content of mercury. Organic combination
(ravenously or intramuscularly with a minimum of discomfort to the patient.
Parke, Davis &, Company
NEW LITERATURE
Just off the press; gladly sent to physicians on request.
MercuroMl Reprints Gland Therapy Booklet on Biological Products
Mentioning The American Physician Insures Prompt, Careful Service
A Csnrirucawe Mark* Ur Buyer mi ggjfcr
"A Road of a Thousand Miles Begins With One Step"
One indication for the use of ALKALOL should, to the rt»ml™g physician:,
suggest many others. ALKALOL does well in the eye, soothes irritation
and overcomes inflammation.
It is an efficient deodorant antiseptic for the ear.
It is idea) for use as spray 01 gargle in the throat. Upon the mucous
membrane of the urethra, vagina, ■ bladder, rectum, ALKALOL
acts in a surprisingly efficient way.
As a wet dressing for wounds or ulcers, or applied to irritation or
inflammation of the skin, ALKALOL satisfies.
Internally it is effectively antacid.
The theory of ALKALOL action — that it helps the cells to help
themselves can be demonstrated by practical test.
You can buy with Confidence — See "Service Guarantee to Reoders" on page 758
The Amerkan Pkguam Advtrtitmg Service
Tffil'
ion
nes
Metabolism and/futrition
Iron — as haemoglobin — is the sole carrier of oxygen to the
tissues, and oxygen is indispensable in all catabclic and ana-
bolic processes.
Iron given per os is largely precipitated in the intestines and
cast off as unabsorbed iron sulphide, hence the tremendous
increase in popularity of intravenous iron therapy.
Ferric Dimethylarsenate (Endoferarsan) administered
through the vein increases the number and haemoglobin con-
tent of the red corpuscles, improving oxidation and favoring
normal metabolism and nutrition.
Endoferarsan is used in anemia, chlorosis, amenorrhea,
debility and convalescence. Ten or twelve doses are usually
given at 3 or 4 day intervals.
Endoferarsan may be had in boxes of six, twenty-five and
one hundred ampoules, from druggists, physicians* supply
houses or from us, at $3, $1 1.25 and $40 per box respectively.
Intravenous Products Go. of America, Inc.
121 MadisonA^ ^TOTTR)^ /fc*Y&rk.Gitj>
'. IntraVenous MlllMIII*B"aai
Mentioning The American Physician Insures Prompt, Careful Service
A Constructive Market for Bayer and Seller
AGOCHOLAN
STRONTIUM CHOLOSAUCYLATE
For the Treatment of Biliary and Hepatic Disorders.
A Prophylactic in the Disposition to GALLSTONES
SUGAR-COATED TABLETS
Two Grain* each
For 5.1* By Literature and Samplal
MERCK & CO. E. B1LHUBER, Inc.
New York St. Loi.ii Montreal 25 Weal Broadway New York
"V^T7 A OT^/^TVTTj *0 ^e Pm^e<l active principles
X 0/\i3 1 UiN Cl and VITAMINES OF YEAST
GIVEN IN PLACE OF YEAST FOR MEDICINAL PURPOSES
Keeps well Pleasant to take Reliable
Literature and Sample on request
MERCK & CO. 45 Park Place New York
An Early Start
HEELS
means much to the growing child. The light*
springy step, the delightful resiliency, and the . .
avoidance of shock and jar bring full measure ^»^^^^^^^^^^^
of pleasure and benefit.
Thus the child who wears O'Sullivan's Heels is happier, the
structures of the feet are strengthened, the gait and carriage are improved,
and there is a marked decrease of nervous irritation, with its all too
frequent depressing effect on the whole body.
The sum total is more comfort, greater efficiency and a real
conservation of health.
O'Sullivan's Heels fill a very definite place in the hygiene of
childhood.
O'SULUVAN RUBBER CO.Inc. New T«rk City
You can buy with Confidence — See "Service Guarantee to Readers" on page 758
October, 1922]
The American Physician Advertising Service
703
No Growth
Without Vitamines
The Bio-Chemical Laboratory of the University
of Cambridge recently conducted an exhaustive
investigation to determine whether the vitamines
known to be present in the raw materials from
which VlROL is manufactured were present in their
active state in the manufactured VlROL as sold to
the public. This report which fully proves the
presence of the vitamines in VlROL will be sent to
any medical man on application.
Advantages of VlROL
It contains the vitamines
It is a well balanced food.
It is easily absorbed in the most delicate con-
ditions.
VlROL exercises a remarkable influence on
growth and development. It is a food of great
value for expectant and nursing mothers, in
anaemia, malnutrition, and all wasting conditions.
VIROL
Sole Agents for United States
Geo. C. Cook & Co., Inc., 59 Bank Street, New York
Mentioning The American Physician Insures Prompt, Careful Service
A Constructive Mar fa fa Buyer and Seller
MENSTRUAL DISORDERS
A large proportion of the patients treated in a physician's prac-
tice are women suffering with some derangement of menstrual or
generative function. These disorders are due in large measure to
diminished or disturbed function of the glands of internal secre-
tion. Owing to the reciprocal relationship that exists between
these glands, a functional disorder of them is, in its last analysis,
always a pluriglandular disturbance — never a monoglandular
malady. It is now recognized that pluriglandular combinations
give better results than sin-
gle gland products. Clini-
cal results emphasize this
and physicians who use
Hormotone
are seldom disappointed.
In those cases that have a
tendency to a high blood
pressure
Hormotone Without
Post-Pituitary
is recommended. Both
products have the approval
of many leading physi-
cians.
Dose of either preparation:
One or two tablets three times
daily before meals.
Literature on request.
G.W. CARNRICKCO.
419 Canal Street New York, U. S. A.
You can buy with Confidence — See "Service Guarantee to Reader^' on page 758
What Does Group Practice Mean to the
General Physician?
THE HUMAN P ACTOR IN GROUP PRACTICE AND THE PAY CLINIC WORK
Am ExeeeSmgfy huohed
The world does not stand stiU.
Modern medical practice must be
adapted to the needs of the mod-
ern world to give people modern
medical service.
Group practice is commencing
to attract considerable attention
as a practical answer to this
problem.
Let us keep one fact before us
always in considering the future
development of medical practice.
It will inevitably be determined
on what will most efficiently make
omi Complex Prohl*
available to the public the serv-
ice of modern medical science.
Any medical journal or other in-
strumentality of medical leader-
ship that fails to emphasize this
point regardless of any other
considerations is doing its follow-
ers a signal disservice.
But such efficiency of service
must also rest on sound economic
and psychologic bases. They are
modern sciences just as much as
is medicine.
If modern medical service is
to be so expensive that it is dis-
pensed to aU but the wealthy as
a charity, you are building up
the body while breaking down
the character and the spirit. This
is vitally important. If medical
leadership continues to ignore
this fact, it ultimately win cost
dearly everybody concerned, in-
cluding the American people.
This is an exceedingly involved
and complex problem. Only prac-
tical evolution, plus a well-inten-
tioned will to intelligently under-
stand by all concerned, wiU pro-
vide a constructive solution.
THE AUGUST Woman's Home Companion car-
ried an article by Thos. H. Halsted, M.D., a
professor in Syracuse University, entitled "Team-
work for Health: Why Group Practice in Modern
Medicine is Growing." Showing how foolishly peo-
ple "doctor" themselves by going from special-
ist to specialist without the directing hand of the
general practitioner, the paper dwells on the genesis
of modern medicine, which as a science has gone
ahead of the available machinery for using it, the
necessity for specialists, and also the need for gen-
eral physicians. Therefore, he believes, the gen-
eral physician and the specialists should be brought
together for the advantage of all, more especially
the patients of all. Twenty to forty per cent, of
all cases, he contends, are obscure or chronic ones,
needing the attention of two or more physicians, the
remaining sixty to eighty per cent, being uncom-
plicated cases that any good general physician can
and should handle.
Speaking of the dissatisfaction in the minds of the
laity with medical practice as it exists today, despite
the fact that doctors were never so efficient, Dr. Hal-
sted believes that group practice will meet the
emergency, and hence his series of articles begin-
ning as noted above will discuss the different methods
employed in the group clinics thus far organized.
A Town of Omly 350$ People
The American Magazine for August carried a
much less discriminating article by Frank Hill on
"Seven Doctors of Union City, Indiana," and their
group clinic. Mr. Hill makes a very attractive show-
ing for the plan. Now, Union City is a town of
only 3500 people ; it is on the Ohio line and has good
railroad connection. It would seem that seven doc-
tors would be enough to serve the total medical
needs of the town and the surrounding country, but
there were sixteen there before the war, which dis-
turbed conditions somewhat, and the place is over-
706
Group Practice and the General Physician
[The American Physician
supplied at present. Four of the six medical grad-
uates connected with the clinic are old residents.
There is one dentist. The sixth man is younger and
the seventh came from Ohio. All are fellows of
the American Medical Association. There are four-
teen physicians in Union City, but the six who
have been doing the bulk of the practice are united
in the clinic. Of the eight others one is a woman,
one a Homeopathist and one an Eclectic. With the
advantages afforded by the clinic the chances are
these seven men will soon be doing almost all of
the practice, for the others are getting old, some
do not belong to medical societies, and others are
probably perfectly willing to drop out of it.
Tet it is more than probable that some of these
doctors on the outside feel rather bitter over the
clinic and are encountering competition that they can-
not successfully meet: That is an economic situa-
tion that is developing wherever group clinics are
organized in small communities. It is a characteris-
tic of life.
The Commtrcimliied Clone im the Small City
The Union City clinic is well housed and has a
capable personnel of ethical practitioners. Such
clinics, in the long run, will doubtless be advantageous
to all concerned, though some temporary hardship
may result. Unfortunately, there are others, and they
are commercial ventures pure and simple. There are
two kinds of commercialized clinics. Two illustra-
tions will suffice.
In a small city with a creditable hospital the
"Outs," as the men not on the hospital staff were
called, decided to start an opposition work in the
form of a group clinic ; but they viewed the proposi-
tion commercially and at least half of them were of
poor attainment and without especial standing in the
profession. So they bought cheap and flashy equip-
ment, advertised in the newspapers, and were very
bitter in their criticism of the "Hospital Crowd.'*
In less than a year the sheriff got the building and
equipment and the two leading •lights in the clinic
are now in irregular practice and doing poorly.
In a larger city there are five Jewish physicians
who are long-time friends, all very capable practi-
tioners and of excellent standing with their col-
leagues. These men have all done well financially.
Not long since they got the "group clinic bug," as
they described it. One of them had made a lot of
money in business ventures aside from medicine, and
he undertook to organize the group clinic. Trouble
began at once, part of it being due to racial prejudice,
which was not justified except as regards this one
man. The reader can imagine the situation. The
whole project blew up and those physicians have
learned a rather sorrowful lesson and are trying to
rehabilitate themselves in the esteem of their col-
leagues. Doubtless they will succeed, for they are
all good men and good physicians.
Whether a commercialized group clinic is organ-
ized by capable physicians or by incapable ones, the
public views it unfavorably and the commercial-
ized project is doomed. This is a good thing to
remember, for it is really encouraging.
Tkt Cornell Experiment
Dr. Halsted lives in Syracuse, which is not very
far from where Cornell University is conducting a
very successful pay clinic, and doubtless his opinion
is largely based on the Cornell experiment. In June
we toured the Finger Lakes district of New York
State and took occasion to feel out the situation re-
garding this much-discussed pay clinic. Certainly
there was little excitement over it in New York,
the public viewing it very favorably, feeling that
it is only just to pay something for medical serv-
ice; and, as Cornell is not profiteering in the work
or being unfair to outside physicians who are capa-
bly practicing modern medicine, there is very little
sympathy with the group of easy-going and out-of-
date practitioners who, despite the fact that they
are estimable citizens and gentlemen, are not in-
formed in a modern sense and are loudly decrying
the whole trend of modern medicine. Every com-
munity has such men, and where group clinics come
in they are almost put out of practice. It must be
conceded that these men are simply being run over
and ignored, and that may or may not be a good
thing, depending on one's point of view. But it is
certainly hard on a lot of fine old gentlemen. We
say "old gentlemen." That is a relative term, for
we met, in his home in Montour Falls, Dr. Stephen
Smith, who is one hundred years old; and he is
not "old" at all in a medical sense, for he is quite
in accord with modern medical trends. There are
a lot of "old gentlemen" in medicine who should meet
Dr. Smith and learn from him how to keep young
in thought. If they did, they would not be so
voluble in vituperation whenever a new thing
comes in. [Since the above was written, we learned
that Dr. Smith has died.]
Also we met a nationally known physician who is
about seventy years old. It would not be fair to
name him, but he said : "Every forward-looking phy-
sician is in favor of some proper form of group
practice controlled by the profession itself, for it
is the best guarantee against medical socialism, or
political control of the profession. Only a few irree-
oncilables and the submerged third of the profes-
sion are opposed to the principle of group practice,
however we may disagree in details."
Thmt "Submerged Tmrt'
Now that "submerged third" proposition may
bother some, for it seems to connect up with age.
But the more we think over it, the less do we fed
that the age incidence is wholly responsible for this
medico-social pathology. Anyone officially connected
with state-wide public health administration, as we
are, comes to recognize the fact, for it is a fact, that
Phila., October, 1922]
Group Practice and the General Physician
707
about one-third of the profession never seem to get
anywhere in particular. Doctor, get out your medical
directory and go ever the roll of physicians in your
county and check the list over on the basis of effi-
ciency and accomplishment, and you will find just
about a third of them never "arrived" for one reason
or another.
Now despite the sympathy you may feel for these
gentlemen, they are the men who oppose innovation,
never get on hospital staffs, secure worth-while ap-
pointments, or are counted in when group clinics are
organized; and they gradually become supersensi-
tive and hypercritical, are out of step. Doctor, you
know a lot of them; so do I. What can we do
about it?
Sometkimg Is Being Done
Years ago retail merchandising was reorganized in
this country, department stores and other modern
innovations forcing merchandising individualism into
the background. For some time there was a sub-
merged third among the merchants; but some of
these men bucked up and made a success of new
methods; others worked on salaries for large firms
and made more money than in self-conducted busi-
ness; some retired, and the unreconstructed either
went into bankruptcy, sold out, or are holding on at a
poor dying rate on the outskirts of business. Some-
thing of the same thing will probably happen in
medicine.
The real reason why the term "general practi-
tioner" has somewhat fallen on bad days is the sim-
ple fact that this one-third of the profession have
come to be known by the public as general practi-
tioners and are graded below the specialists, just as
the old "general storekeeper of the country cross-
roads" is listed at the foot of merchandising. Times
have changed ; that is all. We must change with them
or go down and out.
The New Specialty
"Diagnosis and Internal Medicine" is the way it
reads in the staff roster of the group clinics, and the
diagnostician and internist ranks just as high as does
the general surgeon. These two men are the chiefs,
the others being specialized technicians to handle that
"twenty to forty per cent, of cases" Dr. Halsted
classes as requiring more than one-man attention.
The successful diagnostician and internist, these days,
must measure up to the full stature of a man with
the general public, just as the surgeon must.
We confess we rather like the term "general prac-
titioner," but we cannot help the trend of the times.
We believe general physician is a better term as mat-
ters stand now and that term is being used for the
present in The American Physician. A better term
may evolve. This should not be regarded as a minor
matter. There is much, exceeding much, in a name.
There are general surgeons, but no one of them wants
to be called a general practitioner surgeon ; and there
are general internists, but the man who really becomes
skilled in modern diagnosis and internal treatment
does not want to be called a general practitioner in-
ternist. We incline to the view that these terms will •
narrow down to surgeon and internist; and there will
be orthopedic surgeons, abdominal surgeons, etc. ; and
there will be internists specializing in different divi-
sions of internal medicine.
The Man Who Does Not Fit In
The man who looks at tongues, feels pulses, uses a
thermometer, makes no discriminating diagnosis on a
basis of exactitude, and then looks over his shelves
for the combination tablet that seems more nearly to
fit the case, is the man who is destroying the prestige
of the term "general practitioner," and with him the
average patient is becoming more and more dissatis-
fied. The public is right, for modern medicine has
progressed beyond that sort of slipshod medical prac-
tice.
This man gets along, in a way, until the more
progressive men in his community organize a group
clinic ; then he is out of it, for he does not fit in, and
he joins the "submerged third," which is quite inevi-
table.
Time WiU Stive the Problem
There are many things being written, and some
done, in the group clinic proposition with which we
cannot be in agreement. Some of, its advocates ride
rough shod over all the old ways of doing things, and
others are commercialized, or pedantic, or narrowly
specialized, or utterly selfish, or bombastic, or are
impractical socialists. The whole movement needs
guidance by the medical societies. If the movement
gets out of hand the profession at large will be in-
jured without in the least benefiting the public.
It is to be noted that there are men in practice in
hosts of communities where there are no group clinics,
but who are moving heaven and earth to profit by the
idea. So they make grist of every case that comes to
their mill, no difference how trifling if the patient
has a little money, and they have laboratory and
X-ray tests made, hold consultations, and so squeeze
every dollar out of the case they can. These men are
not all wholly grasping, for they are taught in medi-
cal school to do these things, and they do them with-
out proper discrimination; but some are wholly grasp-
ing, and nearly every physician practicing that way is
apt to become so. It is not to be wondered at that
the general physicians gauge the group clinic idea by
what they see of it at home, and so become prejudiced
against an idea that, properly guided by the profes-
sion itself, may turn out advantageously to all con-
cerned.
That Sixty to Eighty Per Cent
Don't forget that from sixty to eighty per cent, of
cases do not need group attention. If we force one
hundred per cent, of cases into group clinics we will
be unjust, unscientific, irrational and probably sub-
consciously commercial. And we must never forget
the human side of the problem. The medical profes-
sion cannot be made over in a day. The public is
becoming interested in group practice, and we must
study the proposition without bias and reach just
conclusions. — T. S. B.
708
[The
Help Us Get the Facts
Coming
on
GROUP PRACTICE
ON ANOTHER PAGE in this issue appears an
article on group practice. We hope you will
read it. However physicians feel on the subject,
group practice or something of similar nature is
coming; and it is to the interest of the profession
that it be wisely guided, so as to be a help and not
a hindrance to the general physician and to the
public
We are studying this problem. To do so effectively
we will appreciate being placed in possession of the
exact facts regarding group clinics now operating —
how they were organized, financed and launched and
how they function from the standpoint of the phy-
sicians engaged in the work, from that of the pa-
tients treated, and from that of the resident physi-
cians who are not members of these groups.
If you are a member of a group clinic or are in
position to get the plain, unvarnished facts regard-
ing a group clinic near to you, will you write us these
facta, quite in confidence if you so desire; and we
will be under obligations to you. We hope many
physicians respond to this appeal, so we can pub-
lish helpful general findings.
We are not desirous of mere opinion, for or against
group clinics; what we want is actual fact with
reference to existing groups, stated as evidence is
given, not prejudice for or against any group, or
mere personalities regarding the physicians com-
ponent of such groups.
Only by ascertaining actual facts can the pro-
fession reach just conclusions regarding this im-
portant innovation in medical practice.
The Kafan Precipitation Teat in the
DiagnoeiB of Syphilis
Udo J. Wile (/. A. M. A., Sept 9, 1922) conclusions
are:
1. The clinical application of the Kahn precipitation
test compares favorably in sensitiveness with the standard
Wassermann reaction.
2. It has obvious great advantages over the Wasser-
mann reaction in: (1) simplicity of procedure, (2)
rapidity of reading, and . (3) reduction of the sources of
error through elimination of a hemolytic system.
3. Its obvious advantages over other precipitation re-
actions lie in the visibility of the precipitate to the naked
eye, and the frequent spontaneous reactions with strongly
positive serums.
4. Further confirmatory tests, demonstrating parallelism
with the Wassermann reaction, may well lead to the
eventual abandonment of the latter in favor of the
simpler precipitation procedure.
5. As a last advantage, a test embodying only one
reagent plus a serum, offers a greater possibility of
standardization.
Infant Mortality— Its Causes and Prevention, by
Henry Bixby Hemenway, A.M., M.D.
To practice medicine is a privilege; to possess
the qualification of Dr. Hemenway is an honor;
to observe, deduct and record half a century's ex-
perience is a pleasure few are privileged to enjoy.
Therefore, to fail to read, imbibe, and utilize the
substance of this paper — this argosy of service,
suggestion, and help, on the many phases of
infant mortality — is to overlook something unusu-
ally worth while.
Constipation and Its Surgical Relations, by James C
Minor, M.D., F.A.CS.
This subject, of such tremendous importance,
should command the attention of the doctor, who
is vitally concerned in the abating of disease and
preservation of life— both so relentlessly interfered
with by this omnipresent and omnipestilent over-
loading of the lower bowel.
The Study of Psychoses as a Guide to Proper Child
Rearing, by W. W. Young, M.D.
Dr. Young says that we teach the generations
to be doctors, lawyers, merchants, etc, but wc
neglect instruction in that most vital of all life's
duties — parenthood. With very few exceptions,
the prospective parent faces his future responsi-
bility with as few resources as the babe itself. If
we are to rid civilization of cancer of abnor-
mal mentality, we must have mothers and fathers
who know how to be parents.
Gonococcemia and Metastatic Gonorrhea, by Hynun
I. Goldstein, M.D.
Gonorrheal arthritis is too frequent, too intense,
too obstinate a disease to require introduction or
emphasis. Such being the case, we know Dr.
Goldstein's able presentation of this subject will
be fully appreciated by our readers.
Cancer Therapy; The Proper Co-ordination Between
Surgery, Radium and X-Rays, by Isaac Levis,
M.D.
In this, the concluding paper of the article began
in our October issue, Dr. Levin sums up his un-
biased comparisons of the three methods of can-
cer therapy, and stresses the importance of a true
evaluation of these methods and a way for their
proper co-ordination.
Ludwig's Angina, by Mayer Shoyer, M.D.
When crossing a railroad you stop, look and
listen. When crossing Ludwig's Angina you do
not, you rush your patient to the surgeon, or
the patient will go to the undertaker as is em-
phasized in this short but illustrative paper of
Dr. Shoyer.
Muscular Tone and Reflex Pain in Diagnosis,
Twenty-ninth Clinic, by A. Mackenzie Forbes,
M.D.
The duties of a diagnostician are similar to those
of a judge. "In a court of law the evidence is
of the greatest importance. The omission or
addition of one point may change the court's
decision. In a similar way the science of diag-
nosis, the collecting, weighing and properly ad-
judicating the significance of the symptoms is of
the greatest importance."
The following papers
are contributed exclu-
sively to this journal.
Republication is per-
mitted if credited as
follows: AMERICAN
PHYSICIAN, Phila-
delphia.
Original Articles
Sntnen, Mn mbrns, kin nu*A ifcn ust cnfcmi
We are not respon-
sible for the views ex-
pressed by contribu-
tors; but every effort
is made to eliminate
errors by careful edit-
ing, thus helping the
reader.
CANCER THERAPY*
The Proper Co-ordination Between Surgery, Radium and the X-Rays
By Isaac Levin, M.D., New York.
Clinical Professor of Cancer Research New York University and Beilevue
Hospital Medical College ; Chief of the Cancer Division of Montefiore
Hospital; Chief of the Radiotherapy Division of St.
Bartholomew's Hospital; Consulting Radio-
therapeutist Lebanon Hospital
(From the Cancer Division of the Montefiore Hospital for Chronic Diseases.)
Combined Method of Treatment
A notable contribution to the diagnosis and
treatment of cancer by means of a group-
clinic management of the cases. Herein is
shown how thousands of cancer cases can be
relieved, and most early cases saved, by a
combined method of treatment along scien-
tific and rational lines. — The Editors.
Published in Two Sections
This exceedingly comprehensive paper has
to be published in two sections. The second
and final section will appear in the Novem-
ber issue.
THE AIM of any therapeutic measure in medicine
is to completely and permanently eradicate the
disease. The most efficient method for obtaining such
a result is to employ a specific remedy. It is diffi-
cult, however, to conceive the existence of a truly
specific remedy against cancer. The best evidence
gathered from all experimental and clinical research
to date tends to the conclusion that cancer is neither
an infectious nor a systemic constitutional disease,
but manifests itself as a local disturbance in a group
♦ Read in part by Invitation before the Meeting of the
Bronx County Medical Society, March 15, 1922.
of organ cells. It begins its development as a local
condition, a transformation of a small group of nor-
mal cells of a certain organ into cancer cells. Some
of these transformed cells become disassociated from
the primary tumor and are transferred to distal
regions of the organism where they form secondary
metastatic tumors and again act to produce local dis-
turbances.
Even for a distinctly infectious disease like tuber-
culosis the etiology of which is perfectly clear, no
specific remedy is as yet discovere How much more
difficult is it to develop a truly specific method of
treatment for cancer! Such a therapeutic measure
would have to affect deeply the cancer cells and at the
same time remain innocuous to the adjacent normal
cells of the same organ as well as to all the other
normal cells of the organism.
It seems to be characteristic of cancer therapy that
each individual worker employing a single therapeutic
agent becomes enthusiastic over his immediate results
and consequently over his particular remedy. The
surgeon, the radium or the X-ray worker recognize the
worth of their own work only. Just at the present
moment a certain number of German clinicians1
seem to maintain that the results obtained with X-ray
therapy by the aid of the latest machines are superior
to those resulting from any other method of treat-
1 L. Seitz & H. Wlnti. TJnsere Methode der Roentgen -
Tiefentherapie und ihre Erfolge. Berlin, 1920.
710
Cancer Therapy — Levin
ment of canter. This presents a rather unfortunate
situation since snch an attitude must be followed by
disillusionment and resulting pessimism towards im-
portant and useful single agents in cancer therapy.
To date the total results obtained in the treatment
of cancer with all the methods at our command are
methods of surgery, of modern radical surgery, as
well as of radium and X-ray therapy, and the newest
high-voltage technique. As a result of these yean of
study the writer feels justified in making the follow-
ing statement: An individual cancer patient has a
far greater chance for recovery at present than he had
thirty-five years ago. On the other hand, undue en-
thusiasm over immediate results does only harm to
Fig. 1. Permeation of lymph vessel! bj cancer cella (from W. 8. Handle; Cancer of (he Breast),
still limited. It is therefore of the utmost importance
not to impede the correct and scientific progress of
the subject by either an over-enthusiasm over one
method or an unwarranted pessimism over the other.
Surgery, radium and X-ray therapy represent to-day
the sum total of the methods we possess in combating
the disease. The most important problem to-day is
to obtain a true evaluation of the three methods of
cancer therapy and find a way for their proper co-
ordination.
In the years of constant interest and active partici-
pation in the development of the subject, the writer
had the opportunity to follow the results of the old
the progress of the work, since immediate results must
usually be greatly discounted a few years later in
cancer therapy.
Smrfrj is Cacti
In the course of the last quarter of a centnry a
great deal of progress has been achieved in the sur-
gical treatment of cancer. The so-called radical meth-
ods of operative procedure were developed as a result
of anatomical studies of the distribution of the lymph
channels through which the disease spreads.
An excellent example of such studies is the ana-
tomical and pathological investigations of W. S.
Handley1 on cancer of the breast He has shown
Phils., October, 1922]
Caacar Therapy — Levin
711
that groups of cancer cells from the primary tumors
in the breast permeate into the lymphatic vessels of
the deep fascias of the chest wall. Subcutaneous
nodules of recurrences arise only subsequently from
the permeated fascial lymphatics along its tribu-
taries. Fig. 1 shows a number of lymph vessels per-
meated by cancer cells at points indicated by letters
A, B, C, D, E, F. At letter O there is seen a sub-
cutaneous cancer nodule. This nodule is directly
connected with the lymphatics of the deep fascia. As
a result of his investigations Handley proposed cer-
tain improvements in the radical amputations of the
breast for carcinoma. Handley considers the fol-
lowing to be the object in radical surgical removal
of cancer." "The removal intact of the permeated
area of the lymph vascular system which surrounds
the primary growth, and of the lymphatic glands
which may have been embolically invaded along the
trunk lymphatics of the area concerned." Subsequent
investigations have shown that the same rules hold
true for the surgical procedures in cancer in every
locality.
Modern surgery strives to remove all the normal
tissue adjacent to the malignant tumor and into which
the latter spreads most frequently and also to remove
all regional lymph glands. By the aid of these
methods very remarkable results are obtained in the
so-called operable cases. However, though between
25% and 50% of this class of cases may remain well
for a number of years after the operation, they
represent only a small fraction of the whole number
of cancer patients seeking relief.
Vital vs. Smrgicd Sututict
The writer has reported in a previous publication3
a comparative analysis between vital statistics and
surgical statistics of cancer. This analysis has shown
that in the hands of different surgeons the highest
percentage of all cancer cases of a community which
can be cured by surgical treatment, is 15.25% and the
lowest 4.15%, or in all, probably less than 10%. Even
on the supposition of the unattainable ideal, that
instead of only a small percentage of the cancer
patients reaching the surgeon in the operable stage
of the disease, all the patients should come to the
surgeon early, less than 20% of all the cancer patients
may be expected to be cured by the surgical methods
employed to-day. Withal the technique of cancer
surgery has probably reached its limits.
J. M. T. Finney, of Batlimore, discussing the paper
"The Cure of Cancer and Cancer Cures," presented
by A. D. Bevan, of Chicago, before the meeting of
the American Surgical Association in 1910, stated as
follows: ". . . I do believe that we have almost
reached our limit so far as this is concerned, that is,
* W. Sampson Handley. Cancer of the Breast. London.
1908.
• I. Lerin. Medical Record; April 6, 191t.
with regard to technique. We cannot make much
wider dissections than we are doing . . ." This
statement represents the true situation in connection
with the surgical treatment of malignant tumors. The
latter are usually situated in close proximity to the
vital organs, the injury of which would endanger the
life of the patient, consequently there is set a limit
to the length to which a surgeon may go in removing
normal tissues adjacent to the tumors. As a result of
these limitations there may remain small islands of
cancer cells in or near the operating field, even after
a radical operation. For this same reason the knife
may inadvertently cut into such an island of tumor
tissues and throw freed cancer cells into the opened
lymph and blood channels; the malignant tumor will
then recur in the same region or in a distant organ.
A further reason for the failure of a radical opera-
tion consists in the fact that even in early operable9
stage of the disease there may be present minute
tumor nodules in the distant organs which cannot be
detected by any diagnostic means at our command,
but which after the operation develop into large
metastatic tumors.
It is thus self-evident that the need for the addi-
tional methods of treatment of cancer is great. The
actual results frequently obtained by surgery alone
without the aid of the other methods is very well
illustrated in the following report of R. Peterson,4
of Ann Arbor. He presented a paper on "The
Radical Abdominal Operation for Cancer of the Cer-
vix' before the meeting of the New York State
Medical Society in 1920, in which he reports that
40.9% of all the operated patients were permanently
cured. However, he operated only on 60 out of 380
patients with carcinoma of the cervix which came to
him for treatment. Thus in reality 18 patients, or
4.7%, of the whole number were cured, while 14
patients died as the immediate result of the operation.
One wonders whether the total result would not have
been as good if all the 380 patients remained without
any treatment. Nevertheless, Peterson makes the
statement in his concluding remarks that if massive
doses of radium are required then the patients must
be treated with surgery alone because many places in
this country do not possess any radium. It would
seem to the writer that in a well-organized human
society means ought to be found to refer these 380
patients to institutions which possess all the means
f i r treatin the disease.
The term radiotherapy is usually applied to treat-
ment both by the aid of radium and the X-rays. It
is as yet impossible to ascertain whether there is a
qualitative difference between the biological and thera-
peutic action of the two types of radiation. It seems
«R. Peterson. N. Y. State Journal of Medicine, IMS.
zx, US.
712
Cancer Therapy — Levin
[The American Physician
that the more penetreating the radiations are, the
more selective is their biological action, and the
Gamma rays of radium are more penetrating than
the hardest X-rays at our command. None the less
the Gamma rays of radium represent from the stand-
point of physics only a more perfect type of X-rays,
and the action of the two types of radiations must
be to a degree analogous.
The morphologic changes which occur in carcinoma
or sarcoma tissue under the influence of radium and
.X-rays are observed in the tumor cells themselves,
and are manifested by the vacuolation of the proto-
plasm, pyknosis of nuclei, karyoclysis and, ultimately,
complete necrosis of the cell. The cellular changes
are accompanied by a round-cell infiltration, which is
subsequently changed into dense sclerotic connective
tissue, poor in blood vessels. This new connective
, tissue formation ultimately dominates the picture to
such an extent that some observers maintain it is the
only direct effect of radiation, while the destruction
of the tumor cells is secondary and due to lack of
nutrition.
TU Bmi^mad Ad&m m At Omen C*B
The clinical, pathological and biological studies of
the writer in association with B. Joseph5 and M.
Levine,6 indicates that the first effect of the rays is
exerted directly on the tumor cells. This effect con-
sists in the inhibition of the proliferating power, in
the sterilization, as it. were, of the cancer cells. The
degeneration and destruction of the cancer cells and
the formation of the sclerotic connective tissue take
place subsequently through the action of the rays;
moreover this cell degeneration and cell death may
not be due directly to the action of the rays, but
takes place in the natural course of the life cycle of
the cancer cell. This cycle consists of youth, or
period of development; maturity, or period of func-
tion, and senility, or period of degeneration, which
gradually leads to death. In parenchymatous organs,
like the liver and kidneys, the first period is usually
completed during embryonic life or at a very early
age; the second period continues through the whole
life of the organism, and the third period is attained
at the old age of the organism or near its death.
The life of an individual cancer cell, on the other
hand, is very short; it changes rapidly from an
embryonic into an adult and then immediately into
an aged, degenerated cell, and this process takes place
continually, irrespective of any intrinsic aid. But in
a malignant tumor the majority of cancer cells are
quickly rejuvenated before they reach senility through
the fact that each cancer cell is divided into two
young daughter cells. The radiations arrest the
• 1. Levin and B. Joseph. The Journal of the American
Medical Association, 1917, LXIX, 1068.
* Isaac Levin and Michael Levine. Annals of Surgery,
April, 1918, p. 443.
division of the cancer cell, and as a result the latter
matures and degenerates. A certain number of such
mature cells may not degenerate and though poten-
tially cancer cells, may become resistant to the rays.
The round-cell infiltration, which surrounds the
groups of irradiated cancer cells and which is sub-
sequently changed into dense sclerotic connective
tissue, is of secondary occurrence, though for prac-
tical purposes it is of greater importance than the
destruction of the cancer cells themselves. The im-
portant role of this connective tissue consists in the
following : After the most perfect results of radiation,
as stated above, there may remain a certain number
of viable though stunted cancer cells; the dense con-
nective tissue wall surrounds these cells and keeps
them in check. The formation of the connective tissue
around the rayed cancer cells is not due to the direct
influence of the radiations, and raying of other con-
ditions like thyroid gland, cheloid, etc, is not fol-
lowed either by cell infiltrations or by connective
tissue formation. The experimental investigations of
the writer7 also indicate that this connective tissue
formation apparently represents an attempt by the
organism to protect itself against the further growth
of the cancer by walling it off from the normal tissues
by a connective tissue barrier.
It is evident from the study of the mechanism of
the biological and therapeutic action of the radiations
that it is superior theoretically to surgery because it
may either destroy in situ or inhibit malignant tumor
tissue without injuring or removing any of the ad-
jacent normal tissue. Thus theoretically radiotherapy
is the nearest approach to a specific method of treating
cancer we can conceive of to-day. However, as will
be shown later in practice, radiotherapy notwith-
standing its biological advantages has its limitations
as well as has surgery.
Rmiimm Tkermpy
During the last decade there has accumulated a
large number of cancer cases which were treated by
radium alone without the aid of surgery or any other
method of treatment. As an instance it may be well
to cite briefly the report on the radium treatment of
uterine cancer, which C. F. Burnam,8 of Baltimore,
presented at the same meeting with R. Peterson before
the New York State Medical Society in 1920. To-
gether with H. A. Kelly they treated, up to 1919,
seven hundred cases of uterine, cervical and vaginal
cancers, and had excluded from treatment only suf-
ferers with advanced general carcinomatosis. Of the
cervical cancers irradiation alone cured 50% of the
operable cases, 31% of the border line cases, 9% of
the inoperable cases and 11% of the recurrent inop-
Journal of Experimental Medicine, 1911,
T I. Levin.
XIV, 139.
•C. F. Burnam.
XX 316.
N. Y. State Journal of Medicine. 1920,
Phila.. October, 1922]
Cancer Therapy — Levin
713
erable cases. In a previous publication8 the writer
has shown from the results of his own and other
investigator's work, that conservatively 6.7% of the
inoperable cases may be clinically cured by radium.
It will be shown later that good results may be ob-
tained by X-ray therapy alone. However, there are
reasons within the physical qualities of these two
types of radiations why radium is a more efficient
agent that the X-rays.
It has been stated previously in this article that
the harder the rays the more selective and conse-
quently the more efficient therapeutically is their
action. The Gamma rays of radium are by far the
most penetrative rays known to us to-day. The
following phenomenon in the physical behavior of the
radiations presents another and a most important
proof of the greater therapeutic efficiency of Gamma
ray of radium over that of X-rays. A beam of rays,
when it leaves the point of its formation, travels in
the form of a pyramid. The further away from the
apex this beam travels the more diffused it becomes.
The closer therefore a square unit of the surface of a
body is to the apex of the pyramid the greater the
intensity of the rays.
It has been shown that the diminution of this
intensity is in inverse ratio to the square of the
distance of the surface of the body from the source
of the rays. The Gamma rays of radium are formed
from every molecule of a radium salt or from every
atom of radium emanation ; consequently when a small
cylindrical tube of radium is placed over the surface
of, or better still within, a tumor, the distance be-
tween the source of radiation and the tissue to be
affected can be made almost infinitesimal. The X-
rays, on the other hand, originate at the focal point
of the target of an X-ray tube which is in itself
10-15 cm. from the bulb surface. In reality in X-ray
therapy the distance due to the physical and mechani-
cal conditions of the apparatus between the focal
point and the surface to be affected is between 30
and 50 cm. To this must be added 10 cm. or more,
being the distance from the skin to the tumor. As a
result a far greater quantity of the X-rays must
enter the organism of the patient in order to obtain
at the tumor the quantity needed to influence it. The
radiations are, however, not indifferent to the rest
of the organism, but produce a reaction on normal
tissues and particularly on the blood and blood-
forming organs, which may become so severe as to
counteract the beneficial effect of the rays on the
tumor, since the irradiation, as was stated above, must
be accompanied by a great deal of protective co-
operation on the part of the blood and lymphoid
tissue.
The Actimt em Bleed emi Lywtpkmtic Tissmet
The writer conducted, in association with M. M.
Sturges,9 an experimental investigation, which shows
this difference in the action of the two types of radia-
tions. The study consisted in an analysis of the blood
of frogs and rabbits after treatment with X-rays or
radium. The whole body of the animals were treated
with the same quantity and quality of X-rays. The
radium treatment consisted in the introduction by a
method to be described later into the dorsal lymph
sack of a frog of a minute capillary glass tube about
4 mm. long containing from L0 to 0.6 millicuries of
radium emanation. In the rabbit a laparotomy was
performed and from two to four radium emanation
capillaries were inserted into the spleen.
The difference observed in this investigation in the
reaction of the blood to the X-rays and radium on
f rogs and rabbits is quite significant.
A similar amount of X-raying produced a similar
change in the blood of a rabbit as it did in the frog.
On the other hand, an insertion of radium in the frog
produced a similar change in the blood of the animal
as the X-rays, an insertion into the spleen or the bone
marrow of a rabbit of 2 to 4 capillaries, i. e., of 2 to
4 times the amount of radium emanation used on a
frog, produced no change in the blood of the rabbit
whatever, though it produced a deep local effect on
the spleen and bone marrow tissue.
Biologically the amount of X-rays used on the frog
must equal the amount of radium emanation contained
in the capillary since the biological results obtained
were identical. A larger amount of radium emanation
used on the rabbits must have produced some general
biological effect on the blood of the animal since it
produced such an effect on the blood of a frog. How-
ever, the effect on the blood of the rabbit was appar-
ently so small when distributed over the comparatively
large amount of blood and blood-forming tissue of
the rabbit that it produced no tangible result on it
and did not change its structure.
The comparison in the action of the X-rays on the
two species of animals, on the other hand, shows that
the same technique produced the same general effect
on the blood of a rabbit as on the blood of a frog.
The reason for it lies in the fact that the quantity
of the X-rays entering the animals must be multi-
plied by the square of the surface of their bodies,
consequently the rabbit obtained a greater quantity
of radiation.
These experimental results tally well, as will be
shown later, with the clinical findings. The advan-
tage of radium over the X-rays, generally speaking,
consists in the fact that the same local effect can be
obtained by the former without the general reaction
which is frequently so severe in modern X-ray
therapy.
• I. Levin and M. M. Sturges. Proceedings of the Society
for Experimental Biology and Medicine. 1921, XVIII, p. 295.
714
Cancer Therapy — Levin
Tat r«Ua« W lUimm Thnm
The method of using radium for therapy which
was generally employed heretofore consisted either
in nealing an insoluble salt of radium element
in a glass tube or in a small hollow needle built of
irido- platinum or "non-corrosive steel" or else ill
incorporating the radium salt in a varnish and spread-
ing it over the surface of a flat applicator.
This method lacks, however, both flexibility and
compactness and is very unwieldly for utilisation of
large quantities of radium. While occasionally a
whole gramm may be used on one patient, it is fre-
quently necessary to use as little as 0.3 of one milli-
gram for one area of a tumor.
The more recent method of employing the so-called
"radium emanation" obviates many of these diffi-
culties. It is very compact (an equivalent of 1 gin.
of radium element may be condensed into 0.6 of a
cubic millimeter) and flexible, since the available
quantity may be divided in any desired manner. As
Fig. 2. Photograph of radium emanation apparatus Id the
writer's laboratories. A — Sate containing; tbe radium solu-
tion flanks; B — The glaaa tube lending: from the flask to the
•et of pomps.
will be seen later, the use of radium emanations is
creating entirely new and very promising methods
of radium therapy. Before discussing, further the
developments in therapy produced by the use of
emanation, the writer will permit himself to digress
into a brief discussion of the physical qualities of the
salts and the emanation of radium.
Radinm is an elementary body with an atomic
weight of 226.4. Its so-called radioactivity is dne to
the fact that it constantly emits alpha, beta and
gamma rays, of which the two latter are employed
in therapy. These rays are emitted in the comae of
the disintegration of the atom of radinm. The radinm
element emits only an alpha ray and is thus trans-
formed into "radium emanation," or "niton," which
is also an elementary body, but has the structure of a
heavy gas, the atomic weight of which is 222.4, i, «.,
4. (the atomic weight of helium or the Alpha par-
ticle) less than the atomic weight of radium. Radium
emanation also emits only alpha particles and is then
disintegrated into a series of new elementary bodies
so called Radium A, Radium B and Radium C, which
are solid bodies. Only the latter two substances
(Radium B . ..d Radium C) emit beta and gamma
rays and have a therapeutic value. Consequently,
for purposes of therapy the results will be identical,
whether radium salts or radium emanation is the
source of radioactivity. They will both have to dis-
integrate into Radinm C before they can be employed.
Since it takes the radium element about 1700 years
to lose a half of its amount through disintegration, it
is obvious what a small fraction of it changes into
radium emanation during each unit of time. The
first advantage of the latter substance over the radinm
salt is thus evident; it may be concentrated into
smaller space. The radium emanation, though heavy,
can be collected and manipulated like any other gas.
To obtain it from the radium the latter has to be kept
in solution in a flask which is directly connected with
a system of mercury pumps.
Fig. 2 shows a photograph of the apparatus used
in the writer's laboratory. The radium salt is dis-
solved in water acidulated with hydrochloric acid in
glass flasks, which are placed in a lead-lined safe
The flasks are joined to one glass tube which leads
out from the safe into the collecting apparatus. The
latter, as stated above, consists of a system of mercury
pumps connected with a highly efficient electric pump.
The object of the apparatus is the following : a vacuum
is created in the flasks containing the radium solu-
tion. As a result the radinm emanation gas, together
with hydrogen, oxygen and chlorine formed in tbe
flasks under the influence of the radiations, as well
as water vapor and other gases forming as impurities
in the apparatus, collect in the glass tubes and flasks
of the latter. Of all these gases the radinm emanation
occupies the smallest space. The apparatus, which
was designed originally by Prof. Dunne,10 of Harvard
relet! Journal,
Phil... October, 1922]
Cance r Therapy — Levin
715
University, contains, besides the vacuum pumps, a
purifying apparatus to absorb the additional gases
and thus obtain the pore concentrated radium emana-
tion gas. Fig. 3 presents schematically the apparatus
employed in the writer's laboratories. It consists of
two independent units, so that when one unit becomes
defective the other may be used while the former is
command to measure either the quantity of radium
salts or radium emanation. The unit of measure for
radium emanation is one millicurie, which means the
amount of gamma rays equal to an amount emitted by
one milligram of radium element.
Fig. 4 shows another division of the radium labora-
tories of the writer containing the electroscope and
galvanometer. Unlike the tubes containing the salts,
the amount of radium emanation within the capillary
is constantly changing and therefore a complete record
of each tube has to be kept.
Smrfatt Apflicmlirt W Raibm £mmMm
To prepare the emanation tubes for use on pa-
tients, several tubes of a desired strength are placed
parallel in wooden or brass boxes of the necessary
dimensions. These boxes act as additional filters since
the glass and the % mm. of silver of the tubes filter
off only the alpha and softest beta rays and create
the correct distance between the radium and the sur-
face of the tumor to be treated. When the configura-
tion of the diseased area is irregular a perfect mould
can be prepared of dental compound and the tubes
scuttle ar.win* 0c the set of pUa.p» of ths »P™»d ™ >*• FiK- 5 "to** applicators for various
i apparatus. A— Electric pomp; B— Tube lending parts of the bodv.
from safe; C— Purifying system; D— Last receptable flask; -,,,,, ,. , ,
b— Capillar j glass tobe. By all these methods a more or less large quantity
beine- corrected °^ ra^'um '•"■nation is placed at one of the surfaces
When the purification of the emanation is completed of the tumor, left for a number of hours and then
it is driven into the last reeeptacle flask (Fig. 3d) of removed. Even when an applicator is placed inside
the apparatus and from there into a long capillary <>* "" organ, like the rectum, uterus, esophagus, etc.,
glass tube (Fig. 3e). The capillary is then sealed in relation to the tumor itself, the radium is placed on
off and divided into small tubes of from 12 to 3 mm. the surface of it.
long and abont 0.5 to 0.3 mm. in
diameter. The longer capillary
tubes are immediately placed in
silver capsules Ya mm. thick and
16 mm. long, coated with multi-
colored enamel for the purpose of
identification. Three and one-half
hours later, when a sufficient
amount of radium emanation has
changed into radium A, B and C,
and the gamma ray activity within
the capillaries reached its equilib-
rium, the contents of the tubes
are measured by the aid of an
electroscope or galvanometer type
of measuring apparatus. The
principle of the measurement is
based on the fact that the gamma
rays of radium ionize the air
within the ionization chamber of
the apparatus and the intensity of
this ionization is commensurate
with the quantity of the gamma
rays of radium. This indirect
i the only one at our
The measuring division of t
Ion lis Hon chamber naed In
Cancer Therapy — Levin
facrat
*ns> Applictitm W ftmW Tito tt JtariaM E«MliM
This method presents a comparatively new departure
in radium therapy, but the results up to the present
are so gratifying that the writer is convinced that it
is certain to play a most prominent part in the future
development of the whole Held of radiotherapeutics.
For this method the radium emanation and not the
long, containing between 0.3 and 1.5 millieuries of
radium emanation are inserted by the aid of a trocar
(Fig. 6) into the tumor tissue and left there. The
capillaries may be sterilised either by boiling or
immersion in a solution of iodine and then in alcohol.
These tubes exert a comparatively weak but eontinn-
Fig. 6. Set of applicators for surface application of ra-
dium. 1 and 2 shows an intra laryngeal applicator devised
by Dr. 8. Yankauer. 3 la a rectal applicator devised by the
writer, the perpendicular rod of hard rubber is used for
protection of the operator while opening and closing the
applicator, i shows an applicator which may be used for
oesophagus or as an Intracervlcal applicator. B shows a
match box. 7 shows a special mould of dental compound to
conform to a case of carcinoma of the tongue.
1 and 2 show different
rubber handles a
rotection of the
■f bare capillary glass ti
salts of radium must be employed. The technique
is as follows: Bare capillary tubes about 3-5 mm.
pa- --
a mlcropbotograph of a
spleen of a rabbit into which a bare tube of radio m emana-
tion was Inserted. At A la seen the necrotic area; B micro-
photograph of a crown gall Into which a bare radium ema-
nation tube waa inserted; A aaowa a protecting cushion of
cellulose surrounding the necrotic area.
oub action on the tissues which lasts for several weeks.
The cumulative action of one millicurie is calculated
to equal 132 millicurie hours, or in other words,
equal to one milligram of radium salt applied to the
same area for 132 hours. However, the action ex-
erted on tissues by the buried tube of emanation is
entirely different qualitatively from the surface appli-
cation.
Depending upon the mass of the tumor, several
Phila., October, 1922]
Cancer Therapy — Levin
717
such tubes are inserted at accurately determined dis-
tance from each other and also at a correctly safe
distance from the neighboring normal tissues. The
tumor tissue immediately surrounding the capillary
is influenced by the soft beta rays and becomes
necrotic. (Pig. 11.) This area of necrotic tissue
seems to act as a filter and the next zone of tumor
tissue is influenced only by the hard beta and gamma
rays. As an ultimate result the tumor is replaced by
a connective tissue capsule which wholly encloses the
glass capillary, which by that time becomes inert and
causes no discomfort to the patient. The studies of
the writer with Dr. M. Levine on crowngall — a plant
tumor — have shown that the necrotic area is sur-
rounded by a protecting cushion of cellulose.
Aipmrntrnges •* tk* Mttimi
Tumor tissue is destroyed much more promptly and
by a much smaller quantity of radium by this method
than by surface applications. The necrotic area sur-
rounding each capillary is very small, and if they do
not contain much more than one millicurie of emana-
tion and the tubes are not placed too close to each
other, there does not take place any severe general
sloughing. In the course of the last two and a half
years the writer has used this method extensively in
cases of intraperitoneal tumors (carcinoma of the
gastrointestinal tract, the uterus and ovaries, hyper-
nephroma ta and retroperitoneal tumors).- A laparot-
omy is performed and when it is found that the tumor
itself is inoperable, t. e., cannot be radically removed,
then instead of palliative procedures or mere explora-
tion, emanation tubes are introduced into the tumor.
The patients make an uneventful recovery, there is
no rise of temperature, no peritoneal irritation or
subsequent sloughing of the tissue. In a word, the
insertion of radium emanation does not add in the
least to the hazard of the operation. The tumors
shrink considerably and the final effect of the irradia-
tion is usually noted in about six weeks.
This method seems to present an ideal combination
of surgical removal and an irradiation. Each such
intratumoral insertion of radium emanation should
be followed by surface applications of radium emana-
tions or by X-ray treatment of the periphery of the
tumor for purposes of prophylaxis.
The EMciemey •/ Rmimm
The perusal of the foregoing pages and a close
analysis of the mechanism of the action of the various
methods of radium application clearly indicate that
radium is the most efficient single agent in cancer
therapy. Intratumoral application of radium may
destroy the primary malignant tumor as completely as
does surgery. A surface application of a few grams
of heavily filtered radium at a distance of, say, 30
cm. from the skin of the patient, will on the other
hand, deliver a beam of rays by far more homoge-
neous and penetrating than any machine constructed
by human mind and hands ever will be able to do.
The efficiency of radium is in reality limited less by
its potentiality than by its cost. It is the writer's
conception that radium should stand in the center of
the problem of cancer therapy, and surgery and X-ray
therapy be placed at both ends as complementing the
action of radium. If the statement is still generally
made that surgery is the main method of therapy and
all radiotherapy is only assisting the latter, this is
merely a concession to the former achievements of
surgery. In the next chapter an attempt will be
made to give a true evaluation of the place of the
X-rays in cancer therapy.
Fimd Section imNovttmbtr
The second and concluding section of
Cancer Therapy'9 will be published in the
November issue.
a
Children Pay Penalty for And- Vaccination
Propaganda
As ever in the history of smallpox, the case-inci-
dence of new outbreaks is greatest where the influence
of anti-vaccination propaganda is most effective. The
unvaccinated children are the chief sufferers. This
fact is shown on a gigantic scale in the recent ex-
perience of the Philippine Islands.*
Students of the prevailing world-wide menace of
smallpox have seen many statements from anti-
vaccination propagandists that the sad experience
of the Philippines in 1918 and 1919 was a repudiation
of the principles of modern public health measures
for smallpox suppression. These statements are mere
allegations that 50,000 smallpox deaths occurred in
the face Qf systematic, persistent vaccination. The
real truth is that the practice of effective vaccination
had been exceedingly lax since the general campaign
of 1909 or thereabouts and that most of the 50,000
deaths occurred among the children and other ele-
ments of the population unprotected by the indiffer-
ent pursuit of vaccination in recent years in the
Islands. The age statistics given by Drs. Heiser and
Leach for Pangasinan and for Manila show a pre-
dominance of both cases and deaths among the un-
vaccinated. A careful review of these facts will make
it possible for American health officers to refute
the diligently circulated misstatements of the anti-
vaccinationists. — Statistical Bulletin Metropolitan Life
Insurance Company.
•Heiaer, Victor G.f and Leach, Charles N.t "Vaccination in the
Philippine. Still Effectnre," Jour. Amer. Med. Asto., July 1, 1921,
p. 40.
718
Pathological Personalities — Boehme
[The
PATHOLOGICAL PERSONALITIES'
An Opportunity and a Duty of the General Physician
VITAL PROBLEM; WIDE EXTENT LITTLE REALIZED; INCIPIENCY RECOGNITION DIFFICULT YET INDISPENS-
ABLE FOR SUCCESSFUL RESULTS; OVEREMPHASIS OP LABORATORY TESTS; LACK
OP RECOGNITION OP THE ELEMENT OP PERSONALITY.
By Gustav F. Boehme, Jr., M.D.,
609 Haas Bldg., Los Angeles, Calif.
It is the author* 8 belief that ours is an age
of increasing insanity and mental defective-
ness, the basic principles of which hinge
closely upon "pathologic personality''
Something undoubtedly must be done, and
Dr. Boehme indicates a large opportunity
for the physician to prevent if possible and
to cure where possible these unhealthy mental
states. — Editors.
WHEN I was studying rhetoric, some years ago,
a rule of description that was given us was, that
in order to produce a clear mental impression of a
scene or an event it was necessary to assume a point
of view and to paint the word picture with this
position constant. When I approached the problem of
personality I soon found that there was no such
constant vantage point, no rock upon which to plant
the mental feet firmly. And from the recesses of the
mind a Shavian recollection intruded itself. I was
reminded of the story Shaw tells about himself. It
seems that upon one occasion he worried about his
vision and to make sure that all was well he consulted
an ophthalmologist, who pronounced his eye-sight
"normal." Shaw, however, was disappointed. Turn-
ing to the doctor he said, "You don't mean to tell
me that my eyes are like every one else." (For, said
h*, I did not want to be like every one else.) "No,"
replied the physician, "your eye-sight is rare, indeed ;
it is exactly perfect, emmetropic, and that seldomly
occurs." And said Shaw, "I was happy, for now I
was able to explain to myself why I saw so much
more clearly than others, my eye-sight was not be-
fogged by mal-adjusted spectacles."
Here, also, was my predicament. I did not know
what was normal, I did not even have a norm by
* Read before a stated meeting, Los Angeles Neurologic
and Psychiatric Society.
which to measure personality. I have, therefore,
deemed it best in this brief review to leap from
mountain top to mountain top, to shift the view eon*
tinually, to try to arrive at some conclusions at to
what after all "pathologic personality" signifies.
My attention was first drawn to this matter
some years ago when examining school children and,
later, prostitutes and public offenders for so-called
mental defects. At first the matter seemed a simple
one. The Goddard revision of the Binet scale seemed
an easy way out, but soon we found that the actual
measurements missed certain salient factors. Then
came the use of the point scale of Terkes. This
offered a better solution for our problems, yet there
was a feeling of something missing, so many evidently
peculiar cases were falling outside the realms of
these apparently positive tests. The Terman scale,
the various form-board tests, the picture scales, per-
formance tests, mechanical tests, all seemed to miss
fire.
I remember comparing the reactions of various
groups of subjects to the mechanical tests. It was
interesting to see competent mechanics utilize the
"look and try" method, and then to see groups of
Army officers, of physicians and other workers, essay
the same tests, all reacting differently. Again it
might be noted that Terkes himself stated that a
great many competent individuals failed in the
various mental tests simply from the fear of appear-
ing ignorant In other words, there were factors
well outside of the definite, ponderable reactions of
the psychologist that were at work to modify so-
called exact judgments.
Cm We Drep At Actitu PmUerm?
Barrie, in his play, "Dear Brutus," makes the point
that were we given a second chance we would repeat
our former lives, simply because we would not be
able to overcome our action patterns. And so, when
dealing with the individual, the personality factor
becomes of vital importance. But how approach itf
Personality is a complex matter. Let me quote two
accepted definitions. Says Coleridge, "Personality
PhB*., October, 1922]
Pathological PeraoaaHties — Boehme
719
is individuality existing in itself, but with Nature as
a ground"; or, again, I find in Webster, "Personality
implies complex being or character having distinctive
or persistent traits among which reason, self -conscious-
ness and self -activity are usually considered essential."
Both are but conglomerations of words that define
but poorly the vague mental concept we have in our
minds when we use the word. Burroughs, in his
"Breath of Life," says: "We have the words and
they shape our thoughts.'* That is the difficulty in
all so-called psychological and philosophical discus-
sion; we play around with phrases and have no
clear pictures in our minds.
The individual is complex. He consists essentially
of a phylogenetic entity and an ontogenetic entity,
to which may be added the ethical self. The phylo-
genetic entity is to the individual the resultant of
race development plus the individual passing into the
next generation. As Shaw says, we are ever passing
through a door which we never quite reach. So per-
sonality is in the first place the result of race move-
ment, the result of heredity, and secondly the result
of movement forward, as exemplified by our limita-
tions, by current opinions and customs. To have
killed an individual who stole my horse some time
ago would have been a normal reaction; to do so
today would be evidence of disease, a perversion of
the moral sense and a violation of our present codes.
Again, we live our own lives; our ontogenetic self
lives and reacts to our welfare. To be clean, to
bathe daily, is today a strict necessity, yet it is only
yesterday that the bath tub was used as a coal bin,
that Saturday night was bath night, and it is only
two centuries ago that the church forbade bathing as
immoral, in certain communities. So we could run
the gamut of personal reactions for the individual's
welfare, and find that each one chooses for himself
what he deems best, and that that choice is oft times
regarded as pathological by others.
And, again, one views the ethical phase. It is easy
for the law to state that insanity consists in the lack
of knowledge of right and wrong, and one of our
members stated not so long ago that a dog or a cat,
yes, even a clam, knows the difference; but one can't
get off quite so easily. Read Kant's "Critique of Pure
Reason," compare it with Janet's "Theory of Morals"
or Wundt's "Ethics" and one soon learns that even
here learned minds differ. On one hand stand the
proponents of "Duty," which is the measure of right,
is right itself; on the other we find those who stand
for the existence of natural knowledge of good, and
between them those who speak of acquired and nat-
ural right.
ttyeUUgy mmi laumity
And as personality contains all these elements —
plus — shall I say action pattern — to pronounce an
individual pathologic or insane is not as simple a
problem as it would seem on the surface.
However, certain things have been clearly dis-
tinguished and an attempt will be made here to point
out the salient factors. The approach by age periods
probably offers the best solution of the difficulty.
Baby psychology or baby abnormality mentally has
not been as yet clearly defined. Baldwin has probably
done the best work in this field. Even here, however,
we are able to distinguish personality differences.
The crying babe, the laughing babe, the well-behaved
infant, the "enfant terrible," all point to differences
of make-up early in the plan of life. I believe that
here a great many deviations in personality might be
produced, especially if parents were cognizant of the
fact that the baby early acquires habits, or lack of
habits, and duties, or lack of duties. Regularity,
proper hygienic surroundings, low-voiced conversa-
tions, equability in the home, are potent factors in
the building of the coming child and man.
From the third year to puberty children vary
markedly and personality differences are clearly de-
fined. A child may pass his age test and yet differ
materially from another child with the same score.
One is active, playful; the other is quiet, thoughtful;
a third may be looked upon as pre-precox, and never
arrive there.
Again, certain primitive or atavistic influences
seem to change personality. One child runs away;
it measures up well, yet .the Wanderlust" is there;
another delights in making fires — a juvenile pyro-
maniac — a third cannot tell the truth, a fourth steals
whenever it has the opportunity. Tet all of them
appear normal, or rather like other children otherwise.
This will be brought home to an observant psychol-
ogist or medical advisor when making mental tests,
that one child moves rapidly and attacks problems
entirely differently from another. Temperamental
and personality differences are marked.
Any one observing these children over some period
of time would soon begin to classify them and if he
makes later tests, say, at graduation from school,
would be surprised at the difference in end-results
obtained by modern education. He will find the
mechanically inclined, the child with literary predis-
positions, the musically, the artistically predisposed,
all coming out of the same pedagogical stew-pot.
But, more than that, he will find children who are
"shut in" apparently, who seem headed straight for
dementia precox; or, again, he will find individuals
with marked psychic or motor unrest who seem pre-
disposed to manic depressive insanity. It is surpris-
ing however, HOW FEW GET THERE. In reading
over the childhood of some of the world's greatest
personages insanity might easily have been predicted
for many of those who were later to lead men, to
720
Pathologic*! Personalities— Boehme
[The
carve their names on the pyramids of posterity.
DmBctmm
With adolescence come other changes in personality.
Here develops waywardness in girls, and too often
criminal tendencies in the male sex. The police heads
are disposed to believe that a great many cases of
prostitution begin here, and what is more remarkable,
that a type of woman exists who is a prostitute by
nature. The Rockefeller investigation showed that
but few girls were led astray; that they wanted
the life. In frequent conversations with this type of
woman I have often, in attempting to offer other
modes of living, been repulsed by them. Asked if
the frequent promiscuous contacts made no difference,
these women have frequently told me that they en-
joyed the variety. Certainly a pathologic reaction, if
our present standards are correct. Yet these indi-
viduals are not below par. I have frequently been
amused by figures showing the per cent, of so-called
mental defect in these women, but that percentage
has never been checked off against an equal group of
so-called "normal" women.
Combativeness, the gang spirit, physical brutality,
develop in the male as secondary sex characters. In
"normal" individuals these can be directed into
"normal" channels with ease; with the pathological
types, with great difficulty, and sometimes not at all.
Here also develop the first signs of "inadequate
personality," builders of * castles in the air, the
"manana" type. I have seen much of this group in
teaching and in vocational guidance work. The wish
to do is there, but the consummation, never. How-
ever, these individuals can be harnessed mentally and
under guidance generally make good clerks, secretaries
or underlings, and in spare moments write harmless
verse or join the Christian Science church or other
cults. Give them an anchor and they are harmless,
but let them go about of their own free will and they
develop into criminalistic types. Their superficial
brilliancy often times overshadows their inadequacy
so completely that their dangerous aspect is forgotten.
It is this type that are tools of "Red Leaders,"
rioters, gang heads or other strong criminal types.
Eccew&ncths$
In adult life these types still exist, but differences
are more clearly marked. The "crank," the "nut,"
may appear pathological when, perhaps, in the next
generation he may be looked upon as a far clearer
thinker than his fellow-man. Whitman, striding
bare-headed through the streets, living in squalor,
was a fool, yet he revolutionized modern poetry.
Thoreau, giving up Harvard, refusing its diploma
because he said it was not worth five dollars, living
in a shack, becomes America's greatest philosopher.
Emerson is reviled. St. Gaudens is laughed at.
Millet is called the crazy painter. All had personality.
One could cite the eases of many great men who had
distinctly pathologic personalities, who were the idols
of posterity.
Mm—m Grmp§
It seems to me that when we enter the field of adult
personality that we have no standard, and the nearest
approach I can make to the problem is to classify
people into the following great classes:
(1.) Those who react in general as their fellow-
men. These are the "poor norms'' or "happy norms,*
as you will, who do the greatest part of the world's
work, who never dream, who plod along and procreate
more of the necessary norms.
(2.) Those who are pathologically beneficial to the
community. They may have all the ear-marks of
pre-dementia precox or pre-paranoia, but they do
create new thought and advance civilization.
(3.) Those who are pathologically detrimental to
the community. These may or may not be legally in-
sane, but their reactions are out of gear with what is
considered best for the communal good.
(4.) And, finally, there remain those who are
always inadequate, who may be molded to either the
benefit or detriment of the community.
Tk Omit •/ ftrtmdkf
In the light of latter-day researches I cannot pass
over the relationship of the endocrine system to
personality. Undoubtedly this vital organ group is
potent in the development of temperamental changes.
Thyroid types are common. If a thyro-praevic
condition is present we have apathetic states. If
hyperthyroid conditions exist we have emotional in-
stability and peculiarly a love for music.
Pituitary types are, if excess secretion is present,
usually markedly artistic and emotional. If decreased
secretion exists there seems to be a slowing up of the
mental processes.
Gonadic hypersecretion tends to the production of
hyperactivity mentally as well as physically.
But this field is still being worked out. Suffice it
to say that Cannon, Crile and Fraenkel have set out
fairly well the personality factor as related to endo-
crine dyscrasias.
Again, disease processes already present in an
individual may act to vary his type. It is interesting
to note how mental giants have suffered from infec-
tious diseases. Chopin and Stevenson were tubercular,
and not long ago some one, in going over the list of
phthisical individuals who have achieved fame,
wondered whether it would be necessary to inoculate
the human race with disease to produce genius. The
students of consumption have all called attention to
the unusually optimistic frame of mind and the bril-
liancy of the intellect of the average tubercular.
Syphilis also acts to produce personality changes, but
usually in a detrimental manner, for paresis is a
deteriorating psychosis, yet one cannot pass lightly
Phila., October, 1922]
Pathological Personalities — Boehme
721
over Benvenuto Cellini, whom Jelliffe has diagnosed
as paretic from his autobiography. Here an individual
apparently in his pre-paretic stage has drawn a
remarkable picture of his time that is classic and has
also managed to create lasting artistic objects. This,
however, is the rare instance.
Climate, too, seems a potent modifier of personality.
Faurot, Deputy Commissioner of Police of New York
City, has pointed out the variations of crime due to
climatic and geographical location and certainly the
keen observer will note dispositional changes with
variations in the meteoric states. That the weather or
temperature, per se, change personality I doubt. But
the grey day, the rainy day, the bright day, cause
varying reactions in individuals according to their
"action patterns'' and are, at times, the immediate
cause for apparently pathological reactions.
It is thus evident that personality may be modified
by many factors and that to pronounce an opinion of
a pathological state is wrought with many dangers.
However, our purpose here is TO DO SOMETHING
to prevent and to cure, if possible, these states. To
do so requires the establishment of a norm, and that
standardization should rest in the hands of the neuro-
psychiatrist and not those of the psychologist; or,
better yet, a co-ordination of both will bring best
results.
The well-established psychoses are comparatively
easy of demonstration. Border-line states require
much careful consideration. But — and here is the
crux of the matter — can we foretell psychoses in their
incipiencyf Can we prevent them if prognosticated f
Pre-paretic states are usually accompanied by
somatic changes that clear the way to treatment. But
the pre-precox, the pre-paranoiac, the pre-epileptic
manifestations, are today practically impossible of
solution. It is easy to argue "ergo hoc, propter hoc"
when making a retrospective diagnosis, but is it
possible to look forward and tell which individual is
pathological mentally f To date I think not. Ec-
centricity, unusual reaction to stimuli, peculiar trends
may be suggestive, but that is ALL. When these
states are recognized a careful study of the individual
becomes necessary.
Our task, however, must be divided. Parents must
be educated in parenthood. This is one of the failures
of all modern education. The average male is not
fitted to be a father. Most women were educated to
a degree in motherhood. Today's mad rushing after
pleasure, gaudy attire and so-called sexual freedom is,
however, rapidly destroying the "mother of yester-
day." The understanding of the child, of its develop-
ment, should be brought home in all our high schools,
at least.
The teacher should, as part of his or her training,
be prepared to note mental peculiarities. The school
records should contain, besides the marks and the
statements of nutrition and tonsillar removal, each
teacher's estimate of the child, a record kept much as
employment cards are maintained in large factories of
today. They will act as guides to vocations as well
as indicating pathological mental reactions.
Psychiatrists should be attached to all educational
systems, not to replace psychologists, who obtain some
of the symptoms, but as experts in medical diagnosis,
to sum up the total picture as worked out by the
parent, the teacher and the psychologist, as well as
the physician.
In this way we can, perhaps, establish norms of
personality definitely, and by grouping accurately,
not in the vague impressionistic manner utilized today,
the mental inequalities, perhaps it will be possible to
point out a pre-paranoia or a pre-precox or other
mental state.
A word before closing this topic. Today is an age
of increasing insanity, of mental defectiveness.
Everywhere crime is increasing, acts of violence are
becoming more common. It has been easy for super-
ficial thinkers to attribute the great unrest to the
"World War." While it, undoubtedly, has played a
part, it seems to the writer that the basic principles
have not been recognized, and they hinge closely upon
"pathologic personality." We have gradually, but
surely, been getting away from the basic principles of
DUTY, TRUTH and WORK. The seeking of the
easiest way out, instead of the appreciation of the
problem and its direct solution by work, is the mode.
I recently talked to a pedagogue about making school
lessons work combined with responsibilities and he
insisted that everything in life should be made pleas-
urable, that effort should be reduced to a minimum.
It is to be wondered whether he realized the pleasure
and the beneficial effect upon the individual of work
and duty accomplished for the sake of that work and
that duty alone.
Modern life is producing pathologic reactions. A
recent film caption read, "She was just like 100,000,000
other Americans, she wanted what she wanted when
she wanted it/' We are losing our poise, our con-
ception of the basic principles of right and wrong
and are developing "Detrimental Pathological Person-
alities." Therefore, it seems to me that we must take
a stand in the matter. Just how to do so is a problem
for all of us. It seems to me that the way out is for
the physicians to form committees for study of the
pathological forces at work everywhere, and especially
it would seem that we should make an intensive study
of the developing child, besides taking an active part
in his education. The basic principles of duty and
work, properly instilled, will do much toward the
prevention of "Pathological Personalities."
722
Ectopic Prcgaaacy —
[The
Early Recognition the Vital Factor
m
ECTOPIC PREGNANCY
DIFFICULT DIAGNOSIS CONSTITUTES A PROBLEM REQUIRING THE PHYSICIAN'S KEENEST ABIUTY
By Gilbert I. Winston, M.D.,
344 North Fifth St., Reading, Pa.
Few conditions are as dangerous as ectopic
gestation. Few conditions require as prompt
and as efficacious attention as does this fatal
disease. The excellent recapitulation herein
presented, together with the cases illustrating
the points dwelt upon in this paper, should
prove of interest and value to both physician
and surgeon. — Editors.
THERE ARE FEW abdominal conditions, which
if kept in mind will aid so much in preventing
serious consequences if recognized early, or saving
life if recognized later, as ectopic pregnancy. By
ectopic pregnancy or extra-uterine pregnancy we
mean a pregnancy taking place outside the uterus.
Pregnancies taking place in abnormal positions of
the uterus are not classified as ectopic pregnancy,
even though their termination might be just as serious
as ectopic pregnancy.
The ovum may be fertilized and become attached
at any point between the ovary and the uterus. The
most frequent tubal pregnancy occurs in the median
part of the tube, secondly, in the ampullary part of
the tube, and thirdly, in the uterine or interstitial por-
tion of the tube. The least frequent of primary extra-
uterine pregnancy occurs in the ovary.
As the ovum continues to grow, the part enveloping
it is stretched or distended. Adhesions or inflammatory
changes take place around it and, finally, the part
ruptures.
When the tube ruptures the consequences depend
on the location of the rupture. The fetus escapes
into the adbominal cavity if the upper part of the
tube is ruptured and is called tubo-abdominal preg-
nancy. If the lower part of the tube ruptures be-
tween the folds of the broad ligament, an intraliga-
mentous sac is formed. If the sac in the interstitial
portion of the tube ruptures, the fetus escapes into
the uterus and is spoken of as tubo-uterine pregnancy.
If the ovarian pregnancy ruptures into the abdominal
cavity it is called ovario-abdominal pregnancy. All
these pregnancies, however, are secondary to the
primary implantation of ovum and occur after the
containing part ruptures and dislodges the fetus into
the surrounding structures.
The causes of ectopic pregnancy are numerous and
all more or less theoretical.
1st. Inflammatory conditions of the tubes and
ovaries, particularly gonorrheal infections. This acts
by either causing congestion and swelling of the walls,
thereby occluding the lumen of the tube and thereby
preventing the passage of the ovum ; or by causing a
gluing of the mucous membrane of the tubes; or by
forming blind pouches which catch the ovum or by
causing loss of the cilia.
Tumors within the tube or pressure of any kind
from without against the tube also causes an obstruc-
tion to the passage of the ovum. Pelvic adhesions
bind down tubes and ovary and occlude the lumen.
Cases of long standing, sterility, and disease of the
corpus luteum are all given as causes.
Ectopic pregnancy may occur as first pregnancy in
women married for some length of time without having
been pregnant, or it may occur in multipara who have
not been pregnant for some years or it may occur
shortly after a puerperal infection or abortion. A
pregnancy can occur simultaneously in both tubes or
a tubal pregnancy accompany a normal uterine preg-
nancy— an illustration of which will be described
later.
The most common form of ectopic pregnancy is
tubal pregnancy. The ovum burrows its way into and
implants itself in the walls of the tube, corresponding
to pregnancy in the normal uterus. A decidua may or
may not be present, but usually a decidual tissue is
found around the implantation of the ovum. As the
ovum grows the tubal wall is stretched, causing the
lumen of the tube to be occluded and a necrosis of
the cells of the tube opposite the ovum. At the same
time the villi erode their way between the muscle
fibres and the blood vessels. Conditions in the tube
are quite different from those present in the uterus. In
the uterus the decidua is thick and the mucous mem-
brane acts as a protective membrane. The blood
vessels are small and the muscle fibres of the uterus
Phila., October, 1922]
Ectopic Pregnancy — Winston
723
are capable of much stretching and hypertrophy. On
the other hand, in the tube there is little or no decidua,
the blood vessels are large and the muscle fibres are
not adapted to marked stretching and hypertrophy.
The villi soon eat their way into the blood vessels and
muscle fibres of the tnbe and cause a destruction of
same.
The ovum now continues to grow, causing at the
same time a slight hypertrophy, stretching and over
distention of the tube. About the second or third
month, usually due to some traumatism as straining
at stool, coitus, bi-manual examination, a sudden jar,
one of two conditions occur1 — either a rupture or tubal
abortion*
Rupture usually occurs when the pregnancy is in
either the isthmic or interstitial portion of the tube.
This rupture may be one of two kinds — intraperitoneal
or retroperitoneal. If the rupture is intraperito-
neal the fetus is usually discharged in the peritoneal
cavity and with it concomitant hemorrhage and hema-
tocele is formed. Shortly after the blood reaches the
peritoneal surface, it has a tendency to clot and the
peritoneal surface also throws out fibrin, which causes
the formation of adhesion between the tubes, intes-
tines or the various abdominal viscera enclosing the
free blood between these structures. This collection
of blood between these walled off structures is called
an hematocele. If the hemorrhage is continuous or
repeated, the newly formed sac may become over-
distended and rupture, causing a second hematocele
and in this way the woman may become very anemic
and die of repeated or continuous loss of blood.
At times the hemorrhage is very acute and profuse
and the woman in a short time may die of shock or
hemorrhage, or if she survives a large hematocele is
formed.
If the rupture is retroperitoneal, the hemorrhage
usually takes place between the two layers of the
broad ligament, the blood extending to the side of the
uterus and to the lateral wall of the pelvis. This
hemorrhage is controlled, as a rule, by the pressure
due to the limited and confined space of the broad
ligament and this is termed a hematoma.
Tubal abortion takes place when the tubal preg-
nancy is in the fimbriated end of the tube because the
ovum is near the open end of the tube. The abortion
usually takes place into the abdominal cavity and the
pregnancy, if continued, has its sac adherent to the
intestines, uterus, ovaries, or omentum. The placenta
usually becomes attached to the tube, ovum, uterus, or
abdominal wall.
When the pregnancy is in the interstitial part of
the tube, abortion takes place into the uterus, but
this is a rare occurrence.
Ovarian pregnancy is a rather rare form of ectopic
pregnancy and is usually secondary to tubal preg-
nancy. Tubal pregnancy may become detached from
the tube and attached to the ovary and in that way
give the impression of being a primary ovarian preg-
nancy. To be certain that this is a primary ovarian
pregnancy, we must make sure that the structures
outside of the ovary are completely intact.
As the ovarian pregnancy continues to grow, it
distends the ovary and finally causes it to rupture,
causing the same effect as was previously described in
tubal pregnancy, namely rupture or abortion with
their after-effects, hematocele or hematoma.
After tubal abortion takes place, the fetus and
blood clote are usually absorbed. When tubal rupture
takes place, if the placenta becomes detached by
hemorrhage or is torn, the fetus usually dies and is
absorbed and the blood clots usually undergo lique-
faction and absorption.
If the fetus escapes alive, it continues to grow as a
secondary abdominal pregnancy. The fetus may
escape either by itself or inside the amniotic sac. A
new sac is now formed by the adhesions set up to the
intestines, uterus, omentum, or abdominal wall. The
placenta may be attached to either of these structures,
but is usually attached to the organ adjacent to its
primary attachment. The blood vessels in the
structure around the placenta enlarge and increase in
number to a marked extent.
The child continues to grow until term. At term
the placenta usually becomes separated from its
attachment by hemorrhage and the fetus usually
dies. After the death of the fetus, either at term or
earlier, spurious labor sets in, at which time the
uterine decidua is thrown off.
After the death of the child, the soft parts become
macerated, the amniotic fluid becomes absorbed, the
remaining mass undergoes suppuration — the pus find-
ing its exit through the adjacent structures, either
the bowels, bladder, vagina or abdominal wall.
The other termination is mummification in which
the child is dried up, calcium salts deposited, giving
us a lithopedion which may be present in the abdomen
for years.
During ectopic pregnancy, the uterus hypertro-
phies the same as in a normal pregnancy up to the
size of a three-month pregnancy and contains a
decidua which is usually thrown off when uterine
contractions set in.
Combined extra and intro-uterine pregnancy is
rare, and when present, uterine abortion may preceed
or follow tubal rupture. In either case the condition
is grave. If the tubal pregnancy is recognized and
removed, the uterine pregnancy may go to term.
The symptoms of ectopic pregnancy vary markedly,
depending on the stage of the pregnancy and the
degree in which the changes take place. As a rule the
patient gives a history of having missed one or two
menses and complains of a colicky pain on one side
of the pelvis, due to uterine or tubal contraction.
724
Ectopic Pregnancy — Winston
[The America* Physkiin
There is usually a slight bloody discharge from the
uterus which is usually dark in color and makes one
think of an abortion. The concomitant symptoms of
pregnancy — nausea, morning vomiting, headache, etc.,
are usually present.
In other cases the patient has no prodromal symp-
toms and the first symptoms are after straining or
coitus, those of a ruptured tube or tubal abortion,
namely extreme pelvic pain, dizziness, pallor, uterine
bleeding, shock and the symptoms of internal
hemorrhage, cold, clammy akin, pallor, rapid feeble
pulse, air hunger, etc. There is usually irritation of
bladder and rectum, causing frequency of urination
and diarrhea.
These symptoms may be of such severity as to
cause death in a few hours, or the patient may react
from this primary rupture and hemorrhage and in a
few weeks, with an increase of blood pressure, have
another rupture and possibly die as the result of
shock and hemorrhage. As a rule, in cases of ectopic
pregnancy the shock and symptoms of hemorrhages
are out of all proportion to the actual amount of
blood lost and the shock is partly caused by the
sudden contact of blood with the peritoneum. A
bluish discoloration around the umbilicus has been
described as present in extra-uterine rupture with
hemorrhage.
On pelvic examination before the blood has clotted
in the first twenty-four hours, nothing is revealed,
but symptoms of pregnancy. After the first twenty-
four hours when blood has dotted, a mass is felt in
cul-de-sac if rupture has been intraperitoneal or
hematocele is present. If rupture has been retro-
peritoneal, a hematoma is felt in broad ligament
extending from side of the uterus to pelvic wall.
The patient now usually shows signs of a low
grade pelvic peritonitis — pain, nausea, vomiting, con-
stipation or diarrhea, a slight fever, rapid pulse,
anorexia, slight jaundice, frequency of urination and
pain and tenderness of the lower abdomen..
The symptoms may continue for several weeks, at
which time the clots may be absorbed and the symp-
toms subside. In other cases the blood clots may
undergo suppuration, in which cases the symptoms
above described become exaggerated, namely, pulse is
increased, temperature rises, pain and tenderness
increase, nausea, vomiting and symptoms of cachexia
and absorption soon become manifest. If this proc-
ess is not interfered with, the suppurating mass
usually evacuates into the intestines, rectum, bladder,
abdominal wall, causing a purulent sinus, and thereby
giving an exit to the pus. If this does not take
place, the patient usually dies of sepsis.
If after the rupture, the fetus continues to grow,
symptoms of peritoneal irritation arise, namely,
abdominal pains and tenderness, nausea, vomiting,
diarrhea or constipation, frequency of urination, and
loss of strength. Fetal movements are more pro-
nounced than in uterine pregnancy. The symptoms
and signs of pregnancy continue and the abdomen
enlarges in size. The enlargement may be median or
assymetric.
If the fetus dies, the symptoms and signs of preg-
nancy disappear and the patient soon develops the
symptoms of a decomposing foreign body — the symp-
toms of toxemia or sapremia — anorexia, subnormal
temperature, rapid pulse, jaundice, coated tongue, loss
of weight, etc. If this process is not relieved by
surgical procedure or by suppuration into the bowels,
bladder, or abdominal walls, the patient dies of
sepsis, peritonitis or exhaustion.
If the fetus becomes calcified — lithopedion forma-
tion, the symptoms of pregnancy disappear, involu-
tion of uterus takes place and the symptoms of
peritoneal irritation subside.
The diagnosis of early ectopic pregnancy before
rupture is usually made where a woman with a previ-
ous history of pelvic inflammation and who has been
sterile for some time, complains of having missed one
or more menstrual periods, of sharp colicky pains on
one side of the abdomen, with more or less bloody
discharge from the uterus. The patient may complain
of early symptoms of pregnancy, such as morning
nausea and vomiting, etc. On examination, we usually
find softening of the cervix, enlargement of the uterus
and a mass to one side of the uterus. The examina-
tion should be made very gently lest we rupture the
tube by rough manipulation. To make a diagnosis
on the above symptoms would be making a diagnosis
on a classical picture. ' In the average case, however,
all the symptoms are not present and a diagnosis
must be made from a few of the above symptoms.
The diagnosis of the ruptured ectopic pregnancy
is made when a woman who gives the above history,
or who has apparently not complained, with the ex-
ception of possibly having missed one or more
periods, suddenly complains of violent low abdominal
pains, dizziness, and soon becomes unconscious, with
pallor, subnormal temperature, cold, clammy perspira-
tion. On examination at this time, the uterus is soft
and enlarged, there is uterine bleeding and no mass
can be felt in the pelvis. In twenty-four hours a
mass can be felt in the broad ligament beside the
uterus if the rupture has been retro-peritoneal and
resulted in a hematoma, or in the posterior fornix,
pushing the uterus on to either side, if the rapture
has been intra-peritoneal and resulted in a hemato-
cele.
The diagnosis of secondary abdominal pregnancy
is made in a pregnant woman on the history of hav-
ing had slight pains in lower abdomen in first two or
three months of pregnancy, and complains of very
painful fetal movements low in the pelvis, irregular
bloody discharges from uterus, marked abdominal
pain and tenderness, frequency of urination, invalid-
Phila., October, 1922]
Ectopic Pregnancy — Winston
725
ism and various intestinal symptoms. On examina-
ti ', the cervix is found to be soft, the uterus is
empty, though enlarged, and the fetus enmassed on
the outside of the uterus; fetal heart sounds are heard.
The fetus seems to be directly under the abdominal
wall. The abdominal tumor increases in size to term,
spurious labor is present at which time there is
uterine bleeding and discharge of decidua from
uterus.
Ectopic pregnancy must be differentiated from
various other conditions. The first and most frequent
condition to be kept in mind is abortion.
Ectopic
In abortion the onset is The onset is acute and
gradual with regular inter- pains are irregular and eol-
mittent pains in the lower icky and usually confined to
abdomen, resembling labor one side,
pains. The external hemor- On examination hemor-
rhage is usually profuse, rhage is dark in color and
although it may be moder- usually very scant,
ate in amount. The symptoms of shock
The symptoms of hemor- and hemorrhage are out of
rhage and shock correspond all proportion to the appar-
witb the visible amount of ent blood loss,
blood. On examination, the de-
On examination we usu- cldua may be found dis-
ally find the cervix dilated charged from the uterus and
and piece 8 of placenta tissue a mass felt beside the
or fetus in the blood clots uterus,
or in the uterus.
Every case of abortion, however, should be care-
fully examined for ectopic pregnancy by bi-manual
examination before curettement and should marked
shock or collapse come on after a dilation and curett-
ment, one should immediately think of a ruptured
ectopic pregnancy.
At times there is difficulty in differentiating preg-
nancy in retroflexed uterus from a hematocele in the
pouch of Douglas.
RetroMexed Uterm* Ectopic Gtwtation
In retroflexed uterus, there History suggestive of ee-
ls typical history of preg- topic pregnancy. Marked
nancy, and pains and hemor- colicky pain, to one side and
rhages are slight, if present. slight bleeding.
On examination, angle is On examination, angle is
felt at cervix and place felt at cervix and fundus is
where fundus should be is found bi-manually in normal
empty. position and in front of
Fundus is smooth, hard, mass. Mass is irregular,
and movable, and feels like soft, not movable and does
pregnant uterus. not feel like pregnant uterus.
Urinary symptoms are Urinary symptoms usually
present early. present after fifth month.
Further Dimgmttic Cms ufcratioa
It is sometimes difficult to make a differential
diagnosis of an early normal pregnancy complicated
by an ovarian cyst or intraligamentary fibroid from
an ectopic pregnancy unless the physician has pre-
viously examined the patient and been aware of the
pathologic condition. If an operation is performed
in these cases for ectopic pregnancy, this mistake is
pardonable as the pathologic condition can be cor-
rected at this operation.
Ovarian cyst, salpingitis, intraligamentary fibroids,
hydrosalpinx, and similar conditions without any preg-
nancy must be differentiated from ectopic pregnancy.
In these conditions the uterus is found unchanged
alongside the mass — symptoms and signs of preg-
nancy are absent, and the history of the case should
be remembered. In a marked case of salpingitis or
pyosalpinx, we usually get a history of previous
pelvis infection, such as gonorrhea, there is marked
pain and tenderness, leucorrheal discharge, fever, leu-
cocytosis with increase of polymorphonuclear and
the swelling and tenderness is usually in either side
of uterus.
A rupture of ectopic pregnancy must be often
differentiated from a ruptured pus tube or twisting
of ovarian cyst with its pedicle. The points to be
considered are the previous history and the symp-
toms and signs of pregnancy being absent in these
conditions if not complicated by pregnancy, and the
presence of jaundice in ectopic
We must sometimes differentiate appendicitis from
a right tubal pregnancy. In appendicitis we con-
sider the history, the absence of symptoms and signs
of pregnancy, the presence of marked pain and ten-
derness high up at McBurney's point, the fever, leu-
cocytosis, nausea and vomiting and on examination
find the uterus tube and ovaries to be normal.
In ectopic we consider the history, pain and tender-
ness is low and not so marked, absence as a rule of
fever, nausea and vomiting, presence of symptoms
and signs of pregnancy. The patient is anemic and
on pelvic examination we find symptoms of pregnancy
and a mass alongside the uterus is low in pelvis.
From the above description it can readily be seen
that the diagnosis is at times very difficult, if not
impossible, and in such cases the patient should be
watched and be very carefully observed in a hospital
and all pelvic examinations and manipulations made
very carefully with as little traumatism as possible.
Pr+gmosU
The prognosis depends on the time at which this
condition is recognized and the facilities for imme-
diate operation after rupture takes place. If recog-
nized before rupture and operated, chances are very
good. If recognized immediately after rupture "and
immediately operated on, chances for patient are also
good. If rupture takes place and is not recognized
and not immediately operated on, patient usually dies
of shock, hemorrhage or anemia, due to successive
hemorrhages, of suppuration of hematoma or hema-
tocele.
If patient does recover without operation, adhesions
and low grade pelvic inflammation usually remain,
which impair the health of the patient.
TrtutMeut
The treatment comprises two divisions : before rup-
ture and after rupture.
Before rupture, as soon as diagnosis of ectopic
pregnancy is made, abdomen should be opened and
tube containing fetus removed.
After rupture, if called immediately after the at-
726
Ectopic Pregnancy — Winston
[The American Phjricias
tack, the woman is usually in shock. The abdomen
should be immediately opened, tube picked up, uterine
and ovarian arteries clamped, tube and fetus removed
and blood clots removed. This operation should be
done very quickly as the patient is usually in very
poor condition. If the abdomen is filled with blood
that is not clotted, it may be removed in a receptacle
and transfused into vein of patient. Otherwise saline
transfusion should be given immediately after clamp-
ing of blood supply, or sooner if absolutely necessary.
If the patient is seen some time after rupture and
hematoma or hematocele is formed and patient seems
to be improving, patient may be let alone, as the
blood dot and fetus may undergo absorption and
patient make spontaneous recovery. If patient, how-
ever, shows signs of secondary hemorrhage, she should
be subjected to immediate operation for removal of
hematocele or hematoma.
It is wise at all times, if conditions warrant, to
remove hematocele or hematoma, thereby preventing
secondary suppuration and in this way 'speeding up
recovery which without operation extends over a
period of several months.
The treatment of secondary abdominal pregnancy is
operation at about eight and one-half months, and
removal of fetus. The sac is usually made up of
bowels, bladder, omentum and abdominal wall, and
the placenta is usually attached to any of these
organs which have a very rich blood supply. The
treatment of sac and placenta must, therefore,
greatly depend on conditions present. If the sac and
placenta can be removed without endangering the
life of patient, it should be done. However, in a
great many cases, removal of sac would cause a
rupture of bowels, bladder, etc., with its marked
hemorrhage and added removal of placenta would
cause very marked and often uncontrollable bleeding.
In such cases sac should be fastened to abdominal
wall, and the placenta removed, if feasible — otherwise
left alone and sac drained, thereby getting rid of the
placenta and part of sac by secondary suppuration,
breaking down of the tissues and drainage.
When the diagnosis of lithopedion is made, this
should be removed to prevent any later suppuration,
and discharge of some of the structures.
c mmi Uttrim Frtgmmtey
C—$ •/ fee*
No. 1. Case of Dr. M. Z. Gearhart. Patient, H. B. ;
age 41. Youngest child eight years of age, last
menses three months ago; was under care of another
physician for uterine bleeding and pain in lower
abdomen for two weeks. Patient was then put to
bed, and vaginal examination showed the opening
in the cervix to be of one finger dilatation and the
uterus the size of three months' pregnancy. D. and C.
was done and fetus and placenta removed. Patient
did well and made good recovery. On tenth day,
when patient was to be discharged, she suffered
severe attack of abdominal pain and symptoms of
internal hemorrhages, shock, cold, clammy sweat, rapid
pulse, air hunger, marked pallor and subnormal tem-
perature. Hemoglobin reached 16%. Blood trans-
fusion was done, hemoglobin increased to 50%. On
examination mass could be felt in left abdomen and
vaginal examination revealed a mass on left side
beside uterus.
Abdomen was opened and found ruptured left tubal
pregnancy, which was removed. Patient made com-
plete recovery.
No. 2. Secondary abdominal pregnancy; ease of
Dr. Darrah. Mrs. L. A.; age 27. Family history
negative. Patient married, has two children, living,
ten and nine years of age, respectively. Has had
a miscarriage between the two children.
Menstrual periods began at fourteen years and
always regular. Duration four days, two pads daily.
No menstrual pains.
Last regular period began June 28, 1921, and in
about two weeks developed some pain in pelvis and
back, accompanied with nausea and vomiting. Patient
was treated for three and a half to four months for
inflammation of the womb. Was able to work in
factory at intervals, but had to stop on account of
pain in abdomen and legs about two months ago
(April 1, 1921). On May 30, 1921, had severe pain
in back and abdomen, but had no medical attention
and no vaginal bleeding. On June 8, 1921, at 7 A. M.,
patient was taken with severe pain in back, but had
no abdominal pain and no bleeding.
Admitted to hospital at 9JL5 A.M. with pain in
back and left side of abdomen, with great thirst and
some slight dyspnoea.
Physical examination showed patient to be wel)
nourished wtih irregular distended abdomen, appar-
ently of about seven months' pregnancy. Irregular
mass in upper right abdomen — below costal margin.
Large soft mass along entire left side of abdomen —
no fetal movements nor fetal heart sounds.
Vaginal examination showed uterus enlarged to
about size of three months' pregnancy and pushed
somewhat to left of pelvis — large boggy mass felt on
left side of abdomen bi-manually — no vaginal dis-
charge.
Patient had great thirst, very restless, and evidence
of air hunger; lips pale and becoming increasingly
so; pallor of fingers and finger-nails gradually de-
veloping cyanotic appearance. Heart rate 130, but
normal in action. Lungs negative.
Median incision — gush of blood immediately after
opening of peritoneum; also large blood dots. Seven
months' living fetus extracted from upper right side
of abdomen from a free position among intestines.
Cord clamped and ligated immediately, ruptured tube
left side. Placenta fastened along side of spinal
column, very adherent. Placenta removed by forcibly
detaching same, and amniotic sac sutured to peri-
toneum. The bleeding from placental site controlled
by firm packing of iodoform gauze — skin sutured by
silk worm gut.
Patient was given intravenous on operating table
and condition was poor.
Patient made complete and uninterrupted recovery.
Phila., October, 1922]
Gall Bladder Diseases— Foster
727
A Practical Survey of
Gall Bladder Diseases
"WHY SHOULD NOT A DISEASED GALL BLADDER BE REMOVED JUST AS MUCH AS A DISEASED APPENDIX?"
By G. S. Poster, M.D.,
967 Elm Street, Manchester, N. H.
Surgeon to Notre Dame Hospital.
Smrgiai, N M Thtrm^tmitc
Gall bladder diseases, experience has
shown, yield more readily to surgical than to
therapeutic measures. However, the scalpel
must here cut with caution and care, as is
asserted by Dr. Foster in this short, clear-cut,
sensible paper. — Editors.
TBE PROFESSION today is very well agreed
regarding the treatment of a diseased or infected
gall bladder. When the appendix was first recognized
as a pathological entity much medical treatment was
instituted and many failures resulted. The high
mortality of appendix cases under strictly medical
treatment gave rise to further study of the subject.
Surgery came into its own and has been most success-
ful in bringing the mortality down to near the base
line. In gall bladder diseases, surgical treatment
has well proven its worth and has not alone lowered
the mortality, but, say, effectively ameliorated the
suffering and relieved the condition. No doubt, as
time goes on, this trouble will be recognized as a real
surgical entity which should be thus treated. Even
now the medical profession is very well agreed on this
point.
When a surgeon sees a gall bladder that is infected
or otherwise pathological, this question, when he has
made the diagnosis, will arise. Is this a case for
cholecystotomy and drainage or one for cholecystec-
tomy alone f Experience with surgical treatment of
pathological gall bladders impresses one with the
better results obtained from a cholecystectomy in the
majority of eases. Brickner has well asked if a gall
bladder is diseased, why should it not be removed just
as much as an appendix?
Careful study of a series of gall bladder cases some
treated by cholecystotomy and drainage and others by
cholecystectomy, will show far better permanent
results by the latter treatment. Removal of the dis-
eased gall bladder rids the local area of the pathology
and should give far better results. It would seem
that men of the surgical world are rapidly becoming
adherents of cholecystectomy in preference to cho-
lecystotomy and drainage in the majority of their
cases.
Looking back over gall bladder cases of the past
decade I find that in our own clinic we are uncon-
sciously doing more cholecystectomies and with better
results. We also find that cases where cholecystotomy
and drainage has been done either by one of us or by
someone else are continually coming in with the old
complaint and a recurrence of the trouble. Where
stones have been found several years ago and the gall
bladder drained we are continually having these cases
come in and find that stones have again formed. No
doubt, many others are meeting this same situation.
CwrfrmWicrtiMi to ChtttcytUctimy
Of course, one meets cases where for one reason or
another it would not be advisable to remove the gall
bladder. For instance, an old chronic gall bladder in
a person of advanced years, sixty-five or more where
at operation the gall bladder was found very firmly
imbedded in adhesions and much matting. Here we
face a condition and, on the whole, a poor surgical
risk. Such cases demand the best of surgery and
expedient work with extreme care, as in such cases
we so often find a coexisting lymphangitis which
complicates the cases. Here the operator must decide
the modus operandi on the spot after the abdomen is
opened. Our experience leads us to favor cholecys-
totomy and drainage in these cases.
At best we are facing a fair degree of hemorrhage
if we attempt to dissect out the gall bladder. Then,
again, drainage is of material help in clearing up the
lymphangitis. We can also look to nature for much
assistance in producing a post-operative atrophy of
the gall bladder itself after drainage has cleared the
field locally. This is a fact worthy of honorable con-
sideration. Then, again, less luck is experienced by
the patient in this type of case.
There are types of pyo-cholecystitis which come in
as urgent emergencies. Those patients are many
times in rather poor condition and not good surgical
risks for any lengthy operation. They will, however,
do well on the average if the gall bladder is opened
and drained.
728
Gall Bladder Diseases— Foster
[The American Physidaa
So many times these abscess gall bladders have very
thin walls and an attempt to dissect out the offending
member will result in rupture at a disadvantageous
point for good drainage. Also, the surrounding field
cannot be kept clean and there is a likelihood of con-
tamination if the pus be virulent. Of course, many of
these cases have old chemically worn out pus of no
material value so far as contamination is concerned.
We have many times taken cultures of this pus and
could not produce any growth on the most favorable
culture media.
These two types of gall bladder just reviewed seem
the ones most fitting for a cholecystotomy and drain-
age in so far as our experience with cases goes. We
have learned to respect the septic gall bladder with
abscess and the one covered with old chronic, well-
organized adhesives and an associated lymphangitis
and chronic -pancreatitis as warranting only one pro-
cedure— carefully established drainage.
However, one other condition is quite often met
which demands cholecystotomy and drainage. This
is where we have an acute or chronic pancreatitis with
its existing lymphadenitis and lymphangitis. In these
cases the gall bladder itself will not often be markedly,
if at all, involved. Here we seek to produce drainage
of the area which is best accomplished through drain-
age per gall bladder route. Such procedure gives
very satisfactory results. The hardened and undular
or reddened and swollen pancreas will soften and
reduce under this treatment. The lymph glands will
drain and the channels become normal again.
The Afected Ceil Bidder, Recurrence mmd Mdigmmey
Most other types of gall bladder diseases require
removal of the offending member. They can well be
compared with cases of the appendix. Who would
think of leaving a chronic, sub-acute or acute appendix
in the absence of abscess formation f Who would
think of opening the appendix and draining it to cure
the condition f If such a procedure were to be uni-
versally followed how frequently the attacks would
occur and how futile would be the attempt to produce
a cure by such a method? In just the same light we
must look at the diseased gall bladder. In the past we
all have seen gall bladder cases readmitted and re-
quiring a secondary operation which merely empha-
sizes the need of a cholecystectomy in many cases.
The presence of stones in the gall bladder always
calls for removal of the gall bladder, for cholecystot-
omy and drainage merely gives temporary relief.
Later on the stones return and a secondary house
cleaning is necessary.
This condition infrequently seen in gall bladder dis-
ease should not be passed without consideration.
Malignancy in or about the gall bladder is a most
serious thing. Just what good will come from drain-
ing the gall bladder is a grave question. If we
attempt to remove the gall bladder under such circum-
stances we are pretty apt to run up against severe
hemorrhage. Possibly when this condition is met the
best thing to do is to withdraw. Later on, perhaps,
at the time radium treatment can be given. We mnst
consider the use of the x-ray in these cases or some
toxine such as Coley's fluid.
As a rule malignancy in or about the gall bladder
is better left without further surgical interference
when found after opening the abdomen. It is far
better to withdraw modestly than to shorten life or
produce some severe shock without accomplishing any
material good in the end. The writer believes these
cases should be left to radium, x-ray or toxine therapy
It is better judgment to hang up the "Stop, Look, and
Listen" sign than to further damage the locality.
Possibly an exception to this rule might be in a very
small area where the pathology could be quite readily
removed, but these cases are very rare and post-
operative treatment should be left to radium, x-ray, or
toxine influences.
On the whole, however, in most cases, the gall
bladder should be removed. This will give far the
better results in the percentage of average and will
bring about a very satisfactory permanent relief or
cure as you may care to term it.
Just a word as to the advisability in cholecystec-
tomy. We find that we are most and more frequently
closing the abdomen. However, we do not make this
a steadfast rule. It may be said that drainage in
these cases is not essential to avoid post-operative
sepsis, but rather that the drain in the form of a two-
inch gauze pack serves to check serious oozing. This
would seem the only real reason for establishing
extra abdominal connection. Whenever in doubt as to
the steadfast control of serious oozing we carry out
the rule of using the gauze pack and removing it
under gas-oxygen on the fourth day.
«
Remmi
1. Cholecystectomy seems to be the proper opera-
tion in the average pathological gall bladder case.
2. Drainage is not established in cholecystectomy
for the real purpose of drainage, but to control serious
oozing.
3. Real drainage is not necessary, but rather the
use of a firm gauze pack when there is any question
of leakage of the circulatory system.
4. Pyo-cholecystitis demands cholecystotomy and
drainage.
5. Multiple adhesions with risk of severe hem-
orrhage demand cholecystotomy and drainage.
6. Pancreatitis (acute or chronic), with co-existing
lymph channel or duct involvement demands cho-
lecystotomy and drainage.
7. Malignancy in or about the gall bladder is
generally not purely surgical except for exploration
Phila., October, 1922]
Trifacial Neuralgia — Lurie
729
or diagnosis. Radium, x-ray, or toxine seem fittitig
as after treatment.
8. Drainage is not necessary in cholecystectomy.
9. Far better and more permanent are the results
from cholecystectomy than from cholecystotomy and
drainage in the average case.
Obscure Etiology of Trifacial Neuralgia
Complicates Satisfactory Treatment
By William A. Lurie, M.D.,
1130 Maison Blanche Bldg., New Orleans, La.
Trifacial neuralgia results from a variety
of factors of imperfectly understood origin.
Because of this obscure etiology, the treat-
ment is equally unsatisfactory. To remedy
this, the paper of Dr. Lurie attempts to un-
ravel the complicated elements involved and
explain matters on logical and sensible
bases. Its practical value, then, is self-
evident. — Editors.
TBE ETIOLOGICAL FACTOR in many con-
ditions which are old in their description may be
more simple than is often considered. This is being
substantiated almost daily by the explanation of
many heretofore unexplained origins of conditions in
the better understanding of physiological chemistry,
bacterial flora and growths, as well as the influence
on bacterial growth of physiological changes, and
Trice versa. The trend of thought is definitely chang-
ing from bacteriological to chemical influence and to
the chemistry of bacterial action.
In tri-facial neuralgia every one of the number
of etiological factors have been considered and many
new ideas have been originated and treatment has
been directed along each of the various lines indi-
vidually and with little or no great or marked success.
Prom time immemorial the anatomical reason for
this rather intractable condition has been considered
as existing in the teeth and in consequence countless
numbers of patients have suffered the loss of teeth
of various numbers and have been the subjects of
much surgery directed at the nerve trunks and the
ganglions. Little, if any, of this surgery has been
phenomenally successful except in the cases of ex-
treme radical procedure and then often some mutila-
tion has resulted.
The point for study which seems to have been the
most prominent in the cases which have come under
my observation has been that of the associated
anatomy and anatomical changes the result of physio-
logical development or of surgery and repair. By
surgery, in this instance, is meant the extraction of
teeth or perhaps antrumal surgery.
Grim? BiMtmrU*
The history in the majority of cases of this
character can be divided into groups. In the first
group are those cases where the history of the neu-
ralgia begins at about the time of the eruption of
the permanent molars, about 10 to 14 years of age.
This group of cases generally present a good set of
teeth. The patients seem well in every other respect
and their only complaint being that of neuralgic
seizures which gradually become more and more
frequent. These patients, if fortunate enough to
escape the development of dental caries to any great
extent usually have all their teeth. Some of them
found their way into the hands of radicalists and in
them teeth in varying numbers from one to all will
be found missing. The second group are those whose
history points in equally early origin of the condi-
tion, but who have not been as fortunate in the
possession of sound teeth. In this group one finds a
great variation of the local mouth condition and
appearance and likewise a variation in the teeth in
the dentures. In the third group are the cases of
more recent history, that is, the development of the
neuralgia well after the complete eruption of the
usual number of permanent teeth. In this group
there is to be noted those patients that have, or have
not infected teeth which have been treated for a
number of years and in various manners. Here
again we find the teeth missing in varying number
and combinations. In all groups are the cases in
which unerupted teeth and impacted teeth are to be
found or have been found and removed.
A Pily-pkasti Etiohgy
The great difficulty in determining a single etio-
logical factor in cases of this character, scattered
over so wide a possible grouping, with and without
the possibility of the incident of infection, with and
without the possibility of anatomical alteration or
change due to development and with or without
730
Trifacial Ncwalgia— Lurie
[The American Pfcyndaa
surgical interference, can be noted at once. Here
we see that growth, either naturally or in repair,
infection and even the healing after surgery do not
play a positive nor absolute role as the etiological
factor, yet are coexisting factors in all cases. Com-
binations of all these factors and many more seem
to fail as the positive etiological factor, yet by a
careful study a constant finding might be discovered.
In a careful study of the development of the tis-
sues of the facial area and particularly the nerves
and their end fibres as expressed in the fibres of a
root canal, there can be noted the possibility for the
easy development of a tooth that might in some
manner subsequently become the causative factor of
a neuralgia. In the formation and development of
a tooth the apical or root end, during the early
stages, is wide open and permits the easy accommo-
dation of all the tissues which later go to form the
pulp-chamber and root canal contents. As the tooth
develops and the root takes form, the apical end
closes down and constricts these tissues. This closing
down or constriction continues throughout life-time
until in the senile condition the apical opening is
often entirely obliterated as a canal, yet, no doubt,
permits the passage of some nerve fibres and vessels
to nourish the tooth, in conjunction with such fibres
and vessels as come through the peridental mem-
branes. One question presents itself at this point
very forcibly, that is, what are the influences, either
physiological, chemical or bacterial, which may develop
in conjunction with or as the result of surgery or
injury, which may cause a condition of neuralgia?
Nerve fibres, and particularly those which are
distributed to the teeth during an ordinary lifetime,
seem to withstand and undergo great variations and,
perhaps, greater alterations and more changes than
those in any other part of the body or attached to
any other organ or set of organs. Another difference
over other innervated organs, which occurs in teeth
and nowhere else is that with a dual nerve and blood
supply a tooth often remains in position indefinitely
even after the loss of the major portion of either or
both nerve and blood supply. It may be that in the
study of the changes mentioned and the differences
described one may find a partial explanation if not
a complete one for the origin of neuralgia.
MWn Opermmii
For the present let us consider what takes place in
the nerve trunks and fibres elsewhere about the body
in the event of injury, removal or amputation of an
organ or member.
Perhaps the best illustration possible, and one in
which the possibility of pressure and injury of an
abrasive character, similar to such as is met with in
the mouth, is to be found in nerves after amputation
of a member. Tenderness of the stump and scar for
a lesser or greater period is a common finding. After
the complete healing and cicatrization there often
follows a painful stump. The pain in these stumps
is of a neuralgic character and, at times, excited by
a definite and specific form of irritation and which is
found to be always similar in application. This irri-
tant sets up pain of varying intensity. If long
enough continued the patient describes the condition
as a cramping of toes or fingers or a bending or
pressure on a certain joint. The description is
always the same. This pain is excruciating. The
neuralgia patient describes a definite irritant or
pain on irritation which occurs at about the same
time. The amputation stump patient comes to opera-
tion and a nerve is discovered in the scar at a point
where it may be irritated by pressure, heat or some
other form of irritant. Many of these nerves are
found to have developed a neuroma on which the
guilt of pain, etc., is fastened. Many times the
excision or resection of the nerve trunk and neuroma
have the desired effect. Pain and other symptoms
are relieved.
Let us now draw an analogy between the condition
as it is to be found in the amputation stumps and in
and about the tooth socket before and after tooth
extraction.
The development of a tooth and the changes which
take place in the root canal have been partially
described. From this description it can be noted
that the possibility of irritation is unlimited. What
are the possible conditions which simulate a painful
neuroma and how do they develop, is the next natural
question f
Given a case in which an accident occurs to a
tooth. A pulpitis develops. This may subside quickly
or continue to the time of the death of the pulp. In
these cases there is often an early destruction of
periapical alveolar tissue. Interference directed to
the relief of the condition may save the tooth through
the extirpation of the pulp. By this operation, the
nerve and root-canal contents, blood vessels, etc, are
cleaned out from the canal and the putrid tissue
removed and the irritation relieved. The remaining
canal is filled with some foreign non-absorbable
material. Everything conducive to healing is done
and often healing takes place.
What happens? The inflammation periapically
causes a loss of bone substance. Within this inflam-
matory area the destruction of nerve tissue takes
place. After the subsidence of the active infection
and inflammation through any manner of treatment
absorption of some of the debris takes place and
regeneration begins. The nerve fibre begins growth
at least from the terminal neuron on. That portion
[Cmdmmm •ftku Artidt m Pmgt 73$)
efficient Organization of Medical I ractice
THE GENERAL PRACTITIONER IS THE FUNDAMENTAL FACTOR IN EFFICIENT MEDICAL SERVICE
While surgery, *** specialties, hospitals, People or* to be served, the primary tm- ordinate* in constructive co-operation art
institutional medicine, public health work, portance of the function of the General the essential service of the Family Physician,
industrial medicine, etc., have their definite Pr action er must be recognised. Other divir This is an integral purpose of The American
functions, if the best health interests of the sions of medical service must be properly co- Physician.
Have High Educational Standards Become
a Danger?
Just W hat is the Coal the Medical Profession is Seeking?
ARE WE LOSING SIGHT OF EVERYDAY NEEDS OF EVERYDAY PEOPLE?
like Fi
ai tks Pkyakim Is to Trent PeanU
People are getting heartily
tired of being sent from
specialist to specialist, diagnosed
and pawed over galore, and no
real treatment administered.
Patients should be considered
as something more than scienti-
fic problems. After aU, the
patient is a human being, even
as you and J. No matter what
the developments of medical
science, the work of the medical
profession still is and always
wiU be to treat humans, whether
to prevent disease or to cure or
to manage it. To so immerse
students in scientific technicali-
ties and to develop such an ultra-
scientific seal that they lose in-
terest in the human beings for
whom the science has been de-
signed, is a case of the tail wag-
ging the dog with a vengeance.
A new emphasis [intelligently
adapted to modern develop-
ments] of old truths is needed,
and badly needed. And the longer
neglected, the worse the need is
going to become.
THE LITERARY DIGEST has reproduced from
a religions publication an article that contends
that clergymen in the denominations that exact high
educational standards are trained beyond their con-
gregations and are unfitted to serve successfully, or
with happiness to themselves, except in big city
churches; and the article draws a parallel with the
medical profession, showing that advocates of peculiar
dogmas, such as the "holy rollers," are thus gaining
entrance into communities, just as are chiropractic
and other peculiar cults in medicine, in both instances
to the detriment of the people who are unable to
find trained physicians willing to reside with them,
or preachers who understand their needs.
The ArtkU Goes em to Say:
"The good old 'family doctor/ who knew little of
modern medical science but a great deal of common
home remedies and usually a great deal of common
horse sense, who always heretofore grew up in such
communities and remained there to take adequate care
of its medical needs, is fast passing out of exist-
ence. Such men are not able to meet the high tests
now exacted for medical practice. And the young
doctors who have spent many years in preparing
themselves to meet these new medical requirements
simply cannot be persuaded to go back and live
and work in such environments. Even if the fees
could be made large enough to make such a prac-
tice profitable, the long ugly drives over all kinds
of roads, and the kinds of folks and homes to which
they would have to minister would soon become
so distasteful that no amount of money could hold
most of them there. The consequence is that there
is a most serious shortage of doctors in many such
sections, and an actual suffering for medical atten-
tion in many places — and there is a tendency toward
almost prohibitive prices in some communities. . . .
"Unless our medical associations devise some plan
of admitting to the profession the kind of men who
can serve and will serve such communities — serve
them just as they now are and will be for a genera-
tion to come — and unless the various denominations
do likewise for the ministry, a most grievous in-
justice will be worked increasingly against these
unfortunate communities. The Herald is heartily sym-
pathetic with the religious and medical leaders wno
732
High Educational Standards and Professional Training *&* American Physician
are agitating for better trained men in their profes-
sions; but there rests upon these leaders a moral
obligation to recognize the fact that a uniform
rule will not do and that our ministerial groups and
our medical associations must find some practical
way to meet the imperative needs of this complex
situation."
Horn) We View It
Several physicians have spoken to us about this
article and they are far from accord over it. There
is, however, quite a general agreement in opposition
to such elaborate pre-medical courses, to overburden-
ing the medical curriculum with needless studies, and
to unnecessarily severe requirements by state boards
of examiners. Some physicians think that the post-
graduate hospital requirements are unwise and fit
the young doctor for city and hospital work only, not
for general practice. In other words, the young doc-
tor is spoiled in the hospital. Others stress the lack
of reciprocity as working against locating in new
places. Three physicians who have sons in medical
schools complained rather bitterly about conditions.
We have been back on a visit to the school from
which we graduated years ago. Remembering
the hard benches and the very plain environments
of the then lecture halls and laboratories, and how
sumptuous we regarded the "New Library Building,"
we were astonished to find these substantial buildings
all torn down to make way for a thousand-bed, fire-
proof hospital and other "marble halls'* of beauty,
fitted for rich men's sons to inhabit. The new "New
Library Building" is very much finer than the state
capitol thirty miles away; the "Alumni Hall" is a
sumptuous structure; the millionaires of New York
City have few club houses superior to those now
at the University; a residence hall for law students
and covering four city blocks has been provided for,
and to "meet the crying need" for a proper place
to practice football in winter time a tremendous
structure over 300 feet long is in process of erection.
Such are the times. But, when we asked what the
graduating class in the medical school proposed doing,
we were proudly told that all but two had "posi-
tions." These two were, presumably, going into
medical practice because they had not "landed
positions.'*
We also visited a theological seminary with which
we were familiar years ago. Here, too, every brick
had been torn down to make way for a replica of an
old English castle; and nearly the whole graduating
class there had "positions" and very few wanted
pastorates.
As there has been a great cry about the need for
rural hospitals, and one has recently been provided
for by a rich man, we looked into that matter and
found the architects busy planning marble and
mahogany features galore, hoping to get the money
after while to erect sufficient wards.
Now what is an old fellow — a mere doctor — to
think t Everywhere it is sumptuous surroundings
for "people of taste" and, of course, of wealth. A
young fellow from a small town enters medical school,
finds himself in luxurious environments, and is
promptly spoiled for a life in the average town or
rural community. This is not good. As it impresses
us, it is not the so-called backward communities —
usually not so backward after all — but the materialis-
tic and wealth-seeking tendencies of the age that are
spoiling medical and other professional students for
an average life in the average environment. There
is nothing in the medical studies themselves that will
spoil any man or render him unfit for average
professional work, no difference how high the educa-
tional standards may be. It is the false standard of
living, not the educational standard, that is at fault.
The Roman Catholic Church educates its priesthood
far better than most Protestant denominations do with
their ministers; but the candidate for the priesthood
lives an abstemious life of hard discipline and train-
ing, and we do not hear in that church of priests who
are utterly unhappy and unsuccessful except in a city
parish. It is folly to say that average people need
half-baked doctors or preachers.
The Prmctieti Side
Nevertheless, the merely academic side in profes-
sional training is often over-stressed, too much at-
tention being paid to pure science and too little to
applied science. This is markedly the case in medi-
cine. The graduate of a Class C medical school has
often become distinguished because he had real stuff
in him and worked hard after graduation. And we
can educate a Class A graduate into innoeuous
desuetude, who then stagnates and never amounts to
much as a practitioner.
Our standards are too academic and theoretical.
As a real test of fitness a state board examination
amounts to little; and yet one of the main functions
of a medical school today is preparing its students
to pass state boards.
There is sometimes a lot of bluff in education. W.e
knew a young man required to pass off two years of
Greek in a written examination. He had never even
studied the Greek alphabet, but by means of a
short by-mail course he passed the examination.
Another by-mail student passed the Bar examination,
and he soon became the attorney-general of a west-
ern state. Another man wanted credentials in a very
practical avocation with a theoretical foundation
that some class as a profession and others as a
{Continued one leaf over)
October, 1922]
The American Physician Advertising Service
733
Bowel Torpor in the Elderly
is usually the result of a progressive atony of the bowel, with a
gradual decrease of the natural mucus and other secretions.
The loss of moisture dries the feces and interferes with their
free and easy passage. Under such conditions
INTEROL
serves as a safe and
lowing its systematic
DIRECTIONS:
In treating the el-
derly, begin with a
tablespoonful morning
and night on an
empty stomach, in-
creasing or decreas-
ing as conditions re-
quire.
Samplt and Interol
brochure on request.
efficient substitute for the physiologic secretions. Fol-
use, the bowel contents are kept soft, the intestinal
canal — especially the large intestine — is adequately
lubricated, and the feces are passed along and evacu-
ated in due time without straining, pain, or discomfort.
INTEROL thus constitutes an ideal medium for the
relief of bowel torpor in patients of advanced age.
Allied Drug and Chemical Corporation
2413 Third Are. New York City
Manufacturers of
ORASEPTINE— Internal and External Antiseptic, Wash, Spray and Douche.
ADACCO SALT— Effervescent Saline Laxative and Uric Acid Solvent
VELOGEN— "The Doctor's Hand-maid and Household Emollient."
44
When you're thirsty it's too late to
about digging a well. "
Confronted by the condition known as ascites or anasarca, the
prima] consideration is how best to strengthen the heart, overcome
circulatory stasis, promote resorption of effused fluid and its re-
moval from the body. Diuretic action alone is usually insufficient.
But ANASARCIN TABLETS bring about increased strength of
cardiac contraction, regulation of cardiac rhythm, dilatation of the
arterioles, more thorough circulation, more complete elimination of
urinary solids as well as fluids.
Test ANASARCIN TABLETS in
Cardiac Valvular Disease (lost compensation).
Chronic Blights Disease. Post-Scarlatinal Nephritis.
Albuminuria of Pregnancy. Hepatic Cirrhosis*
Exophthalmic Goitre. Cardiac Neuroses.
Sample*, literature, case reports to any physician
THE ANASARCIN COMPANY
Winchester, Term.
Mentioning The American Physician Insures Prompt, Careful Service
734
High Educational Standards and Professional Training
(The
business. He had a wealth of book lore and theory
on it, but never did a stroke of practical work in
that line; and he got the certificate, making over 90
per cent, on his examination papers. Yet, practical
men who have spent years in that work and who could
walk a dozen circles around him in actually doing
things would have trouble making 50 per cent in that
same examination.
It is up to the man. When we see man after man
succeeding in technical work purely on the basis of
home or by-mail study, we are compelled to view
education very much in its personal relationship
instead of its pedagogic one- In medicine especially,
it is doing things that count, and if our Class A
schools were relieved of the folly of preparing stu-
dents for state boards instead of for practice we
would have better graduates.
Cem't B* Dmm
The modern idea is that a finished doctor can be
made in school and hospital. Gentlemen, it can't
be done. The old preceptor system was possessed
of advantages from which we could still profit. There
is no occasion whatever for lowering medical stand-
ards for the ambitious man to attain to; but it is
not necessary to exact that no one may practice
until after he attains to the maximum of them.
While with our preceptor, before entering medical
school at all, we put up medicines, did surgical dress-
ings, attended to certain routine treatments, and even
took entire charge of minor cases at the bedside.
There is a great fault in our way of doing things,
for the young graduate of a Class A school, with
a hospital year after graduation, is more apt to cease
study and stagnate thereafter than is the man who
knows he is not "finished" and keeps up reading and
study. There is no law preventing any "one-horse
doctor" from becoming a master clinician in due
time; but there ought to be a law compelling the
cocky Class A man to keep up to his "one-horse*'
competitor, who is apt to go ahead of him within
five years, speaking clinically.
As a matter of fact, many of the "good old family
doctors" had frightful mortality records; they were
picturesque but far from efficient. It would be a
crime on society to go back to their way of doing
things. Farmers would not go back to the way their
fathers managed their farms, and they do not want
doctors who are "back numbers." Farmers are driv-
ing to the city today because they appreciate modern
medicine and go there to get it — and they pay for
it, too.
Let us not blame the so-called "backward com-
munities" more than is necessary; they are judged
far too superficially. There are large sections of
our cities infinitely more backward than are the
rural sections. Tet the ignorant foreigner in the
city wants to be attended by the "Professor" and he
appreciates modern medicine. Any man who thinks
the good old American stock in the country is long-
ing for the return of "Good 01' Doc'' is mistaken.
On the other hand, both town and country is getting
heartily tired of being sent from specialist to special-
ist, diagnosed and pawed over galore, and no red
treatment administered.
Patients should be considered as something more
than scientific problems. After all, the patient is a
human being, even as you and I. No matter what
the developments of medical science, the work of the
medical profession still is, and always will be to
treat humans, whether to prevent disease or to cure
or to manage it. To so immerse students in scientific
technicalities and to develop such an uJfra-scientifle
zeal that they lose interest in the human beings for
whom the science has been designed, is a case of the
tail wagging the dog with a vengeance. A new
emphasis (intelligently adapted to modern develop-
ments) of old truths is needed, and badly needed.
And the longer neglected, the worse the need is going
to become.
As to preachers of high educational standards that
the journal quoted by The Digest mourns over, the
trouble with most of them is that they cant
preach, despite their educations. They were taught
how to study and lecture, but not to preach. And
the finicky young doctor who is too high bred to
practice in the country can't doctor. The people
know it, and he finds it out sooner or later if he
gets up against the real job of being a country
doctor.
Bmck to Ftnimmtnltii
The way to mend this condition is to compel every
professor in a medical school, every member of a
state board of examiners, every theoretical peda-
gogue in the foundations, and every agitator for mar-
ble and mahogany hospitals, to be thrown heels over
head into a real country practice for six months.
What a turnover there would be when they got back
to the cities! It would be hard on a lot of sick peo-
ple in the country, but a splendid thing for the pro-
fessors and board members. This is not frivolous;
it points a big moral.
Let's get back to sanity, not by reducing medical
standards, but by making doctors up to clinical stand-
ards, not mere academic ones*
•
Pyemia of Otitic Origin
Horace Newhart {Minn. Med., Apr. *22), conclnskms
arc :
1. Pyemia having its origin in suppuration of the
middle ear is more frequent than we have been accus-
tomed to believe.
2. The best results in combating it can be attained
only through early diagnosis, and prompt and thorough
surgical intervention. The former demands nnustal
vigilance and painstaking care on the part of the family
physician, who generally is the first to attend cases of
ear diseases and their complications.
October, 1922] The American Phpsician Advertising Service 735
When the Doctor knows
that Coffee Harms the Patient
T
HEN comes the choice of an alternative which
will provide the most in satisfaction without
harm.
Doctors who know the wholesomeness of
Instant Postum
direct their patients to use this beverage instead of
coffee, as no harm can result.
The rich, full-bodied flavor of Postum carries the
comfort of a hot drink much resembling coffee in taste,
but with no ill effects.
Grocers everywhere sell this well-known, healthful
table drink and in families with children it is partic-
ularly to be advised.
There is no caffeine, or any other ingredient deleteri-
ous to children or grown-ups, in Postum.
A full-sized tin of Instant Postum, together with
literature, will be sent to any physician unacquainted
with its availability upon request written on office sta-
tionery.
Made by
Postum Cereal Company, Inc.
Battle Creek, Mich.
Mentioning The American Physician Insures Prompt, Careful Service
736
Trifacial Neuralgia — Lurie
[Pfciladdptta
Conclusion — Trifacial Neuralgia — Lurie
Cmtiund fnm p*&» 729-73$
of the nerve which occupied the root canal attempts
regeneration. This growth takes place into a soft
area and without a sheath. Nerve tissue growth con-
tinues in an attempt at regeneration and a neuroma
similar to that of an amputation nerve stump
develops. This newly formed neuroma, by way of
the tooth root, suffers the same variety of injuries
as does the amputation stump neuroma. It suffers
in addition a greater and more sudden thermal change
than does a stump neuroma. This, from the fact of
the sparcity of tissue over the parts and the inde-
pendent innervation of the peridental membrane and
mucous membranes of the mouth from those of the
root canal, which connects with adjacent teeth.
MUvimg ffc Pmm •
It is in cases of this variety, that is, those of a
neuroma formed in a necrotic area that the extrac-
tion of the tooth does not relieve the pain nor the
painful exacerbations. In these cases it is necessary
to proceed like in the instances of the amputation
stump neuroma. There must be a resection performed
in which the alveolar tissue is laid bare and the area
evacuated, so that as much of the nerve tissue as
might have become affected can be removed. In the
resection and curettement which follows, the removal
of everything down to a healthy bone base must be
performed. The area must then be obliterated by
filling in of soft parts before the nerve tissue has had
time to redevelop into it. The covering over of the
tooth socket and evacuated necrosed area with the
soft tissue-flap, sutured into position, does this.
Some cases of neuralgia have their origin in an
unerupted and impacted tooth with, perhaps, a
neighboring decayed tooth. Depending upon the ad-
vancement of the condition of the decay and its suc-
cessful treatment, does the determination of whether
or not the impacted tooth and the decayed one should
be sacrificed together. In either case the great factor
in the removal of these teeth lies in the obliteration
of the space after removal and in the removal of all
the nerve tissue about the apex of the unerupted tooth.
As described in the beginning most unerupted teeth
have a large periapical peridental pad and a large
root-canal opening. The retention of this stump after
extraction of the tooth permits of the early develop-
ment of pain.
In broken roots after the extraction of vital teeth,
nerve tissue finds a normal canal along which to
regenerate. It often does, and with it develops the
painful neuralgia. These roots show no changes in
the X-ray picture, for no destruction of alveolar
tissue has taken place. In fact, the condition of
neuralgia is seldom found associated with any
marked alveolar destruction. There is no typical nor
constant X-ray finding in neuralgia. The history
of the development of pain or its continuation after
the extraction of an infected or impacted tooth with-
out alveolar resection is to be looked on with sus-
picion, and indicative of nerve tissue growth into
the old necrosed area.
To conclude, first, there is a similarity in the pain
experienced by patients with amputation neuromata
and tri-facial neuralgias; second, the development of
an amputation neuroma is described as forming in
soft tissue into which a cut-off nerve fibre can grow
without a canal sheath; third, that a tooth extraction
socket, particularly in conjunction with some peri-
apical destructive process, is a similar condition;
fourth, that the unformed apical end of an impacted
tooth when improperly removed gives rise to the
formation of a neuroma similar to amputation neu-
romata; fifth, that the remaining portion of vital
roots may be the avenue of the growth of new nerve
tissue which might be the cause of pain without the
development of any visible destruction or deter-
minable factor by X-ray; sixth, the removal of teeth
particularly infected or impacted teeth by extraction
lays the patient open to the development of a neu-
ralgia or ascending neuritis, and, seventh, that ex-
citation of neuroma in the dental areas is easier, and
possible with a greater number of irritants than in
an amputation stump neuroma.
Roentgen-Ray Therapy of Uterine Fibroids
Eden and Provis are of the opinion that roentgen-
ray treatment should be regarded as the method of
choice in women over thirty-eight for all uncompli-
cated cases of severe hemorrhage in which no neoplasm
is present. The presence of inflammatory disease of
the tubes and ovaries is a contraindication. Fibroids
of the size not exceeding the height of the umbilicus
may be treated with roentgen rays if the patient is over
thirty-eight years old, if the hemorrhage is of the regu-
lar monthly type, and if there is no evidence of in-
flammatory disease of the tubes and ovaries or of
advanced degenerative changes in the tumor. If inter-
current conditions which tend to increase operative risks
are present, roentgen-ray treatment should be regarded
as the method of choice. No case should be submitted
to roentgen-ray treatment without a careful gynecologic
examination to exclude malignant disease, inflammatory
complications and degenerative changes in fibroids. The
risks of failure with roentgen-ray treatment in suitably
selected cases are so small as to be negligible; the
roentgen-ray menopause may be attended by more
severe flushings than the normal menopause.— Lancet.
Wallace Wilson says not all dilated aortas are the
seat of a syphilitic invasion, nor is every aneurysm doe
to the Spirocheta Pallidi, but it is undoubtedly true
that the greatest single factor in producing an infective
aortitis is syphilis. Furthermore, Turnbull found that
specific aortitis was by far the most constant lesion found
in syphilitics at autopsy, and Hubert concludes mat aor-
titis comprises 70 per cent, of all visceral lues.
October, 1922]
The American Physician Advertising Service
717
^
KELLOGGS BRAN
should not be con/used 'with
common brans
which become
irksome to eat II
KUCVESCONSTlMnON
Ukrombud
An Analysis of
Kmllogf* BRAN
cooked and krumblexl
Aside from its regulatory
value, Kellogg's Bran com-
mands attention as one of
die most valuable foods
known. Read this analysis:
Moisture 2.50
MINERAL SALTS S.41
Protein 15.8
Pat 2.8
Crude Fiber 8.9
Carbo-hydrates 61.6
Calories (per pound) 1460.46
Patients eat Kellogg'i Bran readily because it
is highly palatable. It may be prescribed with
confident expectations of results because it is
ALL BRAN— cooked, then shredded and bum-
bled— and really a delight served as a cereal,
sprinkled over the patient's favorite cereal, or
made up into countless bakery products.
Kellogg's is also often served in gravies, soups,
etc., its nut-like flavor adding much to food.
Kellogg's Bran has won the favor of hundreds
of physicians because of its taste appeal aside
from its natural regulatory value. It is a revela-
tion compared with common brans. We ask that
you try Kellogg's Bran to be personally assured
how it induces better peristaltic action by adding
indigestible residue in the bowel tract. Eaten
regularly each day — at least two tablespoonf ute
(in chronic, old-age or bed-ridden cases with
each meal) — relief may be confidently looked for.
Attention is also called to the analysis of
Kellogg's Bran in this advertisement.
We would be pleased to send you a large
package of Kellogg's Bran with our com-
pliment. Kindly mail a request card today
to Kellogg Toasted Corn Flake Co., Battle
Creek, Mich,
die original BRAN
•v # : •
Qttd JsTtutiblcd
Mentioning The American Physician Insures Prompt, Careful Service
'Book IteUews
Acute Epidemic Encephalitis (Lethargic
An Investigation by the Association for Research in
Nervous and Mental Diseases — Report of the
Papers and Discussions at the Meeting of the
Association, New York City, December 28 and
29, 1020. Prepared under the direction of Walter
Timme, M.D.; Pearce Bailey, M.D.; Lewellys
F. Barker, M.D.: Sanger Brown, 2d, M.D.;
Charles L. Dana, M.D; J. Ramsey Hunt, M.D.;
Foster Kennedy, M.D.; George H. Kirby, M.D.;
Hugh T. Patrick, M.D.: Bernard Sachs, M.D.;
William G. Spiller, M.D.; Israel Strauss,
M.D.; E. W. Taylor, M.D.; Frederick Tilney,
M.D.; T. H. Weisenburg, M.D. Paul B. Hoeber,
New York, 1921. $2.50.
An excellent treatise on lethargic encephalitis, corn.
prising the best effort, experience and thought of a
group of men throughout the country most qualified
to speak on the subject.
Considerable advances, especially during the late
War, have been made in the study of the heart, and
a number of good books have been since written on
this important subject Nevertheless this non-volu-
minous treatise of Dr. Flint will find a worthy place
among works on the heart. Dr. Flint's standing in
the medical world, his experience and efforts qualify
him as an expert and teacher in his chosen field.
The book further is complete, starting with the heart
in antiquity, taking it through the Galenic and Ve salun
periods and bringing it to our own days. "The author
has succeeded in bringing together the salient points
concerning both the doctrines of our ancestors and
the researches of the most recent investigators . . .
so selected and combined as to give a sharp picture
of the whole."
The Heart—Old and New Views
By H. L. Flint, M.D, Late Captain R.A.M.C,
Cardiological Centre for the Northern Command;
Physician to the Mansfield Hospital. With illus-
trations. Paul B. Hoeber, 67, 69, 71 East 59th
Street, New York, 1921. $4.00.
Self-M acterv Through Conscioai Autosuggestion
A book of absorbing interest to the medical profession
is "Self-Mastery Through Conscious Autosuggestion."
by Entile Coue, in which the Entile Cone system of auto-
suggestion startled the medical profession of London, t»
fully explained. This work, in English, is written ti-
the famous French psychologist whose clinics at Nancy
are the talk of Europe and who recently created a sen-
( Continued c
■r)
Save the Tissues
Most effective anti-
septics destroy or in-
jure sound tissue white
killing the bacteria.
THERAPOGEN
Soluble Thymol-Terpene
positively does not! On
the contrary it stimulates
granulatio
It
corrosive — three virtues
most desirable. It is not
a creosol or tarry acid
compound. It is aromatic.
No complicated technic
like the Dakin— simply a
matter of application.
Send for sample and fold-
er wiving clinical uses.
Wholesale Dr<i( Houses Supplied
COUPON FOR SAMPLE
THEO. MEYER, alS 9. 10th St- Phil.., P..
Plane send me FREE .ample of THERAPOGEN
and circular giving clinical uki
AP
The Obstetrical "Shoe Horn"
Anatomically Comet u
Regard* Sin ana Shape
Where the, foetal head ei
V be readily deflected
,e caul Eliminate*
" Price. *i. *™
EQU1SETENE IS BETTER
Than other suture material* bacauee: ( I )
Never snarls; (2) No Infection; (3) Many time*
tonalle strength of hone hair: (4) Nat ao atiff aa
■Ilk-worm (ut: (1) Not so pllahle aa aillt; better
than either; (6) Uniformly amooth " '
ballad man)' times: (B) Very economic*
#1.20 for two large sample packages. •
for 1)0 feat.
> Can be
HUSTON BROTHERS
Atla* rtiaailmi Blag. CHICAGO
Complete Lints of Pn>ifcuni' Smppiilt
You can buy with Confidence — See "Service Guarantee to Readers" on page 758
October, 1922) The Americn Physician AdoaHsbtg Service 739
"In the successful treatment of disease proper feed-
ing is as important as the correct use of indicated
TTMHlipitW — Th* ick*! agent for sick and convalescent feeding
##*CUIlt/*C j, according to aU authorities, milk. But as such
it has several shortcomings.
DRYCO solves the problem successfully. DRYCO is dry
milk, produced by the rapid process — 2 seconds
at 212° F. This prevents caramelization of the
sugar, changes the casein into a colloidal form,
breaks up the fat emulsion into an easily digested
free fatty acid.
DRYCO is palatable, easily prepared, rapidly digested,
completely assimilated, bacteria-free. In the feed-
ing of pneumonia, typhoid or any acute disease,
in surgical cases, in chronic wasting diseases or
cachexia, during convalescence and in infants,
DRYCO stands unequalled.
The physician r»ho uses DRYCO Joes not vtorry about the nutrition of his patients.
LITERATURE, DIRECTIONS, ETC. ON REQUEST.
The Dry Milk Company, 14 Park Row, New York City
"An International Institution for the Study and Production of Pure Milk Products."
HUGHES' PRACTICE OF MEDICINE
1 9|.t_ Edition Enlarged, Revised. * A A A
l^tn Illustrated. Octavo, xxiv + 810 Pages. Cloth M>^*uu
Revised by R. J. E. Scott, M.A., B.C.L., M.D., (New York)
Fellow of the N. Y. Academy of Medicine, etc.
A complete, modern practice of medicine with additional sections on Mental Diseases and
Diseases of the Skin. It is compact, concise and most serviceable. It fits easily in your travel-
ling case, instrument bag, pocket of the automobile, desk drawer, etc. It gives in quickly
available form, the synonyms, definitions, causes, pathological anatomy, symptoms; diagnosis,
prognosis, treatment, prescriptions, etc. In the preparation of this edition such changes and
additions have been made as the progressive development of medical science required. The
general arrangement of the first part of the book has been materially modified. The specific
infectious diseases are subdivided into four groups; diseases due to bacteria; due to protozoa;
due to metazoa ; diseases of unknown etiology. This accords with modern views on pathology
and etiology. Several new sections have been added such as those on Trench Fever ; Notifiable
Diseases; Poisoning by Wood Alcohol; Acidosis; Functional Activity of the Kidneys; Cole-
man's Diet for Gastric Ulcer; von Jacksch's Anemia; Leukanemia; Disorders of the Salivary
Glands; Sinus Irregularity; Premature Contractions of the Heart; Classification and Treat-
ment of Mental Diseases; Numerous lesser additions and alterations, tests, etc., have been
made.
P. BLAKISTON'S SON & CO., Publishers
1012 Walnut Street Philadelphia
ON APPROVAL ORDER
Please send for 10 days* examination the new Hughes' Practice of Medicine. I will remit in 30 days
if I keep the book.
Name
Address
A P.
Mentioning The American Physician Insures Prompt, Careful Service
740
Book RorWwt
[Pkikdelf*
sation in London and Paris. This book contains a com-
plete exposition of his theories, methods and cures, with
practical suggestions for application, simply and clearly
explained. The price is $1.00, postpaid. Order your
copy now from the American Library Service, 500 Fifth
Avenue, Dept. 600, New York City.
the physiology, pathology, analysis, diagnosis and then-
peusis of the respective parts considered. In treating the
multiplicity of the many-phased subjects nothing by way
of .the practical, the established and the helpful has been
left out. It is a truly woithy text with which one will
not be disappointed.
The Allen (Starvation) Treatment of Diabetes —
With a Series of Graduated Diets
By Lewis Webb Hill, M.D., Junior Assistant Visiting
Physician, Children's Hospital, Boston; Alumni
Assistant in Pediatrics, Harvard Medical School;
and Rena S. Eskman, Dietitian, Massachusetts
General Hospital, Boston, 1911-1916. With an
introduction by Richard C. Cabot, M.D. Fourth
Edition. W. M. Leonard, Publisher, Boston, 1921.
This is a handy little book and will, no doubt, be
highly serviceable to both patient and physician.
Diseases of the Digestive Organs — With Special
Reference to Their Diagnosis and Treatment
By Charles D. Aaron, Sc.D., M.D., F.A.C.P., Professor
of Gastroenterology and Dietetics in the Detroit
College of Medicine and Surgery; Consulting Gas-
troenterologist to Harper Hospital. Third Edition,
thoroughly revised. Illustrated with 164 engrav-
ings, 48 roentgenograms and 13 colored plates. Lea
& Febiger, Philadelphia and New York, 1921.
$10.00.
We are much impressed by the thoroughness and
completeness of this third revised and improved edition
of this book. Not only is it thorough, but it is logical
and orderly. It begins with the mouth, follows the
pharynx, esophagus, stomach, liver, gall bladder, bile
ducts, pancreas, small intestines, appendix, cecum, colon,
flexure, rectum and anus. And as it proceeds it takes up
What to Do in Case of Poisoning
By William Murrell, M.D., F.R.C.P., Formerly Senior
Physician to the Westminster Hospital. Twelfth
Edition. Revised by P. Hamill, M D., Die,
F.R.C.P., Lecturer on Pharmacology and Thera-
peutics, St. Bartholomew's Hospital; Examiner in
the University of London; Physician to the Met-
ropolitan Hospital. Paul B. Hoeber, 67-69 East
59th Street, New York, 1921. $1.25.
Cases of poisoning are fortunately not frequent, but
when they do occur the physician must act promptly.
This booklet affords a means of briefly but precisely
reviewing the essential points on cases of poisoning.
The Submucous Resection of the Nasal Septum
By W. Meddaugh Dunning, M.D., Consulting Otolo-
gist, Fordham Hospital, New York City; Con-
sulting Otologist, Manhattan State Hospital, New
York; Consulting Pharyngologist, Ossining City
Hospital, Ossining, N. Y.; Consulting Laryng-
ologist, The Alexander Linn Hospital, Sussex,
N. J.; Assistant Surgeon, Manhattan Eye and Ear
Hospital, New York; Surgeon, Bronx Eye and
Ear Infirmary, New York. Surgery Publishing
Company, New York, November, 1921.
A brief treatise on the submucous resection of the
nasal septum, well written, well compiled and vividly
illustrated.
0 Pfl. Cascara Compound-Robins©
MILD, 1 GR.— STRONG, 4 GRS.
2^ It is the failure of the secretory function of the bowel, together
IfjB with a poor bile secretion, which, in nine cases out of ten, is
©responsible for constipation. ^^
Most cathartics altogether overlook this factor and address \fi
mf^k themselves solely to a stimulation of the musculature. Some even /^
T&r inhibit intestinal secretion. The result is a rapid, unsatisfactory \Jp
f^k bowel movement, followed by paralytic reaction. /*^
2^ Pil. Cascara Comp. (Robins) is a rational therapeutic formula, \£
mBm which promotes a natural flow of secretions, which is, in turn, the/Zn
jjg^ physiologic stimulant of peristalsis. Thus a normal evacuation i»\^
fd produced, without subsequent inhibition. Al
^^^ Samples and descriptive literature on request ^^
IN) A. H. ROBINS COMPANY Richmond, Virginuflw
You can buy with Confidence — See "Service Guarantee to Readers" on page 758
October, 1922) The American Physician Advertising Service 741
?
ANNOUNCING
A nm. NON-NARCOTIC Orug
AllQNAlXoche
which is both
HYPNOTIC**, ANALGESIC
AUGNAL which is administered orally in tablet'
Arm, is a prompt, efficient sedative, hypnotic
and analgesic, capable of Controlling
pain and producing sleep tnthe |
'many conditions in which Morphine and other
narcotics have hitherto been the onlyrecome
Supplies and Literature will be
furnished on request
TheHOfFHANN-UROCNCCHCMICAlllfoRNS
New York
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
plete with stand 130.00 eacb.
NO. OMS HAND APPLICATOR
Same design as 0670 only 8" dlam.
Consumes 200 wi
1'
Consumes 200 watta. 120 volts A. C.
or D. C. Made of Aluminum, weight
16 os. Finish, Black and Nickel.
Price complete without stand 110.00
eacb. Folding Stand only for No.
064a, 16.00 each.
Write for Interesting and Instructive literature
, a. mi
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A New Non-Narcotic Drue;
Which Is Both Hypnotic and Analgesic
In a paper read before the Philadelphia Neurological
Society, Dr. M. A. Burns says : "Allonal "s the only
demonstrated synthetic hypnotic which, like morphine,
simultaneously develops hypnotic and analgesic effects,
and over and above that alkaloid possesses the unmis-
ukablc advantage of being relatively feehly loxic.
"Allonal— (each tablet contains one grain of allyl-iso
propyl -barbituric acid and one and two-thirds grain oi
amidopyrin)— ts a hypnotic of the barbituric acid series.
which includes veronal, dial and luminal. In small
doses it acts on the central nervous system inducing
sleep, without any noteworthy depression. The desired
effect is produced by doses half as large as required
with the other known hypnotics of this series, and even
when high doses were given the unpleasant by-effects
familiar with the other hypnotics n
"The primary action of allonal is
on the sensory nerves. There is
tion, nor any apparent depressant <
tion, unless the latter has been ei
Allonal has no hemolytic
It
that of a depressant
io effect on respira-
ction on the circula
feebled by previous
action on the blood.
ted by the kidneys."
ill be remembered that Dr. Dinkelspiel also wrote
of his experience with allonal in the September issue
of this publication, "Analgesia and Sleep Without Nat-
American Physician readers will no doubt be giad
to know that this new drug is now offered to the pro-
fession by The Hoffman La Roche Chemical Works.
v York City, from whom supplies and literature will
i request.
be furnished o
Dryco Solves the Problem
There is a story to the effect that an old druggist used
to say every time he took down his bottle of aqua dost
and proceeded to fill up the prescription bottle, "Well,
here goes the profit."
A quite similar statement has been made in regard
to the water content in milk. From an economic, as well
as a dietetic standpoint, the 87% of water in ordinary
cow's milk might be regarded as useless, to say the
least. The profession has become easily converted to
the practical advantage of using milk solids in dry form.
There have been several milk powders placed upon the
market. The old saying. "Of the many, one is best," ii
easily exemplified by Dryco. Dryco is a pure, uniform,
stable dried milk, produced by the rapid heating pro-
cess. Within six hours after it comes from the cow
the milk is passed over large steel rollers heated to
212° F. The time required to change the milk, as such,
into a dry, flocculent powder is only two seconds.
Dryco is easy to prepare, economical to use and, what
is most important, will be digested and assimilated even
in cases which cannot take ordinary milk. Many physi-
cians have become acquainted with the value of Dryco
for infant feeding. As many, if not more, probably have
failed to realize the great value of Dryco in the feed-
ing of acutely ill, convalescent or invalid patients.
To know Dryco is to use it. To use it is to swear by
it. It is well worth the while of every physician who
does not know Dryco to send for interesting literature
regarding it, as well as for copies of a booklet, "The
Doctor's Rubaiyat," which will Drove both entertaining
and interesting.
Address the Dry Milk Company, 15 Park Row. New
York, N. Y.
You can buy with Confidence— See "Service Guarantee to Readers? on page 758
October, 1922]
The American Physician Advertising Service
If you have not received your copy of
the last Breon's Medical Gleanings, a magazine
devoted to Intravenous Therapeutics, write to
the nearest Breon Branch and a copy will be
sent to you at once.
fa
GEO. A. BREON & COMPANY
NewYork
Chicago
Kansas City
Atlanta
Pioneers in Intravenous Therapy
Mentioning The American Physician Insures Prompt, Careful Service
744
Helpful Points
[TliiUdcMiii
DRIED MILK
PLUS +
DURING the war, a
British Commission,
appointed to investigate
dried milk reported:
"When breast feeding is im-
possible, dried milk is a very
valuable food for infant
feeding. . . •
The physical and chemical
changes produced by the pro-
cess used in the preparation
so alter its character that it
is better borne in the infant's
stomach than ordinary cow's
milk whether raw, cooked or
sterilized. . . . The effect on
nutrition is marked."
NESTLE'S MILK FOOD
is dried milk plus cereals,
malt, and sugar. It is a com-
plete Food, presenting in
digestible form everything
that the infant needs to as-
sure normal growth.
Write Nestle's Food Com-
pany, Nestle Building, New
York, for complimentary
packages.
NESTLfiS
MILK
FOOD
For Babies and Invalids
Gallstones
The formation of gallstones results from the bacterial
infection of the biliary system. The germs of any gen-
eral or local infection may be carried in the bile into
the gallbladder, or by the blood to its walls. Whether
these germs will then induce infection or whether they
are to be rendered harmless, depends upon the condi-
tion of the bile. Should the free flow of the bile be
interfered with and become stagnant, then infection may
occur. Once infection occurs inflammation of the
mucous membrane and the walls of the gallbladder is
induced. The most general form of gallbladder disease
is chronic or subacute cholecystitis, and during an attack
the contents of the gallbladder becomes thicker and
more viscous, due to the admixture of products of in-
flammation, and sedimentation of the bile begins. Dur-
ing prolonged inflammation the minute particles, con-
sfsting largely of cholesterin, making up the sediment
continue to increase in size by the further precipitation
of concretions. These are known as gallstones.
The early symptoms of gallstone disease are consti-
pation, nausea, belching and vomiting, feeling of full-
ness and tenderness, and radiating pain. During this
period of distress and before acute attacks of gall-
stone cholic set in, the disease may be greatly benefited
by treatment with Agocholan.
The primary cause of the symptoms described above
is the precipitation of concretions in the stagnant bile.
It follows that a free flow of bile must be established
while the precipitated particles are still small, so that a
growth to actual stones cannot occur.
The object of medicinal treatment would, of course,
be to stimulate the flow of the bile, regulate the bowels
and relieve the feeling of discomfort and tenderness.
Agocholan accomplishes this most satisfactorily. Be-
fore offering this new pharmaceutical to the medical
profession, its therapeutical value had been proven by
clinical investigation. .
Agocholan comes in 2-grain sugar-coated tablets, in-
formation and samoles may be had upon request from £.
Bilhuber, Inc., 25 W. Broadway, New York City.
Creosote in Tuberculosis .
It is not always possible and it is often not advisable
to send the tuberculous patient away. And with over a
million active cases home treatment of tuberculosis is
absolutely necessary. .» __„
In this regard creosote is of paramount importance.
Dr Beverly Robinson has stated that we have no rem-
edy equal to creosote in the treatment of tuberculosis.
It has been found to diminish the cough in frequency
and severity; the breathing becomes deeper and more
satisfactory ; night sweats diminish and soon ?lsaPP^.
An easy and effective means of administering creosote
is offered in Mistura Creosote Comp. (Killgores) a
trial will undoubtedly convince you of its merit barn-
pies will be sent to American Physician readers on re-
quest Address: Charles Killgore. 55 West Third bt,
Cor. West Broadway, New York City.
Have Been in Clinical. Use Seven Years
Testogan and Thelygan (formula of Dr. Iwan Blocnj
contain sexual hormones, i. e., the hormones of tne
reproductive glands and of the glands of internal secre-
tion, and are indicated in sexual impotence and insuffi-
ciency of the sexual hormones. They have been in clini-
cal use seven years, and are, therefore, not untnea
PrExUtensive literature will be sent to American Phy-
sician readers on request. Address : Cavendish Chemi-
cal Corporation, 295 Pearl Street, New York.
(Continued one leaf over)
You can buy with Confidence— See "Service Guarantee to Reader/9 on page 758
Oetohtr, 19221 The American PJQgfcJan AJirertuing Service
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
-Invaluable to the Busy Practitioner
The busy physician will find the new edition of
Hughes' Practice of Medicine invaluable in his every-
day work. It gives complete modern practice of medi-
cine in the most compact, concise and serviceable way.
Jt will fit easily into your traveling case, instrument bag,
pocket of the automobile, desk drawer, etc.
This authoritative book gives, in quickly available
form, the synonyms, definitions, causes, pathological
anatomy, symptoms; diagnosis, prognosis, treatment, pre-
scriptions, etc. You will find it invaluable. The price
is $4.00, and it is sent on approval for ten days' examina-
tion; if you find it satisfactory, pay in thirty days.
Turn to page 739 and send in the coupon today to
P. Blakiston Son & Co., Publishers, 1012 Walnut St..
Philadelphia, Pa. ; the book will be sent on approval
so that you may see just what it is before obligating
yourself.
Write for This Symposium
In every recent discussion of malaria the subject of
the relapse phase has become of more importance. The
Rockefeller Foundation report to the International
Health Board is practically devoted to this side of the
malaria problem.
Every effort to improve the treatment by modifica-
tion of quinine administration has failed to diminish
the importance of considering the relapse in malaria.
This subject has been ably presented in a Symposium
on Malaria, including the Rockefeller Foundation re-
port and views of many authors in a thirty-two page
book. Every physician interested should write for a
copy of this Symposium on Malaria.
It is distributed, free of charge, by New York Intra-
venous Laboratory, 100 W. 21st St., New York City.
HUk Proteins
Certain proteins, as those derived from milk, have
been observed to cause leucocytosis and other changes
in the blood when injected intramuscularly. The defen-
sive forces of the body are stimulated thereby and with
telling effect, it is said, against a number of circum-
scribed lesions. Dr. Edw. Ahlswede (Arch. Syph. tmd
Derm., May, 1922) names sycosis, some forms of ecze-
ma, furunculosis, buboes, erysipelas, arthritis, epididy-
mitis, among the lesions that can be successfully
treated with milk protein injections. In Europe, quite
remarkable clinical success has been reported by Bruck
Muller, Forster and other physicians of note.
It is thought that they act by way of the myeloic (bone
marrow) system.
Injections are best made into the buttocks, their fre-
quency varying with the case. Lactigen is the prepara-
tion to use. Literature may be obtained by writing to
the Abbott Laboratories, Dept. 49, 4739 Ravenswood
Ave., Chicago.
Genuine Atophan
Atophan has been manufactured for quite some time
past in the manufacturing plant of Schering & Glali,
Inc.. at Bloomfield, N. J.
The product is made by a special process, which en-
tirely eliminates the possibility of unpleasant empyreu-
matic admixtures, and thus still further improves this
standard synthetic in the treatment of rheumatism, gout.
neuralgia, neuritis, sciatica, migraine and "retention"
headaches.
Schering & Glatz, Inc., 150 Maiden Lane, '
City, will be glad to send a trial box of Atophan
lets to American Physician' readers on request.
(Continued one leaf over)
1 York
A glance at the formula of PNEUMO-PHTHYSINE
will at once suggest its mode of action, as also the numer-
ous indications for its clinical application. The anti-
bacterial properties of all the drugs contained in
PNEUMO-PHTHYSINE are well established. In addition,
guaiacol and quinine tend to reduce fever temperature;
methyl salicylate lessens pain; quinine also promotes
healing.
PNEUMO-PHTHYSINE is indicated in all localized
and painful inflammatory conditions.
The fact that all the active drusi contained in PNEUMO-PHTHYSINE are readily
absorbed through the (kin; that they are taken up into the circulation and exert their
characteristic effects, both locally and aytematically, will be diicuwed in detail in the
Fall, 1 922, inue of Endennic Medication, which will probably appear early in September.
As\ for jour copy nan.'
Pneumo-Phthysine Chemical Co.
Chicago, I1L
You can buy with Confidence — See "Service Guarantee to Readerf on page 7
October, 1922]
The American Physician Advertising Service
747
9HMWMMMniMiniHMIimiMIUMMUUUtHI
IIIIMIIMMIII«lllll»IWIIMIIIIIWMI«IMIIIIIWi«l«IWIIHttllim
The Principle of Adrenal Support
Is a Sensible, Rational Tonic
=
i
s
E
i
Hypoadrenia
in Tuberculosis
If you find low blood pres-
sure, decreased urea, subnor-
mal temperature and asthenia
particularly in incipient and
latent cases of tuberculosis —
you also have adrenal insuf-
ficiency to contend with.
We don't claim to cure
Tuberculosis with Adreno-
Spermin Co. (Harrower),
but we do suggest that, along
with other therapeutic meas-
ures, the inevitably depleted
adrenals be considered.
When you consider that infectious fevers,
emotional strain, fright and shock all deplete the
adrenal glands, and that asthenia, hypotension and
suboxidation are the results of this depletion, it
is apparent that a tonic is needed that zvill sup-
port these played-out glands.
Repeated tests have demonstrated conclusively
that by supporting the adrenals with Adreno-
Spermin Co. (Harrower) you can raise a low
blood-pressure in actual mm. Hg., increase elimi-
nation (24 hours urea) in grams and encourage
alimentary, cardiac and general tone.
One doctor said of this formula, "People would
be after it with guns if they knew its value."
Send for free booklet on "Adrenal Support"
The Harrower Laboratory
Horn* Office: Box 68* Glendale, California
NEW YORK, 31 Park Place BALTIMORE, 4 EL Redwood St.
CHICAGO, 186 N. La Sallo St. KANSAS CITY, MO„ 711 K. a Ufo Bid*.
DENVER, 621 Central Saving* Bank Bid*. PORTLAND. OREL, 607 Plttock Block
HiUWIIUHIIHHIimMIIWWIt
DALLAS, 1806% Commerce Street
imnHmwmimimnnmwmimimiinmiimin
immuiiummimnnimmiiwiHiiniiiniig
With Over a Million
Cases of Tuberculosis
HOME TREATMENT
IS ABSOLUTELY NECESSARY
Dr. Beverley Robinson has stated that we have no remedy
equal to creosote in the treatment of tuberculosis.
It diminishes the cough in frequency and severity.
The breathing becomes deeper and more satisfactory.
Night sweats diminish and soon disappear.
Nutrition is aided and weight is increased.
A fair trial of Mistura Creosote Comp. (Killgore's) will con-
vince you of its value.
Dose: — Teaspoonful in one-third of a glass of milk or water
after meals.
Samples sent to Physicians on request.
CHARLES KILLGORE
Manufacturing Chemist Established 1874
55 WEST THIRD ST., COR. WEST BROADWAY NEW YORK
Mentioning The American Physician Insures Prompt, Careful Service
748
Helpful Points
[Philadelphia
Clin
The broad field of indica-
tions covered by
ELECTRARGOL
(Electric colloidal silver)
which includes
pneumonia -pleurisy
meningitis -influenza
rheumatism -endocarditis
is explained in detail among
the reports and researches
embodied in "Therapeutical
Colloids."
Colloidal Therapy is stead*
ily gaining in favor. Every
physician should read "Ther-
apeutical Colloids" — sent
free on application to
E. Footer* A Company, Inc.
90-92
New York City
PARIS, FRANCE
Therapeutics of Proven Merit
Ernst Bischoff Co., Inc., of New York, in accordance
with a long established policy to market only 'Thera-
peutics of Proven Merit and Individuality," have added
the notable creations of the C. H. Boehringer Son Lab-
oratories to their already proven specialties, Dtatussin,
Digisate, Styptysate, Hydropsin, Propaesine and Spiro-
form.
The Bischoff Co. can now supply four products of
the Boehringer Laboratories, all of which are of particu-
lar interest- to the medical profession.
Alpha-Lobeline, a convenient and exclusive respira-
tory stimulant. The quick and independent action of
this stimulant upon the entire respiratory mechanism
instead of fractional unilateral effects produced by con-
ventional resuscitation methods, has led to its inclusion
in the standardized first-aid outfits of ambulance sur-
geons, fire and police departments, industrial establish-
ments, mining camps, army and navy, railroads and
leading hospitals.
Cadechol (camphor-choleinic acid) facilitates the full
exploitation of the pharmacologic value of camphor in
cardiac and circulatory disturbances, particularly auri-
cular flutter and fibrillation.
Perichol (camphor-choleinic acid with papaverine)
constitutes an effective remedy in the treatment of
angina pectoris.
Laudanon is the accented standard for morphine medi-
cation during long periods without habit formation and
is indispensable for inducing 7-8 hours' sleep necessary
in deep X-ray treatment and minor surgery.
Interesting literature and samples may be had on re-
quest of the Ernst Bischoff Co., Inc., 85 West Broad-
way, New York.
(Continued one leaf over)
For Arthritic and Rheumatic Conditions
The Effective Remedy Is
-Diethyl-Methylene-DisaHcytic-
Dipyruvk Vmchlunk ) Acid
BEFSAL
"This synthetic is something tangible to save the valves of the heart
from permanent injury from the erosive effects of the rheumatic
poison, something positively curative when given in adequate dosage
with sufficent frequency.**— Dr. Lambert Ott.
THE ALTERNATE DAILY USE OF
Administered via the Stomach
IODOMER
and
ARSAMINE
Mercuiy-Diiodo-diaryl Diarsonaie-Diaryl
Is unsurpassed in the treatment of syphilitic conditions
DR. S. LEWIS SUMMERS
Producer of
Synthetic Organic Chemical Compound*
Fort Washington, Penna.
You can buy with Confidence — See "Service Guarantee to Reader^9 on page 758
The Americn Physician Advertising Service
The Reclamation of
Spinal Cripples
By the PHILO BURT Method
mission appealing strongly to the sentiment as well as to
:ssional ambition. Not a few physicians and surgeons have
need their reputations by earning recognition as specialists
e treatment of spinal deformities resulting from disease or
ent.
The experience of many practitioners, as duly and authenti-
reported to us, affords evidence that in many cases which
refused to yield to the latest, approved surgical treatment,
ite improvement, relief from suffering and often complete
mation of the patient have been effected by the aid of the
i Burt Appliance. We have been punctilious in obtaining
led historical records of hundreds of cases thus benefitted
A'ill gladly furnish copies to any interested practitioner. If
vuu will describe the case that is giving you difficulty, we will
send you records of others paralleling it. Our descriptive book will interest
you and your spinal patients.
THE PHILO BURT COMPANY l1M2 OJj rii-w. hi.,. Jamestown, N. Y.
TO REDUCE HIGH BLOOD PRESSURE
without disturbing digestion, or irritating the kidneys, and to maintain
vascular tension at a safe margin, as well aa to strengthen and sustain the
heart.
Pulvoids Natrium Compound
is rapidly increasing in use among progressive physicians.
Send for free special booklet on Hypertension and how to treat it.
Salvarols Suppositories
Racial
require no technique and obtain
action and results equal or (uperior
to arsphenamine intravenously in-
Pulvoids Aurazyme
in conjunction with other indicated
measure* secure satisfactory results
in diabetes meltitus. A trial will
Interesting literature, case reports, price lists and our little periodical, "Drug
Products," will be sent to any physician, gratis, on request.
THE DRUG PRODUCTS CO., Inc.
ISO MEADOW STREET LONG ISLAND CITY, N. Y.
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
Operative
Surgery
Special course in general
surgery, operative
technique and gynecologic
surgery given to physicians
of both sexes. Enrollment
limited to THREE.
Firit utitintthip—No cadaver or dog-work
For particular* add rail.
DR. MAX THOREK
AMERICAN HOSPITAL
846-856 lrvini Park Boulevard, CHICAGO
Long Dliluca Phonal
Lain Vi.ir 01 82-01 S3- 01 54-0 IBS
- STORM «
Binder and Abdominal Supporter
For Men, Women and Children
For Ptoiif. Hernia, Obesity. Pregnancy,
Relaxed Sucro-Iliac Articulation*, High
and Low Operation*, etc.
Askfor 36 page Descriptive Folder
[Catherine L. Storm, M. D.
1701 Diamond St. Philadelphia, Pa,
Treatment of Spinal Cases
Many physicians have found the Philo Burt Appliance
the most efficient means of treatment in the various
spina] deformities and diseases because it lifts the weight
off the spine and corrects any deflection in the vertebrae.
It does not chafe nor irritate and weighs ounces where
other supports weigh pounds. It is easily adjusted to
meet improved conditions where the spine is straighten-
ing and the body is resuming its normal shape and
form. The Philo Burt Appliance can be taken off in a
moment for bath, massage, relaxation or examination,
and can be put on again just as quickly.
The manufacturers of this excellent appliance are
anxious to co-operate with physicians to get the moit
efficient treatment of each case, and they will make an
appliance to order for any case and then allow a thirty-
day trial for the appliance to demonstrate its merit
You will be interested in the Physicians* Portfolio of
letters from doctors, giving their experience with the
appliance. It will be sent to you without charge. Ad-
dress: Philo Burt Co., 115-22 Odd Fellows' Temple,
Jamestown, N. Y.
Natural Way to Relieve Constipation
It is stated by medical authorities that if the use of
bran were to become general — as general as is the eat-
ing of white bread — inside of twenty-five years a stronger
and more vigorous race of mankind would result Not
only this, but human life would be increased from ten
to fifteen years.
It has been found that Kellogg's Bran, cooked and
krumbled, through its mineral salts and its ability to
absorb water, giving bulk and moisture, is nature's way
of assisting in perfect elimination of waste matter. By
the use of bran the system is rid of these waste ma-
(Contmuett one leaf over)
Jr
TAUROCOL COMPOUND TABLETS
\=
THE PAUL PLESSNER CO.
Jf
You can buy with Confidence — See "Service Guarantee to Reader?' on page 758
October, 1922]
The Americn Physician Advertising Service
751
"Sedatole" — "Linctus Comp" — "Hyotole
three admirable demulcent expectorants of which
rve are nor» shipping large quantities to the drug'
trade in anticipation of your urgent requirements
this fall and winter when, owing to the shortage of
coal, "flu," pneumonia, bronchitis, etc., are liable to
occur in your practice, perhaps epidemically. If
you send in for samples please mention your Fed.
Lie. No. — this only for our records. None needed
when you prescribe them ; just keep records.
99
Ethical
Expectorants
Sharp & Dohme— Baltimore
Conscientious Chemists since '60
HEMORRHOIDAL
Suppositories
If imitation is the sincerest form of flattery,
Anusol Suppositories have good reason to
be proud.
But, as always-
Let us beware of the flatterer.
Ample Trial Quantity and Information on
Genuine Anusol Suppositories
from
SCHERING & GLATZ, Inc.
150 Maiden Lane NEW YORK
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
[Phikd.!j*ii
%]0t6CU5Zt^
HtOCAJNE TABLETS
VY/HEN ordinary procaine tablets
" turn yellow one of the ingredients
haa absolutely decomposed.
But. between the time the tablets are
made and the time they turn yellow,
atmospheric conditions are gradually
tapping their strength.
You have no way of knowing that you
will get full strength injections and per-
fect, positive anaesthesia every time
unless you use Dr. R. B. Wane's "In
Vacuum" Procaine Tablets.
Free Sample
Lat your own experience prove the aupe-
rtorily of Dr. R. B. Walte'a "In V.coW
Procaine Tablet*. Send urn your profeaslonel
card end we will Knd you a nenerotii tree
•ample box for your own teat*
THE ANTIDOLOR
MANUFACTURING COMPANY
32 Main Street. Springville. N. Y.
terials, quickly and naturally. Bran will permanently
relieve constipation, if it is eaten regularly; it n in-
valuable as a constipation relief for the aged and for
the bedridden.
You will find Kellogg's Bran, cooked and krnmbled,
a very easy and delightful way of administering this
very necessary dietary element. With this product it
is no longer difficult to get patients to carry oat your
instructions. If it's Kellogg's Bran thev will enjov it
A large package will be sent complimentary to America::
Phvsiciajj readers. Address: Kellogg Toasted Cera
Flake Co., Battle Creek, Mich.
A Valuable Anticongeativc and Corrective
in Uterine Troubles
Many physicians have found Viburno a stand-by in
such conditions as ovarian congestion and congestive
dysmenorrhea; weak pregnancy and deficient lactation;
menopause and its phenomena, including hallucinations,
hot flushes, etc.; nervous and menstrua! derangements
and the troubles of adolescent girls. Sterility, where
no lesion exists, has been found to respond after two
or three bottles.
Sample and formula will be sent to American Phy-
sician readers on request. Address : The Viburno Com-
pany, 116 Maiden Lane, New Yor.k.
Effective Administration of Iron
It is not the amount of iron administered that is im-
portant, but the amount that is assimilated and retained
While large quantities of iron are given by month, it
is largely precipitated in the intestines and cast off as
unabsorbed iron sulphide in the fecal discharge.
However, one grain of Ferric Dunethylarsenate
(Continued one leaf over)
MORPHINE
Dtng Addiction*
Treated by the "fyryte Method"
Asaie and easy ny. Reeubs guaranteed.
Treenntnr i> p-inl— .>d mpporriY*, ™rfiei then
*»" ■■"*■ N° n»™. period ■fgdanonl I
r Lined Overcoats
ome RumriiU will be sold i
$42.50
lafular Retail Price, $68.00
ENT FOR EXAMINATION
at once. State cbeit Deunr
'est. height and weight. Ends*
r expreaaagc; coat win be for-
d at once.
E. HART, Far Dept.
1 West 134th St, New York
You can buy with Confidence— See "Service Guarantee to Readers? on page 758
The American Physician Advertising Service
r TESTOGAN THELYGAN ^
For Men For Women
Formula of Dr. Iwon Block
After seven years' clinical experience these products stand as proven specifics.
INDICATED IN SEXUAL IMPOTENCE AND INSUFFICIENCY
OF THE SEXUAL HORMONES
They contain SEXUAL HORMONES, i. e„ the hormones of
the reproductive glands and of the glands of internal
Special Indications for Testogan: Special Indications for Thelygan:
Sexual infantilism and eunuchoidism in the Infantile sterility. Underdeveloped mam-
_.i. !_„•_« ...j .„. .-I „i™-,.. "»e. etc. Frigidity. Sexual disturbances in
male. Impotence and sexual weakness. obwity and ££ metaboIic dUorders. Cli-
Climactenuro virile. Neurasthenia, hypo- macteric symptoms, amenorrhea, neurasthe-
Chondria. nia, hypochondria, dysmenorrhea.
Fmiakd (■ TABLETS tar telimaJ w ud 1m AMPOULES, Itw lomd-tMl talKUa.
Tnutu Hid Th*lr«u TftbtM*. 40 in ■ box, 91.78. TwMm Axty tm. Hi-. box, *1M
EXTENSIVE LITERATURE ON REQUEST.
CAVENDISH CHEMICAL CORPORATION
29S PmH StlW
IABETIC FLOUR
Starch-free. Produces Bread,
Muffins. Pastry that makes the
k | ^distressing features
M TESi
Grow
I Less and
'Uss •
Litters prepared caaein Diabetic Flow — «ett Hang. A month", supply of 30 boxes $4.85
LISTER BROS. Inc., 405 Lexington A™mm, New York Cily
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
A Stand-By in
Uterine Troubles
VIBURNO
(BEACH)
The but evidence of thia is the
repeat order* received from physi-
cian* and druggists.
Nervine-Tonic and Anticongest-
ive, with calmative and corrective
action on the bladder. Employed
with much satisfaction in ovarian
congestion and congestive dysmenor-
rhea; weak pregnancy and deficient
lactation; menopause and its phe-
nomena, including hallucinations, hot
flushes, etc.; nervous and menstrual
derangements after "flu," and the
troubles of adolescent girls. Sterility
often responds after 2 or 3 bottles if
no lesion exists.
Uolik* similar products, VIBURNO
(unduutad) Ltd.
l bottles
Sample and Formula on Raqoasf
THE VIBURNO COMPANY
116 MaicW Una, New Y«rk
9 Sal Hepatica
THE
STANDARD SALINE
LAXATIVE
Bristol-Myers Co.
NEW YORK
(Endoferarsan) given intravenously, produces an aver-
age increase of 125,000 red corpuscles with a correspond-
ing rise in haemoglobin index. This is soon followed
by improved oxidation, oxygenation, metabolism and nu-
Endoferarsan is used in anemia, chlorosis, debility and
convalescence; ten or twelve doses are usually given at
three or four day intervals. Interesting reprints and
booklet will be sent to you on request by the Intravenous
Products Co. of America, Inc., 121 Madison Ave,, New
York City.
An Ideal Arsenical
Sodium Diarsenol has the therapeutic advantage oi
arsphenamine with the solubility and convenience oi
neoarsphenamine, and gives clinical results equal to oi
better than either of the two. Neutralization with alkali
being obviated, there is no undue handling and conse-
quent decomposition of the highly reactive solution; il
dissolves very quickly in water, giving a solution ready
for immediate injection.
Samples and literature will be sent gladly to Americas
Physician readers. Address; Diarsenol Company,
Inc., Buffalo, Boston or Atlanta,
Woodlawn
Maternity Home
dflff FITH'S COMPOUND MDCTUDE
of Guaiac, Still infia, etc.
A Powerful Alterative -Composed of Guiiac.
Stilling.., Prickly Ash, Turkey Corn, Colcbieam,
Blick Cohoih, Sarsaparilla, Salicylate! of the Alka-
lies, Iodide of Potass, and other well kno-
■bined it
.uch a
s loleii
Rheumatism, Gout.
Lumbago, Neuralgia, Sciatica, etc
Prwcrib* it for "That Stubborn Cass"
To Phyticiani only — we will upon request, tend a
regular eight ounce bottle (S1.2S Bile), for trial,
upon receipt of 25 centi for express charges.
Griffith'. Rheumatic Remedy Company
Newburgh, New York
Pond's
Extract
.Freely applying Pond's Extrai
relief from' pain sod lameness,
lumbago an excellent plan is to i
saturated with Pond*! Extract;
lumbar region and lightly p— ■
until dry. This often prove
PON'D'S EXTRACT CO., Niw Yom
pain-relieving measure
Lame
Back
You can buy with Confidence — See "Service Guarantee to Readers
The American Ph$iirian Advertiting Service
17VKRY DAY doctors are advising a rest, a trip to a sanitarium, a visit to
■*-'a specialist, an operation — anything to get rid of their old, stubborn cases of
Prostatic Disease and Impotence
Maybe you are doing, or ire about to do tbii Terr thing. You are losing postibilitiei of dollars and prestige,
Too many of these cases are passed up by good doctors, only to fall into the bands of unscrupulous men who
YOU' CAN GET RESULTS
will try SUPPOS. PROSTANS thoroughly in one or Iwo cases you will surely
There is nothing secret about S*ipoi. Proliant— foi mula with each bo*.
If after ■ fair clinical test you feel that the results do not more than meet all your expectations, we hereby
Remember. Doctor, that your immediate order means a dear saving of M lo you. It seems a duty to
Fill out the coupon now. Sincerely,
REGENT DRUG COMPANY
Thit Coupon Miami Suceiti and Monty Sovtd at Writ, Pat It tut. Stud Today.
REGENT DRUG COMPANY, The Burden of Proof Raits Upon U.'.'
3152 Woodward Ave.. Detroit, Mich.
I enclose $5.00, send me liz boxes of Name
Suppos. Proitnm (worth $9.00) alio
the above book and "Successful Prosta-
tic Therapy" — free. Address — „_ „
Mentioning The American Physieum Insures Prompt, Careful Service
Helpful Point*
Amenorrhoea
Dysmenorrhoea
and other disturbances of the
menstrual function call for the
tme active principle of Parsley:
APIOLINE
(Chapoteaut)
It Secures Results
by acting directly upon the uterine
nerve endings and producing ovarian
hyperemia, but without disturbing
gastric or renal functions.
Avoid impure or nnialukbl* Kubatitufca*.
Prescribe original vials of 24 capsule*.
Dr. Ph. ChapeUe, New York-Paris
Ph$ticima tample and literature on fcqait to
£. honftn & Co., Inc., American Ag— IS
SO Bhdui Stwt, N«w YoHk
Canada i Lpmaaa Limited, Moatnal
Thest Advertising Pages art
A Constructive Market
Our Advertising Standard!
Advertisements must give honest service to nr
readers and their patients is the bask principle lor the*
standards and for the conduct of The Ajieucis
Physician's advertising pages.
Our attitude in applying these standards is not one
of narrow technicality but of practical service.
Advertisements of the following classes are tut
acceptable for the pages of The American Physio**:
Fraudulent pharmaceuticals; those making dishonest
claims.
Pharmaceuticals charging excessive price; price out
warranted by content and by trade conditions.
Pharmaceuticals and other mixtures for internal me
and containing narcotics or other habit-inducing drop
in quantities sufficient to promote their improper repeti-
tion on prescription (chloral-bearing proprietaries, etc).
Potent pharmaceuticals which justly merit profes-
sional disapproval because of their lay advertising of
manifestly unethical exploitation.
Financial advertisements that claim returns not com-
patible with conservative investment. Only coisirv*-
live investments are advertised.
Farther
Advertising copy is subject to revision by the editorial
staff.
The American Physician agrees heartily with the
principles of the Council on Pharmacy and Chemistry
of the American Medical Association and we exclude
from our advertising pages such pharmaceutical prod-
ucts as they have definitely shown to be unworthy of
professional confidence and the manufacturers of which
have not removed the cause of objection; but we do
not accept such findings as are based on academic dab
without due recognition of general" clinical experience.
Concerning formula;, The American Physician ti
urging pharmaceutical manufacturers to give full thera-
peutic data regarding formuLe, stating quantitatively
active medicinal content, in order that physicians nor
intelligently prescribe. We do not accept advertising of
secret pharmaceuticals.
But We do not Decline - - -
Advertising of original drags, compounds or preparations ini-
lated in current editions, of the. U. S. Pbarmacopoaa or NsBOoat
.w"~™.,,™e£.,,,™\nd "valuable* out which' have not beta
*"" i and ChemitftT. «
.ssual Roll Call — Nov
i to Nov. 23m, 192
You can buy with Confidence— See "Service Guarantee to Readers" on page 758
The American Phytician Advertising Service
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
Acknowledged the Best
Marvel Whirling Spray
MARVEL COMPANY
25 W. 45th Srr»t Naw York
Our Advertising Standards
ture. an da re" wt-1] 'ti/hr
live a realplaee in medical lh
- Ihera despite pbarmacolouc i
Minor antiseptics, maps and loilct article) honeillj «d
□ both physicians »nd lawmen without false or fraudulei
Service Guarantee to Readers
IF YOU HAVE ANY UNSATISFACTORY
DEALING WITH AN ADVERTISER IN THE
AMERICAN PHYSICIAN, WRITE US THE
PARTICULARS AT ONCE.
WE WILL IMMEDIATELY TAKE THE MAT-
TER UP WITH THE ADVERTISER AND SEE
THAT THE ADVERTISER EITHER MAKES
GOOD, OR HIS ADVERTISEMENT IS ELIMI-
NATED FROM THE AMERICAN PHYSICIAN'S
PAGES.
Neosalvarsan
HA
"0
( , V eo a r j P /i c nam in c - Mc tz )
is unsurpassed in reliability,
trypanocidal efficiency and
ease of administration.
I Neosalvarsan is manu-
factured by the process
y used in preparing the orig-
inal Ehrlich product and
offers the physician the
ideal means for treating
the luetic.
MMETZ lABORmMIES.hc
Onr-Th>enly-7ito Hudro* Street, Afrn'Kr*.
Malnutrition
*
if produced by an obstruc-
tive sluggish intestine and
the gratifying results ob-
tained by using
Pluto Water
in these cases show it to be
the best agent obtainable in
disorders of this kind.
Many practitioners di-
rect convalescent patients to
the spring for rest and com-
plete treatment.
French Lick Springs Hotel Co.
French Lick, Ini
You can buy with confidence — See "Service Guarantee to Readers" top of this page-
The American Phyucian AJ*esHmg Service
Dioxogen
Antiseptic Efficiency
Without the' Unknown Quantity"
NEVER was the necessity for prompt and effective
antisepsis in the care of emergency or Infected wounds,
so widely and thoroughly recognized as it is today. As a
logical consequence, never was there a time when the
value of Dioxogen as an all round antiseptic was more
evident
This is eat y to understand on the part of die many medical mm who
Stop to realize that the germicidal efficiency and tissue healing properties of
re due entirely to the para, active oxjrgan it is able to carry directly
0 the wound or place required. Naturally they have come to prefer Dioxogen
to those poisonous and essentially
irritating germicide! like iodine,
carbolic, bichlorides, and so on, the
ic dangers and possible injurious
effects from which are always an
"unknown quantity."
The use of Dioxogen in i
ing infected wounds and injuries
assures maximum antiseptic effi-
ciency with gratifying freedom from
the "unknown quantity" of toxicity
and tissue ir '
The Oakland Chemical Co.
idtntioitmg The American Physician Insures Prompt, Careful Service
Surgical Relations oi Constipation
OMNIPRESENT AND OMNIPESTE.ENT. C faff 786 )
One Reason Why We Lose Practice
FOOLISH QUESTIONS* NO. NOT TO THE PATIENT. (paf 803)
Causes and Prevention of Infant Mortality
{ftp TBI)
Cancer Therapy
•Second and Concluding Section of a Notable Contribution to Diagricili and
Treatment Emphaiizing the Proper Co-ardtnnlion between Surgery. Radium and the X-Raye. {page 793)
The Difficult Financial Problems of Group Clinics
OF FORTYJWE GROUP CLINICS INVESTIGATED BY MERCUR. FORTY-THREE
SUSPENDED BEFORE TWO YEARS OLD. (.page 777)
Full Content! on Page 766
i It - Mr.-, I /"\ . . . 71 /f j. • r\ A
A Conitruciwe Marty for Buyer and Seller
Rheumatism
Gout
Neuralgia
Neuritis
Sdatica
Lumbago
Migraine
What shall it profit
the patients?
to have their suffering! relieved if it's done
by, throwing into their most vital body
i machinery « monkey wrench-like cokhicum,
the salicylates, heart-depressants, kidney-
irritants, intestine disturbants.
Genuine ATOPHAN, devoid of .11
thoio drawback*, it manufactured at
our Bloom Geld. N. J., plant by a
special process, precluding tbe pos-
sibility of even traces of unpleasant
empyreumatic admixtures.
Camplimtnlarf Trial Package and /n/onttoh'on frost
Schering & Glatz, Inc.
ISO Maiden Lane NEW YORK
REDUCED PRICES
NEODIARSENOL
Orders for 50 ampoules — 10% discount.
of Diarsenol. Heodiarsenol and Sodium Dianenc/ia made. They"
ONE-HALF the amount yuu hare been paying for srsenicals of inT
Thin reduction i* msde possible throuan tbe perfection, of manuf
c Health Service.
o meet the standard* of the
solubility, stability, low toxicity and therapeutic
1 Government requirements. Each lot is offidilly
hipped, as all material is made under regulation
If yon are not at present using our arsenical*, try ■ small or
line to any of the offices below will have prompt and careful a
therapeutic efficiency mailed on request.
DIARSENOL COMPANY, Inc.
ATLANTA, GA. BUFFALO, N. Y. BOSTON, MASS.
Forsyth Bldr. Elltcott Square S3 State St.
i buy with Confidence — See "Service Guarantee to Readers" on page 830
Nmnbcr, 1922]
The American Physician Advertising Service
763
Acute Respiratory Diseases offer
an excellent opportunity to dem-
onstrate the value of Therapeutic
Immunization with Bacterial
Vacci
mes
DATA FURNISHED ON REQUEST
Bacteriological Laboratories of
G. H. SHERMAN, M.D.
DETROIT
The combination of tonics and stimulants ex-
plains the clinical results obtained in the
treatment of nervous disorders by the use of
FELLOWS' COMPOUND SYRUP
OF HYPOPHOSPHITES
"A true stabilizer of shaken nerves?'
It contains the "mineral foods", Sodium, Potassium* Calcium, Manganese
Iron and Phosphorous, and the stimulating agents. Quinine and Strychnine.
Samples and Literature sent upon request.
FELLOWS MEDICAL MANUFACTURING CO., Inc.
26 Christopher Street, New York, N. Y.
VaL 29. No. n, Published monthly— Tho Taylors; C. C. Taylor, Publisher; Mrs. J. J. Taylor, Ed. Mgr. Entered as
9tc91Vkclats ******* p*°- J3, iW, at the post office at Philadelphia, Pa., under Act of March 3, 1870. Continuing
!z£Jd£!2£?2*iic Service of, The Medical Council, "Most Widely Circulated Medical Monthly," established in 1806.
COPYRIGHT 1922, by The Taylors, Publishers, 420 Walnut &., Philadelphia, U. S. A. All rights reserved.
MEDfCiL COUSCIL
764
A Constructive Market for Buyer and Seller
[Phikdelphb
No Growth
Without Vitamines
The Bio-Chemical Laboratory of the University
of Cambridge recently conducted an exhaustive
investigation to determine whether the vitamines
known to be present in the raw materials from
which VlROL is manufactured were present in their
active state in the manufactured VlROL as sold to
the public. This report which fully proves the
presence of the vitamines in VlROL will be sent to
any medical man on application.
Advantages of VlROL
It contains the vitamines
It is a well balanced food.
It is easily absorbed in the most delicate con-
ditions.
VlROL exercises a remarkable influence on
growth and development. It is a food of great
value for expectant and nursing mothers, in
anaemia, malnutrition, and all wasting conditions.
VIROL
Sole Agents for United States
Geo. G. Cook & Co., Inc., 59 Bank Street, New York
IL
You can buy with Confidence — See "Service Guarantee to Readers" on page 830
November, 1922 J
The American Physician Advertising Service
765
i
b
i
1
ill
61
"Aegrata Awn anima est, spes esse dicitur**
Alpha-Lobelin
Incomparable stimulant
in subnormal respiration
due to accidents and dis-
eases.
Cadechol
(Camphor- choleinic acid)
Indicated in disturb-
ances of the circulation
and heart insufficiency due
to functional and organic
changes.
Laudanon
Scopolamine
Unexcelled analgesic in
labor and inoffensive hyp-
notic in prolonged deep
X-ray treatment.
Laudanon
Universally accepted
standard for morphine
medication during long
periods without danger of
habit formation.
Perichol
(Cadechol and papaverin)
Efficacious Cadechol
combination especially in-
dicated in the treatment of
angina pectoris.
Laudanon
Atropine
Indispensable analgesic
and hypnotic for overcom-
ing hypersensibility and
tendency to vomit.
For Literature or Further Information Address
Ernst Bischoff Co., he,
85 West Broadway New York, N. Y.
i
i
%
i
M
ra^SS
2J(«
Mentioning The American Physician Insures Prompt, Careful Service
766
Contents
Copyright, *9**, *y Tkt Tgyhrs, AU right* rcstrwd.
Editorials
Difficult Financial Problems of Group Clinics 777
How Shall We Limit or Overcome Cancer? 779
General Features of the Mycotic Infection 780
Orifinal Articles
Causes and Prevention of Infant Mortality.
By Henry Bixby Hemenway, M.D 781
To practice medicine is a privilege; to possess the
qualification of Dr. Hemenway is an honor; to observe,
deduct and record half a century's experience is a
pleasure few are privileged to enjoy. Therefore, to fall
to read, imbibe, and utilize the substance of this paper
is to overlook something unusually worthwhile.
Surgical Relations of Constipation.
By James C. Minor, M.D 786
This subject, of such tremendous importance, should
command the attention of the doctor, who is so vitally
concerned in the abating of disease and preservation of
life — both so relentlessly Interfered with by this omni-
present and omnipestilent overloading of the lower
bowel.
The Study of Psychoses as a Guide to Proper Child
Rearing.
By W. W. Young, M.D 787
Dr. Toung says if we are to rid civilization of the
cancer of abnormal mentality, we must have mothers
and fathers who know how to be parents.
(Contents
Muscular Tone and Reflex Pain in Diagnosis— Twenty-
ninth Clinic.
By A. Mackenzie Forbes, M.D 7»
In comparing the duties of a diagnostician with those
of a judge, Dr. Forbes says — "In a court of law the
evidence is of the greatest importance. The omission
or addition of one point may change the court's decision.
In a similar way, the science of diagnosis, the collect-
ing, weighing and properly adjudicating the significance
of the symptoms is of the greatest importance."
Cancer Therapy.
By Isaac Levin, M.D 7W
This is the second and concluding section of this notable
contribution to the diagnosis and treatment of cancer
by means of a group clinic management of the cases.
Ludwig's Angina.
By Mayer Shoyer, M.D 7»
When crossing a railroad you stop, look and listen.
When crossing Ludwig's Angina, you do not; yon roth
your patient to the surgeon, or the patient will go to
the undertaker, as is emphasised in this short but
illuminating paper by Dr. Shoyer.
Physicians Should Lead Patients to Right Living and to
Children Well Born.
By B. T. Schreiner, M.D.
768)
Chinosol
"A POWERFUL ANTISEPTIC, SOMEWHAT STRONGER IN
THIS RESPECT THAN MERCURIC CHLORIDE AND CONSID-
ERABLY STRONGER THAN PHENOL."
(COUNCIL ON PHARM. AND CHEM. A. M. A.)
««
ASEPTIKONS (sup^/oWs,
producing complete antisepsis
But
Non-poisonous, Non-irritating and No injury to membranes
Indicated in cervicitis, leucorrhea,
specific and non-specific vulvo-vaginitis, in all cases
where complete vaginal antisepsis is desired.
PARMELE PHARMACAL CO., 47-49 WEOT STREET, NEWYOMC
You can buy with Confidence — See "Service Guarantee to Reader*?9 on page 830
NoYcaber, 1923] The American Physician Advertising Service 767
Just completed!
Three separate investigations by competent authorities
on the results of Yeast Therapy
What happens to the living yeast cells in the alimentary
tract?
Has fresh yeast any marked tendency toward laxative
action?
What is its effect on the leucocyte count?
Investigations into these and other phases of yeast therapy
have recently been completed.
It is now definitely established that fresh yeast is absorbed
in part by the system, and produces a marked increase in
leucocytes, thus aiding in the correction of suppurated con-
ditions.
It has also been demonstrated that yeast, after passing
into the intestine, softens and increases the bulk of the feces by
absorption of moisture and produces a distinct laxative effect.
Detailed reports of this work will be given the medical
profession in the near future.
There is still data to be gathered on the inter-relation of
yeast and alimentary bacteria; and further investigations,
sponsored by the Fleischmann Company, are now in progress.
A nerp authoritative book: written by a physician for
physicians. This brochure discusses the manufacture, physi-
ology, chemistry, and the therapy of yeast. A copy will be
sent you free upon request. Please use coupon, addressing
The Fleischmann Company, Dept. S-11, 701 Washington
Street, New York, N. Y.
New brochure on yeast therapy sent on physician's request
The Fleischmann Company,
Dept S-1 1, 701 Washington Street, New York.
Please send me free a copy of the brochure on yeast based on the
published findings of distinguished investigators.
X ^ mill.* - . --- ^ — — . ninii t ■■ — ■■~tTi«iiiiiiiii n nm ,,,ni hwmm ^^mmmmomm
Mentioning The American Physician Insures Prompt, Careful Service
A Constructive Market jar Buyer and Seller
Contents — ™«nued./.
Qonococcemia and Metastatic Gonorrheal
Br Hyman I. Goldstein, M.D. aoi
Gonorrheal arthritis 1b too frequent. Coo intense, too
obstinate a disease to rcqnlrc Introduction or empbaaia.
Such being the case, we know Dr. Goldstein's able
presentation of tbla subject will be folly appreciated by
our readers.
Efficient Future of Medical Practice
On* Reason Why We Loae Practice 808
la Medical Education Becoming Impractical T 80S
Book Review*
The Vitamins 810
Mental Hoapltal Manual BIO
Studio* in Influenza and It* Pulmonary Complication!. .810
The Place of Vcralon In Obstetrics 812
A Manual of Clinical Laboratory Methods 812
New Prices on
Merz Santal Comp.
Capsules
DISPENSING PHYSICIANS CAN BUY
OF US DIRECT
10 Minim Elastic Capsule*, box of 100
Alas bona of IX and bums of 24
S Minim Porta. bottle of 36
5 " " bottle of 500
5 " " bottleoflOOO
Unsurpassed for happy effect in Urethritis,
Cystitis, Prostatic Troubles, difficult mic-
turition, etc.
PRICES AND SAMPLES UPON APPLICATION
THE MERZ CAPSULE CO.
DETROIT, MICH.
Money Back Guarantee to Subscriber*
Tint Akuicm PnraiciA* is published for ant and only *■■
gtnrral practititntr in tvtry possible way; and, it Unit w*ri ar
able profit.
vat poktici or of any cammtrcimi mOtrtit, having absolutely m
Phtsici** ii not jiving aim fnU measure ("preased do-n sn(
if he will unit us we will chttrfnily rtfnnd, without quanta,
the money he paid for the ytmr't ruburiptian, eren if he hat
Sntecn'prioa Continuance
Practically all o
r subscribers, as i
.e ajobW' -
in), and i
mudI tnpply bach uikj), and to be billed
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The Am
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Phys
loan
VU. 27
Novmbcr, 1922
No. 11
The Difficult Financial Problems of
G
roup
Clint
inics
Their Mortality Is Heavy
OF FORTY-FIVE CROUP CLINICS INVESTIGATED BY MERCUR FORTY-THREE SUSPENDED BEFORE TWO YEARS OLD
TTO CLARIFY the subject in the very beginning,
*■ this article deals only with group clinics organized
and conducted along ethical lines by high-grade and
thoroughly trained physicians who are not commer-
cialists and who aim to give up-to-date service in
every respect. Yet, any such project will fail unless
sound business principles and capable commercial
management are assured from the start.
There are two ways of starting a new business or
enterprise and they are these: First, start very con-
servatively and in a small way, with a very small
overhead that is not increased except by being forced
up by the actual demands of increased volume of
profitable business ; second, start with a full organiza-
tion and a large overhead, expecting the volume of
business to catch up with the overhead. This latter
plan can never be successful except with large capi-
tal invested in the venture.
A group clinic does privately what public hospitals
do; or, at least, it does a part of the range of work
done by a public hospital. The public hospital has
often the advantage of public appropriation of money
or of private contributions to its funds; it has, also,
the spontaneous patronage of the community in which
it operates and does not, as a rule, have to work
up business; it procures a large part of its profes-
sional service free of direct charge; and — most im-
portant of all — it does not have to make a profit in
order to succeed.
The group clinic operating in a field already pro-
vided with modern hospital facilities has the above
handicaps that it cannot escape, for it has competition
that has part or all of its overhead donated freely,
that gets professional service for little or nothing
and does not have to declare dividends.
Cty mmd Semi-rmrml Gfmpt
In the large city already provided with adequate
hospital service, the group clinic starting in a small
way attracts so little attention and has so small a
following that it has little chance to succeed. There
is, so to speak, no public demand for it as a busi-
ness enterprise. Hundreds of specialists are already
in the field, referring cases back and forth, perhaps
all within one large office building or a few buildings
within a block or two of each other. This amounts
to a group, all friendly to each other and without
requiring a special overhead, with its complications
and problems of administration, and yet including a
score or more of practitioners of real ability. There
may be, in a very large city, several congested sec-
tions, in each of which are capable specialists, thus
co-operating as groups, if you wish to call them
that.
In such a large city a privately organized group
clinic is apt, any day, to meet the competition of a
semi-public group, such as the diagnostic clinic of
Cornell University. The result is that the pri-
vately conducted group clinic is obliged to cater to
a limited and comparatively wealthy class of patrons
who demand elaborate and very expensive appoint-
ments of every kind. Such a group would be faced
with the necessity of controlling a very expensive
building and carrying a tremendous overhead. Na-
turally, its charges must be very high for any service
it renders.
In the smaller but prosperous communities destitute
of hospital facilities, but which have need for such
service, and if the town does not have sufficient local
enterprise to organize a community hospital, then a
group clinic may fill a great need.
778
Financial Problems of Gronp Clinics
[The
Years ago, out in Minnesota, a lot of people were
hurt in a bad railroad wreck that occurred hundreds
of miles from a hospital. Dr. Mayo was sent for
to attend the injured, and in looking about for a
place to open an emergency hospital, so the story
goes, he applied to the Catholic Sisters who had a
small establishment at Rochester. As the Sisters
always do, they responded willingly to the necessities
of the injured. The work was a success and after
the injured had recovered and departed, Dr. Mayo
suggested that they start a hospital. Now "Will"
and "Charlie" were coming along then and their
father made place for them in the project. Please
note that the institution used was a going establish-
ment and that this, the beginning of the first group
clinic, was a family affair, and it is yet, despite
the fact that a number of other physicians are on the
staff.
Now here is the crux of the whole matter: there
must be a "boss" in any group clinic, or it blows up
sooner or later, and if every doctor in the group
is a bosslet, it blows up sooner and not later. This
is a sad fact, but as forty-three out of forty-five
group clinics investigated by Mercur went out of
business before they were two years old, the mor-
tality is heavy, and one of the main causes of a
post-mortem was determined as the inability of a
number of ordinary medical men to work together
harmoniously. There has to be a "boss" in any
enterprise and a group clinic is no exception.
The two last paragraphs show the main reason why
a group clinic in a small place should be started by
one man, with his own money; and if he lets in others
later on, as he will have to, he will be the recognized
head. If he gets it up to the point of needing asso-
ciates he will have demonstrated by his success that
he possesses the executive capacity absolutely neces-
sary for the chief of a group clinic Doctor, don't
get in on a group that does not have a capable "boss."
You will make more money and do better profes-
sional work by catering to such a leader than by
trying to be one of six leaders. Plenty of doctors
can cut, but doctors with executive capacity are rare
indeed, and the majority of them are poor cutters.
Rem* Momty Needed
If one starts conservatively with a small overhead,
with one paid nurse to do the laboratory work, etc.,
a working capital of $5000 may suffice, provided you
have a building, preferably your own home. But a
working capital is absolutely essential. After you
have made a success of the venture and are the recog-
nized head, it will be easy to get in other men, each
bringing in capital of their own, but then your troubles
will begin if you have even one chronic kicker in the
group.
If the group clinic is to start out full fledged,
with a heavy overhead, don't think of starting with
less than $10,000 working capital, quite aside from
the building and equipment, for each man in the
group. The first year's business is more than apt
to be done at a loss; the second year may break
even, with perhaps a total of $30,000 working capi-
tal left The third year, on such a showing, will
probably show a profit. This shows why a good work-
ing capital is necessary. Lack of working capital is
another prominent cause of mortality among group
clinics.
Km— ledge ei Htpitd MeAedg
We are not speaking here of professional, but of
administrative hospital methods. No one, unless he
has been identified with hospital administration, has
any proper conception of the many things needed
and the host of ways that lose money and retard
efficiency; he must understand hospital team-work,
the methods of keeping hospital records and accounts,
hospital economics and economies, etc. The physi-
cian who spent two years in the Army makes a good
man in a group, provided he is not the kind who
swears at "paper work." This paper work is an
absolute necessity in group clinics. Then, too, there
must be check-up methods, especially in individual
clinical and laboratory findings, individual costs, de-
partmental costs and income, and so on to the end.
Neglect these factors and mortality is sure, even
if it is deferred.
Fmtmce Agmm
If you insist on mixing up your own finance with
the group finance, look out. You may run your
own private practice: that is one thing. But the
finance of the group is quite another thing. You are
in a partnership, with a distinct bargain made that
positively must be lived up to. Corporate bodies
can't work on sentiment or friendship; hard and
fast business methods must rule; it is a bloodless and
cold proposition in management and exact account-
ing, with responsibility exactly placed, and part of
that responsibility is yours — only part. The other
fellow has his rights, and the rights and equities of
the whole group are paramount and must remain so,
else there is a sure death certificate to make out
for the whole enterprise. So, then, a real financier
is an absolute necessity. "A bunch of good fellows"
may gamble over a card game, sometimes one win-
ning and sometimes the other fellow; but at the
end of a dozen games the money is all there, even
if it is unequally distributed. But if this same
"bunch of good fellows" go into the group clinic busi-
ness on a gambling basis, it is only a question of
time until no one of the group has a dollar left
The "good fellow" plan does not go; it is a matter
for management, finance and always a good bank
balance, else there is a certain smash-up. The pro-
PWU.. Norember, 1922]
Finmndal Problem* of Group Clinics
779
fessional side is another story, not dwelt upon here
even if it is important, and it certainly is important ;
but even more important is the problem of dollars
and cents and their handling in a business manner.
Professional deficiencies can be met, even if the'group
has to discipline a man occasionally, or even get
rid of him; but if the whole group is built on the
sands of insufficient capital, poor administration
And lack of method, slovenly financial methods and
the "good-fellow" idea, no amount of professional
caliber will prevent disaster that involves alL
Ower rectors
Doctor, you read about the successful group clinics,
but you do not hear much about the failures. Ton
do not read of the many nights of worry to get the
machinery going, of the jealousies and heart-burn-
ings that must be swallowed bravely, of the records
that must be kept, of the help that must be paid,
and all that sort of thing. Then, too, there must be
constant adjustment of a host of little and annoying
things, and, above all, the everlasting watching of
every factor to make it pay with no legislature appro-
priating money, no church supporting the clinic, no
rich man sending his check to help out. It is all up
to you and your associates, just like it would be up to
you if you were partners in conducting a hotel or
some other business enterprise.
All of this sort of thing runs counter to the tem-
perament and proclivities of most physicians. Un-
less the physician gets firm hold of himself by the
scruff of the neck and revises his whole traditional
attitude, his first six months in a group are the hard-
est half year he ever spent in his life.
Bme r« ffct Ntrwt?
The profession seems to be worried over the group
clinic and what it will do to medicine. Don't
worry; it has not done much yet, as the successful,
privately conducted group clinic is thus far hard
to find. From the difficulties and problems presented
here you will understand just why successful ones
are scarce.
After all this agitation over the group clinic has
passed, the probability is that most physicians will
conclude that "the game is not worth the candle"
and the professional man will conclude that, in the
long run it is better to let hospital people run hos-
pitals and doctors simply practice medicine. If
communities must have hospitals, why should the
hard-working doctor organize them, put up the money
and bear all the brunt T After all, why should he? In
the small town the community hospital may solve
the problem better than will the group clinic.
— T. S. B.
J. T. Mason says, "Ligation will often precioitate a
severe attack of hyperthyroidism. There is always a
reaction; this is especially true following ligation. The
collateral circulation is unquestionably restored within
a few days."
How Shall We
Limit or Overcome Cancer?
MO GREAT DISCOVERIES have been made in
A ^ recent years regarding the etiology, prevention
and cure of tuberculosis, yet the disease is definitely
on the wane, due, no doubt, to better housing, better
food, more outdoor life and the general advance in
personal hygiene and sanitation. The world has been
looking for some great discovery that will solve the
etiology of cancer and lead to a definite and specific
line of treatment, but it has not come. This does not
mean that we should be discouraged, for there is a
better understanding of the disease, it is being
given earlier treatment, and the general improve-
ment of technic, surgical and other, is giving us
hope that the incidence and mortality rate of cancer
may show improvement.
We are offering our readers a notable and sen-
sible discussion on the subject in the department
of original contributions, and it shows that each case
must be treated on its own merits, and also it makes
very clear that no one method of treatment is gen-
erally applicable, all having a place in the modern
group method of treatment set forth so ably.
Cemctr h Mei Omt Simple
The histo-pathology of the host of neoplasms, hu-
man and other, reveals no little diversity, and is not
to be expected that any one etiology is responsible
for this great group. Rather, it is to be expected,
several causes are operative. So, then, it is not prob-
able that any great discovery will have more than
limited application. Our problem is to gather here
a little and there a little, classifying our knowledge,
comparing case with case, group with group, and
so arriving at sane clinical conclusions based on col-
lated observations and exact and duly controlled hos-
pital and other studies.
There is less incidence of neoplasms among the
lower animals than pertains to the human species,
and this despite the fact that human tissues have
more resistance than do those of many of the lower
animals. It would therefore appear that there is
something in the life and environment of man that
promotes this higher incidence and leads to a wider
range of neoplasms. It is our task to ascertain just
what are the underlying factors in modern life that
are leading to the terrifying increase in cancer mor-
tality among us. There has been much speculation
and many scattered observations, all possessing a
certain value; what we need is a co-ordinated study
of all possible influences and vicious conditions; it is
becoming a public health concern, and one in which
every practitioner of medicine can have a part.
j
780
Anno
[The American Pbyneiaa
General Features of the Mycotic Infection
The term mycotic is applied to a variety of infec-
tions due to yeasts, molds, or fungi. Their importance
lies in the fact that when they affect the lungs, tuber-
culosis is so closely simulated that the distinction can
only be made by most thorough examination. Among
the mycotic infections, those best known are strepto-
thricosis and actinomycosis (allied to the fungi; ; blas-
tomycosis, coccidioidal granuloma, sporothricosis and
moniliasis (yeasts) ; and aspergillosis (mold). In none
of them have the reported cases involving the lungs
exceeded 100.
Blastomycosis, sporothricosis and coccidioidal granu-
loma often manifest themselves in the form of skin
lesions which may or may not be associated with
involvement of the lungs. Actinomycosis usually occurs
about the neck or face in the form of chronic discharg-
ing sinuses ; occasionally with involvement of the lungs ;
a sinus may occur in the chest wall These facts are
worth remembering in cases with pulmonary symptoms
and signs in which the tubercle bacillus cannot be
demonstrated in the sputum.
The report of five cases of aspergillosis, one of the
rarest mycotic infections in this country, by Lapenta
(New York Medical Journal, December 7, 1921) serves
to emphasize the fact that these infections are in all
probability not so rare as the number of reported cases
indicate.
Special Features
The usual experience of those who have reported
examples of these infections is that they were at first
believed to be tuberculosis. The patients complain of
cough, expectoration, and blood-streaked sputum or
hemoptyses. They usually lose weight and fever of
an irregular type is present The physical signs, when
the lesion is located at the apex of the lung, are not
to be distinguished from those occurring in tubercu-
losis. The X-ray findings are also those encountered
in the latter infection.
The mycotic infections may involve any portion of
the lung and are often limited to one or the other of
the lower lobes. The condition should not be mis-
taken for tuberculosis if the lower lobes alone are in-
volved, as it is almost universal for tuberculosis to
begin at the apex and extend downwards.
Diagnosis
In the case of a patient who has all of the symp-
toms and physical signs commonly encountered in pul-
monary tuberculosis, but in whom tubercle bacilli are
persistently absent in the sputum, some other cause of
the trouble should be thought of. Failure to examine
the sputum, believing the case to be undoubtedly one of
tuberculosis or a failure to heed the occurrence of a
number of negative sputum examinations probably ex-
plains why more of these infections are not recognized.
The presence of skin lesions or chronic sinuses in
the neck or chest wall or a residence in some one of
the so-called endemic centers should be suggestive. As
few practitioners possess the requisite skill to detect
the various mycoses, the sputum in suspicious cases
should be sent to a competent bacteriologist.
Treatment
In all of these conditions iodide of potassium is
recommended. A number of cures have been re-
ported. On the other hand, many observers have failed
to obtain favorable results from this drug. As it offers
the only hope, however, iodide of potassium should
always be given, once the diagnosis is established. —
Henry Phipps Institute, Philadelphia.
Coming
Visceral Prolapse Surgically Considered, by A. Wiese
"Hammer, M.D., F.A.C.S.
Dr. Hammer says that while the stomach is by far
the organ most usually prolapsed, wandering
liver or spleen, movable kidney or displaced
uterus, may each or severally be found in asso-
ciation. This is especially true in females, be it
the result of tight lacing, repeated pregnancies,
or — again depending upon the latter cause— en-
gendered through muscular strain. Before using
surgical measures, treatment by external mechan-
ical supports should be given a thorough trial
The Barry Diagnosis of Tuberculosis in Children,
by Jacob Rosenthal, M.D.
To write a voluminous treatise on the early
diagnosis of tuberculosis in children is usual and
natural. To write a short paper on such an
extensive subject and still cover the vital essen-
tials of this common disorder, is an achievement
worthy of note. Dr. Rosenthal has accomplished
it — and accomplished it remarkably well
Surgeons, Hospitals and Teachers, Thirtieth Clinic,
by A. Mackenzie Forbes, M.D.
This last paper is a fitting climax to the notable
series by Dr. Forbes, which has stimulated so much
interest among progressive physicians.
Shirring the Round Ligaments in Uterine Retro-Dis-
placements, by Parran Jarboe, M.D., F.ACS.
The frequency of retro-uterine displacements, the
persistency of the condition, the morbid train of
psycho-neurotic consequences, frequently justify
surgical measures. An operation that excellently
serves the purpose in most cases is herein pre-
sented. You will read Dr. Jarboe's short paper with
interest
The Body's Defenses, or How Nature Prevents and
Cures Diseases, by J. W. Torbett, B.S., M.D.
Are auto-corrective and auto-protective powers
the pillars of the art of healing? Is vis medi-
catrix naturae responsible for most cures of
human ailments? What are the elements, the
organs, the structures and functions, concerned
in body defenses and offenses? These are the
items ably discussed by Dr. Torbett in this in-
formative paper.
Cancer Therapy, by L. Duncan Bulkley, A.M., M.D.,
presents another side of this imperative question.
Dr. Bulkley says: "Inasmuch as thorough, rigor-
ous and prolonged dietetic, hygienic and medic-
inal measures yield such far better results is it
not wise for the profession and laity to give heed
to the signs of the times?"
Etiology of the Symptom Complex Called Asthma,
by Henry I. Leviton, M.D.
Is asthma a disease or a symptom? Is it caused
by a food, pollen or micro-organism? Is an
asthmatic a tubercular or a tubercular an
asthmatic — is it one or the other; if neither, what
is the relation between them? All these questions
are thoroughly discussed in this paper, a paper
on a disease which has puzzled and is still puz-
zling the medical profession as to its etiology,
pathology and treatment.
The following papers
art contributed exclu-
lively to this journal.
Republication is Per-
mitted if credited as
follows: AMERICAN
PHYSICIAN, Phila-
delphia.
Original Articles
Sutnen, Itti hiImm, tan luptst wtai mst MMusri
We are not respon- ,
stole for the views es-
pressed by contribu-
tors; but every efort
is made to eliminate
errors by careful edit-
ing, thus helping the
reader.
Causes and Prevention of
Infant Mortality
By Henry Bixby Hemenway, A.M., M.D.,
Medical Assistant, Division of Vital Statistics,
Department of Public Health,
Springfield, Illinois.
Unusually
To practice medicine is a privilege; to
possess the qualification of Dr. Hemenway
is an honor; to observe, deduct and record
half a century's experience is a pleasure few
are privileged to enjoy. Therefore, to fail to
read, imbibe, and utilize the substance of this
paper — this argosy of service, suggestion,
and help, on the many phases of infant mor-
tality— is to overlook something unusually
worthwhile. — Editors.
NO BETTER ADVICE could be given relative
to reading for medical practitioners than those
words of Lord Bacon: "Read, not to contradict and
•confute, nor to believe and take for granted, but to
weigh and to consider."
To properly weigh and consider one must know
-something of the experience of the writer as a basis
for his thoughts, and then compare the written state-
ments with the observations of the reader. Unfortu-
nately, it frequently happens that medical writers
•state, in most positive terms as facts, ideas that are
the result of limited experience or of uncritical theo-
rizing. Even such "half baked" ideas, however, may
-contain the germ of some original and valuable truth.
Fifty Yemrs of Education ami Experience
The writer's medical education began fifty years ago,
when as a bo.y he attended two courses of lectures on
public hygiene, given by that Nestor of American
Medicine, Nathan Smith Davis, Sr., who later became
the writer's preceptor. The reason for these courses
was an epidemic of typhoid fever in college. In fact,
it was those courses of lectures and a love for the
natural sciences which later diverted the writer. from
the legal profession. Licensed in the spring of 1880,
the writer spent nearly two score of years in general
practice — at first chiefly in a small city in an agri-
cultural community ; later in the edge of Chicago. At
present he is chiefly engaged in classifying causes of
death, in an office handling approximately 80,000
death certificates a year.
When he began the practice there were very few
who had the slightest faith in the germ theory of
disease. Relatively more importance was then given
than now to the physics of diseased conditions, and to
atmospheric changes. If in the following lines the
first personal pronoun is used, it is to emphasize the
fact that the statement is a personal observation or
opinion, rather than a fact accepted generally by the
profession.
Scape of Infant Mortality
In the earlier years of his practice the writer
thought of the subject of infant mortality as em-
bracing the first two years after birth, and as center-
ing chiefly about digestive irregularities. Today
infant mortality covers only the deaths during the
first year after birth, and its prevention is chiefly
concerned with the care of the mother before the child
is born. Most of the articles written upon prenatal
care are based upon the saving of maternal life and
health. The saving of infant mortality is quite as
important, and may be quite as striking in results.
Though not in its logical sequence, let us first con-
sider some of the causes of death after the first month.
Early Causes of Death — Feeding
It is generally admitted that the proper food for
a child during its early months is mother's milk, but
if the baby does not thrive, if it cries unduly, the
character of the mother's milk must be studied. One
of the writer's own children, after once feeding on
Jersey milk, when about a month old, absolutely
refused mother's milk, though seemingly that milk
was of good quality.
It need hardly be said here that mothers with any
degree of tubercular or syphilitic infection, or with
acute disease, should not nurse their children. When
782
Infant Mortality — Hemenway
[The American Physician
the mother's milk is deficient in cream, that deficiency
may be at least partially corrected by feeding some
cow's cream of good quality, or olive oil. My own
preference was for Jersey cream.
RmimtmU W Ariikcid F-Hmg
If artificial feeding was necessary my own strong
preference was for Jersey milk, diluted at first with
pure water, and gradually, according to results ob-
served, increasing the strength. The curds of cow's
milk are larger and firmer than those of mother's
milk. In preparing the baby's food I was not accus-
tomed to make the proportions like those in mother's
milk. The presence of cream tends to separate the
particles of casein, and thus to make the curds smaller
and more easily digested. I did not frequently find
that the presence of an excess of cream was harmful.
Consequently I was accustomed to begin with the
upper quarter or third of Jersey milk, diluted one
half with water.
Frttfc mU G-4 Mik
My earlier years of practice were in a community
where it was easy to get the milk fresh from the cow.
In a large city this is seldom possible, but Mahomet
may go to the mountain if the mountain does not
come to him. In case of necessity, especially in the
summer, the child may be taken to the country to
live by the cow.
For reasons given above the writer's preference
was for Jersey milk,, rather than that from any other
breed. The cow must be healthy, and the milking be
done with strict cleanliness. The cow should have
been passed by the tuberculin test.
A most important point in the care of artificial
feeding is that strict cleanliness must be observed.
A tube should never be used for the feeding, and the
rubber nipple must be frequently sterilized. All the
dishes in preparing the food must be not only clean,
but they must be surgically clean.
Emtcritu
When enteritis appears intestinal antiseptics, such
as phenol salicylate, may be used with good results.
If the case is at all severe, all food must be shut off
for 24 hours, and a teaspoonful of pure cold water
should be given at frequent intervals. Without medi-
cation, but with this substitution of water for food,
I have seen a most extreme case recover rapidly.
When enteritis is present food does not nourish. It
is turned into poison which intensifies the harm.
Erwpthe mi Re*piret9ry Distmte$
General epidemic diseases need not be here dis-
cussed, but we find a large number of reports of
deaths in young children from bronchopneumonia,
lobar pneumonia, capillary bronchitis, and acute
bronchitis. If these conditions follow other diseases,
such as pertussis or measles, this should be mentioned
in the certificate of death, and the case should be
classified with the primary cause. Many are primary
pneumonia. Environment has much to do with their
development. Closed rooms, crowded rooms, lack of
outside air, and polluted air are far more dangerous
than exposure to cold or even damp air outside, when
the child is properly protected. Even in the dead of
winter the child should be wrapped up and taken out
of doors for a time every day.
A child overdressed around the throat and chest,
and with lower limbs covered only by stockings, tends
to develop congestion of the respiratory mucous
membranes.
Accidewti mi m Fern MtUSky Figwre*
An undue proportion of deaths of infants occur as
the result of carelessness. Babies pull pots or pans
of boiling water upon themselves, or fall into tubs of
scalding water. Everyone knows of this danger, but
it should be more frequently warned against.
Very many children die during the first few days
after birth. According to the table from the Bureau
of the Census report for 1919, excluding stillbirths,
161,621 infants died during the first year. Of these
26,713 died during the first day, and 53,256 died
during the first week of extra-uterine life. The report
for 1920 gives a total number of deaths during the
first year of life as 174,710. Of these, 29,729 died
during the first day, and 59,030 died during the first
week. In other words, more than one out of every six
children dying during the first year after birth die
during the first day, and one out of every three die
during the first week. This by no means corresponds
with my individual experience, but even if it did such
a tremendous mortality seems inexcusable. It should
be prevented. If the underlying cause is unknown,
it shows the necessity for careful study.
Gcamt Cmut* %i D**h— Frmkyimm
Judging from the certificates of death received,
the more common causes assigned are "marasmus,"
inanition, "failure of the foramen to close," atelectasis,
icterus, prematurity, traumatism in birth, haemophilia,
haemorrhage of the newborn, congenital defects, in-
fectious and hereditary diseases, bronchopneumonia,
and bronchitis.
Parents with diseases transmissible through hered-
ity should not have children. This means especially
those with syphilis, gonorrhoea and tuberculosis.
Syphilis is not directly transmitted from father
to child. The mother must be infected, and the child
derives its infection from the mother. In many cases
such infection is not suspected until perhaps the
death of children raises a question, and a Wassermann
of the mother's blood shows positive. Whenever a
mother has lost two or more children, either by still-
birth or within a few days after birth, particularly
if there is a history of similar deaths in other mem-
bers of the father's or mother's family, it is desirable
that Wassermann tests be made of the blood of the
husband and wife.
Pregnant women should be particularly careful not
to expose themselves to the possibility of contracting
acute infectious diseases. Absolute cleanliness in the
Phila., November, 1922]
Infant Mortality — Hemenway
783
puerperal bed, and in the care of the young infant
will prevent such acute infections of the infant as
septicaemia or tetanus. One case of tetanus, for
example, was caused by the attendant washing and
dressing the infant immediately after having gathered
eggs at the barn, and without washing her hands with
an antiseptic solution before tending to the baby.
It is well known that the germ of tetanus is found
more or less normally wherever horses are kept.
It is well known that the foramen ovale normally
remains open for a week or ten days after birth.
How then can it cause death within that timet An
obstetrician of very wide experience, and a rec-
ognized authority on such subjects, told the writer
that he had never seen but one case of genuine "blue
baby." When physicians reporting "patent foramen
ovale" as cause of death have been questioned as to
the basis of the diagnosis they have uniformly given
the symptoms of atelectasis.
Consider the physical principles involved. Before
birth almost all the venous blood passes directly from
the right to the left side of the heart through the
foramen ovale. Very little passes through the
pulmonary blood vessels. The cells of the lungs are
collapsed, and have not come in contact with atmos-
pheric air. As soon as the child is born the child nor-
mally distends its chest, thus creating a partial
vacuum. The pressure of external air forces air into
the pulmonary air cells, thus suddenly bringing a new
element into contact with the pulmonary mucous mem-
brane, and these young cells are especially sensitive
to the effects of this new contact. In proportion as
this air is cold or abnormally dry, or contains irritant
chemicals (such, for example, as the chlorine of
decomposed chloroform), the air acts as an irritant,
and tends to produce inflammatory changes, as shown
in bronchitis or bronchopneumonia. In one case from
the writer's practice the confinement was at night
and in a small room, lighted by a lamp. Chloroform
was used, and suddenly we became aware of the
presence of large quantities of chlorine vapor, the
result of the decomposition of the chloroform by the
burning lamp. This same irritating result is shown
by the air of poorly ventilated or crowded rooms,
and is intensified by the presence of pathogenetic
bacteria.
Cold air, per se, may not be specially injurious.
It is rapidly warmed by its contact with the mucous
membrane of the nose, which is kept continually warm
by the constant current of blood in the capillaries.
But saturated cold air becomes relatively dry when
heated to a higher temperature. Saturated dry air at
zero temperature is only about one-third saturated at
64° F., and at the normal temperature of the body it
becomes exceedingly dry. It therefore attracts mois-
ture from every possible source. Such air coming
in contact with the tender linings of the lung cells
extracts moisture faster than it can be supplied by
osmosis from the capillaries. This effect is lessened
with the age of the child, but in the very young babe
the mucous membrane becomes abnormally dry, in-
efficient, and is easily cracked by internal pressure
of the blood, thus producing a wound which favors
the development of further trouble. This danger
is decreased if the air of the confinement room, and
especially that of the nursery, is humidized nearly to
saturation.
The lessened pressure within the chest, caused by
chest expansion, has another effect. It decreases the
vascular tension within the lungs, and atmospheric
pressure upon the surface of the body then favors an
equalization of pressure by diverting the blood from
the right side of the heart through the pulmonary
vessels, instead of through the foramen ovale. (In
a case of accidental electrocution the writer main-
tained the circulation of the blood and the consequent
aeration for about two hours by artificial respiration.
When first seen the lips were blue, but they soon
became normally pink, and the skin of the face
assumed the normal hue of health. Though there
was no sign of cardiac action, this change of appear-
ance convinced bystanders that the victim was alive,
and the efforts at resuscitation were therefore con-
tinued.) The pulmonary vessels thus gradually
become more and more dilated, and are thus enabled
to take more of the blood and the foramen is permitted
to close in about eight days ordinarily.
AtdectmtU flwf CUmrm «f Formmtm Orafe
What would happen if, as many physicians seem
to think, the foramen closed instantly at birth f In
the place of a gradual and gentle distension of the
pulmonary vascular system there would be a sudden
and forcible stretching of those vessels which would
interfere with the distension of the air cells, and
would be very likely to produce rupture of the ten-
der vessels, thus filling the cells with blood clots in
the place of air. In other words, an open foramen
ovale tends to prevent atelectasis, and a sudden
closure of the foramen would tend to cause that con-
dition. Practically it may be said that when the
dilation of the vessels is easier than the dilation of
the air cells atelectasis is produced. Irritation of the
membrane of the infant lung, by causing inflamma-
tory changes, favors undue congestion of the pulmon-
ary vascular system. Cold dry air, therefore, may
prove to be an important factor in the production of
atelectasis.
The treatment of atelectasis, therefore, should be
artificial respiration in a warm, humid atmosphere.
The obstetrical authority previously mentioned sug-
gested his belief that a very common cause of atelec-
tasis was the use of pituitary extract to stimulate
labor pains, and he expressed his emphatic condemna-
tion of such use of the drug. Neither my personal
observation nor my statistical investigations have sub-
784
Infant Mortality — Hemenway
[The American Phjacurf
stantiated this claim. On the other hand it must be
remarked that I never personally used the drug in my
obstetrical practice, and I have not felt at liberty to
delve thus deeply into the methods of practitioners in
questioning as to cause of death. In the certificates
of death, and in the replies to questions asked, com-
ing under my observation, the use of this drug has
never once been mentioned.
In the course of my practice, and especially in my
consultation practice, where hyoscyamus, morphine,
or similar drugs have been used at parturition, I have
seen many children physically well developed and
apparently normal at birth, who soon showed lack
of vitality, and they suddenly died within from three
to five days without showing any signs of atelectasis.
I was so convinced that these children died as the
result of drug action that I became strongly opposed
to the use of such drugs.
A death certificate gave as cause of death of a
child five hours old "congenital heart disease." In
response to inquiries made, the physician said that he
had no suspicion as to the cause of the condition.
The child seemed to be well formed and perfectly
normal at birth. It was a full term child. The labor
was of about twelve hours' duration and was not in-
strumental. About five minutes after birth the child
became cyanotic. It resisted all efforts at resuscita-
tion, and in about five hours it died. He mentioned,
however, the fact that the child was born under gas
anesthesia, and that anesthesia was for about two
hours before the birth of the child. Apparently he
did not in any way connect the use of the gas with
the death of the child, but it seems to the writer that
such causation, was very probable.
In many cases of "patent foramen ovale" or atelec-
tasis, the death certificates have mentioned the fact
that the children were prematurely born, or that
there was difficulty of birth. Following this lead, all
such certificates have been questioned and as a result
we have found that this is true of a very large pro-
portion of such cases. It is also true of a large pro-
portion of other deaths, especially within the first two
weeks, where other causes of death have been given;
but whereas in a majority 6f cases of atelectasis or of
"patent foramen" the children were prematurely
born, in cases of icterus there is more of difficulty of
birth.
Icierut mmi DytUcm
While in general practice, my attention was not
specially directed to the causation of atelectasis. I
had noticed the seeming relationship of icterus to
difficulty of birth. My most marked case of icterus
was in a child with right transverse presentation.
Under the care of another physician labor had begun
on Tuesday. I was called on Friday afternoon and
found a hand presenting. Verson and extraction was
immediately performed. This child developed intense
icterus and died about the seventh day. I attributed
the icterus to the compression of the liver before de-
livery. If this suggestion of the causation of icierut
is correct, it may be seen that undue haste in the
delivery of the head, before the os is properly dilated,
may result in such compression of the body aa to
favor the development of icterus. This haste in end-
ing the first stage of labor also favors such compress
sion of the head as to produce cerebral haemorrhage/
with the consequent paralysis, and other injury to
the central nervous system. This may also explain
some cases of lessened vitality.
mirth flwf / flraaf mmrimuty
It will readily be appreciated that a child whieb
has not passed the full period of utero-gestation id
therefore less perfectly prepared to endure the strain
of extra-uterine life. Such a child is more liable to
have pulmonary congestion and to develop digestive
disturbances. Premature birth, therefore, seems to
be a common cause of infant mortality than is gen-
erally appreciated, or than is shown by statistic*
compiled from unquestioned certificates of death.
In this connection, another point should be men-
tioned. It is found that in death certificates of young
infants, reference is frequently made to the fact that-
the deceased child was a "small twin," and the addi-
tional fact is often given that the other twin is well
and strong. Such a record makes an important omis-
sion, namely, the sex of each child. Whole twins, that
is, two infants developed from the same ovum, are
always of the same sex. Part twins, that is, twins
developed from two ova, are probably generally of
opposite sexes. It is probable, in the case of twins of
opposite sexes, that they represent the effects of dif-
ferent periods of utero-gestation. This being so, the
small, weakly twin is probably always prematurely
born.
What causes this prematurity f A few are caused
by accidents, such as falls, or a ride in an automobile
over rough roads. Some are the result of emotional
excitement, such as fright experienced by the mother.
Others are the result of disease of the mother, such
as influenza, pneumonia or fever. In a very large-
percentage of the apparent causes it seems that
prematurity is associated with albuminuria in the
mother. In some of these cases the birth is spon-
taneous. In others premature labor has been in-
duced or Caesarian section has been performed.
When it is remembered that as yet only a relatively
small proportion of pregnant women have systematic
examinations, it may readily be seen that the under-
lying condition shown in puerperal eclampsia may be
responsible for more cases of prematurity than ap-
pear in the records.
EitcU W VUamty ol BJeW <w M«k*r mmi Imhmt
In eclampsia there is a marked increase in the via*
cosity of the blood. Every symptom of eclampsia:
may be easily explained by this condition. Before
albumen appears in the urine the result of this in-
creased viscosity of the blood may be seen in the
Phila.. November, 1922]
Infant Mortality — Hemenway
785
increased blood pressure, and perhaps in valvular
incompetence of the heart. It is the writer's per-
sonal conviction that the danger ahead may be dis-
covered earlier by the systematic taking of maternal
blood pressure than by any other means.
But what causes this increased viscosity of the
blood with the consequent impeding of the capillary
circulation, and the resulting local congestions and
increase of blood pressure f It is known that vis-
cosity of the blood is increased by certain disturb-
ances of the digestive tract, and the consequent load-
ing of the blood with waste products.
Entering now the domain of theory, for I know of
no investigations on the subject, it is suggested that
increased viscosity of maternal blood may be a nor-
mal result of pregnancy, and that the condition only
becomes pathogenic when it is excessive. The nor-
mal individual has many paths for the elimination of
systemic waste — the lungs, skin, kidneys and intes-
tinal tract with the liver. Waste in the portal cir-
culation may be extracted and eliminated by the liver,
without affecting the blood of the general circulation.
The foetus in the uterus must pass all of its effete
matter to the mother's blood by placental osmosis.
The mother's blood, so to speak, is the sewer for the
child. The mother's blood, perhaps already loaded
by the mother's own poisons, must carry the infant's
sewage until it can be eliminated by her excretory
organs. This infant's sewage thus contaminates the
mother's entire blood supply.
Normal circulation of normal blood is essential for
the peculiar nutrition of the foetus through the
placenta. Increased viscosity of the mother's blood
would naturally interfere with this normal nutrition
of the infant. This might readily explain the puny,
weak condition of many infants, and it may explain
many more cases of stillbirth than is generally ap-
preciated. Further, because it would interfere with
the normal exchange of fluids between the mother and
child through the placenta, insofar it would tend to
make the foetus a foreign body, and stimulate the
uterus to expel it.
Even if pregnancy goes to full term, this condition
may explain malnutrition, icterus, and other abnor-
mal conditions. Haemophilia and haemorrhage of
the newborn are causes of death mentioned more fre-
quently than most practitioners realize. Increased
viscosity of the blood tends to produce capillary
stasis, and this in turn tends to cause rupture of the
small blood vessels. Increased viscosity of mother's
blood might easily cause a similar condition in the
infant. In a case of intestinal haemorrhage of the
newborn the writer has seen this general capillary
haemorrhage, beginning before birth, throughout the
intestinal mucous membrane of the small bowel, due
apparently to obstruction to the circulation through
the liver. The mother of this child also had impaired
action of the liver. This case occurred before the im-
portance of blood viscosity was recognized, but years
after this same mother showed marked improvement
in circulation under treatment with citric acid, and
looking back the writer is convinced that she had
increased viscosity of the blood during all the years.
Tnmbmtmt «f Bypcrvuciity «f Bt—i
If tests show increased blood pressure in the
mother, if they show increased viscosity of blood, if
albumen appears in the urine, what can be done to
correct the condition f
The diet of the mother must be studied. Proteids
must be reduced. The patient should eat freely of
fruits, especially the citrus fruits. She must drink
freely of water.
For direct action upon the viscosity I know of no
drug comparable with citric acid and its salts. Even
with most marked albuminuria the free use of this
treatment may clear the urine, and permit the patient
to go to full term and have a normal healthy child.
This occurred in a case in my own practice, where
conditions were not favorable to an immediate forced
delivery. There was a strong mitral bruit also. By
the time I could get her into the hospital she had
shown such marked improvement under this treat-
ment that she was kept under observation, and inter-
ference was delayed. The labor was normal, the
babe was strong, the albuminuria disappeared, and
the heart became normal, without evidence of val-
vular weakness.
The sodium citrate may be given freely. Twenty
grains in water, four times a day when the stomach
is empty, is a fair average dosage.
The following table, taken from the Bureau of the
Census birth statistics for 1920, shows the number of
deaths for each cause of children under one year of
age and under one month of age in the birth regis-
tration area (not the death registration area) :
Under Under
Cause one year one month
All Causes 129,531 62,635
Measles 1,469 70
Scarlet Fever 146 14
Whooping Cough 4,593 302
Diphtheria and Croup 690 76
Influenza 4,044 47J
Dysentery 598 52
Erysipelas 632 1 90
Tetanus 152 140
Tuberculosis of Lungs 576 39
Tuberculous Meningitis 750 23
Other Forms of Tuberculosis 223 18
Syphilis 1,283 559
Meningitis 980 165
Convulsions 1,447 739
Organic Diseases of Heart 473 147
Acute Bronchitis 2,601 559
Pneumonia 4,822 719
Bronchopneumonia 11,958 1,867
Diseases of Stomach 1,740 461
Diarrhea and Enteritis 22,504 2,683
Malformation 9,381 7,227
Premature Birth 29,217 27,912
Congenital Debility 11,653 8.088
Injuries at Birth 5,645 5,577
External Causes 1,570 432
Unknown or Ill-Defined 3,732 2,145
All Other Causes 6,642 1.96S
786
Surgical Relations of Constipation — Minor
[The American Physkua
Surgical Relations of Constipation
By James C. Minor, M.D., F.A.C.S.,
Commerce Bldg., Kansas City, Mo.
Ommprtsemi tmi Ommpe*ik*
The practically universal incidence of con-
stipation, together with its by-products and
end-effects, ranging from the usually en-
countered auto-intoxication to the hypothet-
ical genesis of carcinoma of the rectum, tax
the efforts and skill of the physician to the
utmost. This subject, of such tremendous
importance, should command the attention
of the doctor, who is so vitally concerned in
the abating of disease and preservation of
life — both so relentlessly interfered with by
this omnipresent and omnipestilent overload-
ing of the lower bowel. — Editors.
ABOUT 90 per cent of all cases of constipation
are produced by some one or more of the many
diseases and obstructions that occur in the rectum
and sigmoid flexure and can be relieved permanently
only by surgical interference. Constipation is most
frequently met with of all human ailments barring
none, but should be recognized as a symptom rather
than a pathologic condition; however, it is not the
writer's intention to go into an exhaustive considera-
tion of this subject, as the field is too great.
I would like to call attention to a few conditions
that are very commonly associated with constipation,
and in most cases clear up after having the disease or
obstruction in the rectum removed, and as a con-
sequence effect the re-establishment of a normal alvine
dejection, thereby relieving many very distressing,
and in some instances, alarming symptoms. I refer
especially to lumbago, sciatic neuralgia, kidney dis-
turbances, chronic appendicitis, and gall bladder ob-
struction. A few of the direct causes of constipation
are haemorrhoids, fissure, fistula, stricture, hyper-
trophy of sphincters, growths of various character
including carcinoma and violation of hygienic law,
such as errors in diet and improper habits, quality
and kind of food, and most important, insufficient
quantities of fluid. To emphasize the importance of
the latter, may I call attention to the fact that a large
* Read before the American Proctologic Society, St. Louis,
May 22. 1922.
percentage of normal fecal matter should be water,
so anyone can readily realize how essential is this
ingredient. There are many other causes too nu-
merous to mention. I think I am not exaggerating
when I say there is not one person in twenty
who drinks sufficient water to be normal orv adequate
to the demands of the human system. I think the
medical profession in general today recognize more
than ever before the importance of rectal diseases and
their relation to the whole human economy, and that
no general physical examination is complete without a
careful rectal examination, even though the patient
presents no symptoms of any such trouble. In my
opinion, there is no class of disease that acts more
directly upon the sympathetic nervous system. The
treacherousness and deceptiveness of rectal disease is
very great; to the average individual it sounds absurd
to say a patient can have carcinoma of the upper
portion of the rectum or sigmoid flexure and not
know it, and present no prominent symptoms to in-
dicate it, and yet it is true, as cancer of the rectum
located above the sphincter muscles causes no pain
at all in its early stages. Later in its development,
however, when the deeper structures become involved,
then the pain is very severe, in fact, I know of no
condition in which the pain is more excruciating than
that of carcinoma of the rectum in its last stages.
Purgatives should be avoided as much as possible
because of their irritating effects upon the stomach
and bowel mucosa. In the majority of cases of con-
stipation, after examination, one can arrive definitely
at the cause, and it should be removed, or corrected,
whether it be constitutional or mechanical in its char-
acter. Under the latter we must always bear in mind
the extra-intestinal causes such as the neoplasms of
the abdominal and pelvic viscera and the retrodis-
placements of the uterus or enteroptosis, hypertrophy
of Houston's valves, congenital narrowness, hyper-
trophy of external sphincters and many cases of com-
plete relaxation of the sphincters (as found some-
times in specific cases) where the patient suffers from
constipation due to partial intussusception of the
rectal mucosa and lack of tonicity.
Indirect Ejects
Now as to reflex or indirect effects from const i pa-
Phtla., November, 1922]
Surgical Relations of Constipation — Minor
787
tion or obstipation; first, we have more or less re-
tained fecal matter regardless of the use of laxatives,
and a process of reabsorption is going on contin-
uously, which in turn, effects the general secretions of
the body and intestinal digestion, producing more or
less toxemia, and causing gas pressure which is often
followed by gall bladder and appendix disturbance.
It is a rule to which there are few exceptions that
every anorectal lesion may be caused or seriously
modified by constipation, or obstipation. Venous
congestion is one of the great underlying factors in
the production of rectal diseases; accumulation of
feces in the rectum or sigmoid impedes the return
blood current and may cause traumatic infection even
to the extent of malignancy. The majority of cases,
I think I am safe in saying 90 per cent of all cases
of malignancy it has been my privilege to observe,
have given no history of heredity, but always a his-
tory of some benign condition preceding the malignant
one that could have been corrected by surgical inter-
ference. My observation has convinced me the con-
stant irritation of the stool passing over a benign con-
dition can produce a malignant one, and especially
are the effects exaggerated by a constipated stool, and
for that reason constipation should be classed as a
predisposing cause of cancer of the rectum. It is
difficult, I know, to get the laity to fully comprehend
the importance of this, but I think it can best be ac-
complished through the family physician.
I would like especially to call the family physician's
attention to the importance of examining their
patients more carefully when they present themselves
with rectal complaints, which are usually referred to
by the patient as haemorrhoids, and in the majority
of cases is a mistaken diagnosis. While the patient
may have haemorrhoids, there are many other con-
ditions and complications that are possible to be as-
sociated with the case, and that may be very im-
portant and require immediate attention. By giving
these cases more careful consideration, it will result
in early recognition of many pathologic conditions
that may exist and then with proper operative pro-
cedure and post-operative care, there will be obtained
not only happy direct results, but many other, some-
times serious symptoms in various parts of the body
will clear up, to say nothing of the possible preven-
tion of carcinoma that sends so many thousands to
untimely graves every year.
Conclusion
In conclusion, special stress is to be laid upon the
importance of post-operative care in all rectal cases;
it does not matter what the character of the trouble
may be, because there are the stool and gases to con-
tend with more or less continuously. These cannot
be obviated, and by them the surgical field is ex-
posed to infection; hence, the importance of careful
aseptic and as near as possible antiseptic post-opera-
tive dressings and care.
The Study of Psychoses
A Guide to Proper Child Rearing
By W. W. Young, A.B., M.D.,
Asst. Physician Massillon State Hospital,
Massillon, Ohio
U\e'% Jtot Vital Duty
Dr. Young says that we teach the g$nera-
tions to be doctors, lawyers, merchants, etc.,
but we neglect instruction in that most vital
of all life's duties — parenthood. With very
few exceptions the prospective parent faces
his future responsibility with as few re-
sources as the babe itself. If we are to rid
civilization of the cancer of abnormal men-
tality, we must have mothers and fathers
who know how to be parents. — Editors.
AFTER ALL is said and done we stand helpless
before the vast majority of the psychoses which
have attained full bloom. As long as the individual
mind is accessible to external impressions and we can
bridge the chasm between the rational and abnormal,
so to speak, just so long can we hope to bring about
a more or less normal readjustment. But how many
cases there are who are as inaccessible to any com-
munications from us as they would be were they in-
habitants of another planet. Consequently how often
do we have to admit sadly to ourselves that our ef-
forts must be fruitless!
In such a dilemma there is only one means of ap-
proach: we must get at the root of the matter and
eradicate the seed long before fruition is possible.
And to do this we must take the child from the hour
of birth, study its potentialities for abnormal reac-
tions, and educate it to meet adequately the problems
with which it is to be confronted. We teach the gen-
erations to be doctors, lawyers, merchants, etc., but
we neglect instruction in that most vital of all life's
duties, parenthood. With very few exceptions the
prospective parent faces his future responsibility with
as few resources as the babe himself. If we are to
rid civilization of the cancer of abnormal mentality,
we must have mothers and fathers who know how to
be parents.
In the compilation of a text-book for future parents
there is no more fruitful field of information than in
the study of the psychoses of psychogenic origin. A
psychosis of this character is simply an attempt on
the part of an individual who is unfit to cope with
the problems of life, to meet the issue as best he can.
In other words, there is some fundamental error in
the mrike-up of his psyche which makes it impossible
for him to solve the problem in a normal way. So
788
The Study of Psychoses — Young
[The American Physkiam
a study of these defects will show that they had their
origin in the infantile period of the individual's de-
velopment and consequently there is evidence of its
existence from the time of its incipiency in certain
acts of the individual.
Fmmimmdd Mtcfs
Having discovered certain fundamental defects
which are the seed from which the future psychosis
springs, it would seem a comparatively simple mat-
ter to supply this defect by proper educational meas-
ures; and this is true. Although the task is not so
simple as would appear at first blush, nevertheless it
is possible. And were the parent to study his child
with as much intelligence as he gives to his business,
the day would not be far distant when mental abnor-
malities would all be organic.
The child's mind at birth is a "tabula rasa/9 a
blank tablet, upon which nothing is written and all its
knowledge comes from actual happenings and en-
vironmental impressions. So the parent can write a
story in orderly sequence on this tablet, rounding out
all phases in equal proportions, or he can leave it to
chance to write the story, perhaps accentuating one*
phase and leaving another absolutely untold. We
need but one example to impress us with the ab-
solute necessity for a rational approach to this
problem.
The best example and one which is ever present is
the story of the only or favorite child. In order for
the psyche to be well rounded and symmetrical it must
be polished off by rubbing up against the will and
wishes of others. When the child is an infant its
psychic activities are confined to desires and wishes,
and all of a selfish nature. As he develops and comes
into contact with the wishes and rights of others he
learns that he cannot gratify all of these desires, in
fact very few of them can be attained entirely. And
so he learns to repress these desires and transform
them into external activities, unselfish acts and emo-
tions, philanthropic and altruistic feelings. And so
the child among many children readily learns these
adjustments which are so essential to a healthy psy-
chical life and instinctively without effort meets his
daily problems.
On the other hand the only child lacks the modeling
which contact with other children brings about and
the undivided attention and abnormal love that he
gets turns him into a confirmed egotist. He does not
learn to repress his desires adequately and as a con-
sequence when a desire comes into conflict with an in-
surmountable obstacle he will attain to it through
some abnormal means, which is the best he can do,
instead of repressing it and transforming it into
unselfish channels. And thus develops a psychosis.
Itmpnptr Devdopimcwt
This failure to properly develop shows itself in
many, many ways. His whims never have to give
way before the wishes of brothers and sisters. He is
the sole ruler of the household; his praises are con-
stantly being sung and he is pot up on all occasions
in order that he may demonstrate his attainments. Is
it any wonder that he is vain and egotistical f He
lacks a realization that there exists any such thing
as thought for others, self-sacrifice, etc These qual-
ities are unknown quantities to him.
Again the lack of association with beings of his
own age and the constant contact with adults make
him usually precocious in all things. Consequently
when he becomes a little older he cannot adjust him-
self. Practices of those his own age "bore" him
and it is difficult to find things which will amuse and
satisfy. Thus he is strictly speaking asocial through
maladjustment. This precocity is present also on the
sexual side and he is apt to show sexual curiosity
and attain to sexual knowledge of a polymorphous
nature at an unusually early age. This is a source
of many possible abnormalities.
His lack of proper associates accentuates the
mother or father image, as the case may be, which is
imprinted upon his psyche. Consequently in his
future sexual life this influence may be exerted with
such undue proportions as to result in many different
kinds of sexual abnormalities. For instance, in the
choosing of a mate one is certain to be chosen who
stands for the parent in his mind; that is, who in
some way takes the place of the parent in his love
life because actual sex emotions toward the parent
are interdicted by the teaching of society and ethics.
Standing in the mind for the parent, the physical
facts of matrimony may be abhorrent to him and con-
sequently there arises a conflict between reality and
his subconscious desires which he cannot solve.
What we have said concerning the only child can
just as truly be said of the "favorite child," for he
in the end, so far as his ego is concerned, is the "only"
child. An old vulgar saying quite adequately ex-
presses this : "The only pebble on the beach.'' And
these examples could be multipled ad infinitum. For
every reaction type as exemplified in a psychosis we
can find numbers of inadequately developed psychic
phases which might at one time have been properly
cared for and have produced a psyche able to cope
with its environment.
And so the big fact confronts us that the majority
of so-called "functional" psychoses are never cured
and that we must meet the problem by eradicating the
cause. This we can do by rearing children properly:
in the first place by proper training and instruction;
and in the second place by watching for abnormal
tendencies and readjusting them. The best guide for
the recognition of these danger signals is in a study
of the end-results, the psychosis. And every in-
dividual should be trained to be a parent just as
truly as he is trained for a professional means of
livelihood.
Doctor Mackenzie Forbes9 Post-Graduate Diagnostic Clinks
A Sine* of Thkto Clink* Emphasizing Diagnosis that Should ho Moot Helpful to the General Practxti
By A. Mackenzie Forbes, M.D- 615 University St* Montreal,
Twenty-ninth Clinic
Muscular Tone and Reflex Pain in Diagnosis
LET US CONSIDER the similarity between the
duties of one of our judges of the law courts and
the diagnostician. The judge carefully considers
all evidence available. He reviews this evidence and,
taking into consideration the law applicable to the case
and all precedents, he gives his decision. The diagnos-
tician on his part carefully secures a list of the symp-
toms both objective and subjective. He reviews these
symptoms in the light of previous experience and on
them bases his decision. In a court of law the evidence
is of the greatest importance. The omission or addi-
tion of one point in this may change the court's de-
cision. In a similar way in the science of diagnosis,
the collecting, weighing and properly adjudicating the
significance of the symptoms is of the greatest im-
portance.
Reiex Pom, Somory Disturbances ami Muscular Spasm
Amongst the symptoms which demand careful study
are reflex pain, sensory disturbances and muscular
spasm.
In our clinics for some years we have been placing
an ever-increasing reliance on the information made
available by reflex change in muscular tone in patho-
logical conditions of both abdomen and joints. In the
diagnosis of pathological conditions of the latter we
have been accustomed to teach that muscular spasm
is the first symptom to come and the last symptom to
g-o in any form of arthritis. We look upon hyper-
tonicity as a precursor to muscular spasm. We feel
that hypertonicity always suggests a pathological
condition.
In the surgery of the abdomen our ability to detect
reflex changes in muscular tone and sensation is of
the greatest importance. Clinically increased or de-
creased tone or sensory changes may mean change in
an organ or part beneath the area of hypertonicity
or hyperalgesia, although, on the other hand, it may
mean change in a part far distant.
DUerentiate Between the Degrees of Muscular Tome
Our ability to differentiate between degrees of mus-
cular tone is valuable also in other conditions.
In the early stages of an attack of poliomyelitis
there is a definite change of muscular tone when even
a paresis cannot be diagnosed with certainty, although
thit change is hardly reflex in origin. On the contrary
at the onset of poliomyelitis, increase of tone is prob-
ably due to direct stimulation of the nerve cells,
whereas in later days decrease of tone is probably due
to degeneration of both nerve and muscle cells.
A Valuable AH m Diagnosing
The writer, not two years ago, found this change in
muscular tone to be a most valuable adjunct to his
diagnostic armamentarium when he was called in to
see a patient who resided at one of our large seaside
resorts where hundreds of children were herded to-
gether. The symptoms had suggested to the prac-
titioner in charge that most dreaded disease, infantile
paralysis. The child had been feverish for a couple
of days. He was now well, but somewhat weak.
There was no definite paralysis, only an indefinite
paresis. What affection could have caused so great
a weakness in so short a timet Examination demon-
strated no loss of function but a strange variation in
the tone of individual muscles and groups of muscles.
Poliomyelitis was diagnosed. The diagnosis was con-
firmed by the subsequent course of events.
/■ Psenio-Hypertrophic Muscular Atrophy
Pseudo-hypertrophio muscular atrophy is another
condition in which variations of tone are of extreme
interest, although in this condition it is questionable
whether such changes can be of reflex origin. It seems
that even in the prehypertrophic stage of this affection
there tends to be increase of tone. In the atrophic
stage there is lack of tone.
/■ Muscular Dystrophies
Further studies of changes in tone in the muscular
dystrophies may increase our ability to make an early
diagnosis.
If a patient has suffered from sciatic pains for any
time there may be a distinct loss of muscular tone.
790
Muscular Tone and Reflex Pain in Diagnosis— Forbes [The *****<** **r*»*
although there is no muscular atrophy or suggestion
of a neuritis.
Because of the value of these changes, be they re-
flex changes in the central nervous system or only
local changes, we urge our students to so educate
what we may call in the broadest sense their powers
of observation that they may recognize the earliest
deviations from the normal. We realize that perhaps
the recognition of changes in tone and sensation may
help them to locate the site of a pathological condition
the symptoms of which may be vague or referred to
regions far remote from the site of the lesion.
The E0ect •/ m Duemted Jemi em Adjacent Mnedee
It has long been known that the tone of muscles
adjacent to a diseased joint is increased. Little refer-
ence is made to this, however, in the literature avail-
able except by such writers as Sir James Mackenzie,*
who in his delightful work on symptoms and their
interpretation draws our attention to the importance
of both viscero-motor reflexes and viscero-sensory
reflexes, and also to a lessor degree the hypertonicity
due to the arthritides.
In Montreal we have tried to prove that in any
form of arthritis hypertonicity of the muscles adjacent
to the diseased joint is the first symptom to come and
it is also the last symptom to go. To our surprise!
however, we have found that in arthritis of long
duration, while disease may still be present, hyperto-
nicity no longer obtains. This at first caused some
confusion, but later we adopted the postulate that in
long standing cases the joint often becomes destroyed
and ankylosis supervenes, thus in such cases we are no
longer dealing with a joint which is subject to all the
characteristics of an articulation but, rather, with a
solid union of two or more bones clothed with muscles
which have lost their physiological characteristics.
This postulate has been verified by the work of Sher-
rington, of Edinburgh, as pointed out to me by Pro-
fessor John Tait, of McGill University.
The tone of skeleton muscle is a slight continuous
contraction of the muscle reflexly maintained. The
recepter organs involved in the reflex are chiefly
muscle spindles (in some cases Sherrington showed
that as many as 40 per cent, of the nerve fibres in so-
called "motor" nerves may be efferent nerves from
such spindles).
The Physiology •/ Reiex Change*
Sherrington is inclined to the belief that tone is a
function only of muscle concerned in the maintenance
of posture (posture being here used in a wide
sense) .
If confirmation of the theory that tone is a function
only of muscle concerned in the maintenance of pos-
ture be desirable, one need but note the degree of
tone seen in the muscles covering a joint which has
been recently excised where the muscles have ceased
•Symptoms and Their Interpretation, 1909.
to control posture. As you will have learned in our
previous clinic (No. 5) we often excise a joint affect-
ed with tuberculosis not with the intention of eradi-
cating disease, but simply to give rest, that this, one of
the cardinal requirements for the arrest of tuberculo-
sis, may be assured. Here we have eliminated the
joint, but we have not yet secured an arrest of the
tuberculous process. In our opinion atonicity and not
hypertonicity will prevail.
Let us proceed further in our clinical study of mus-
cular tone. How often do we note the, as yet unex-
plained, phenomenon of greater tone in the right
rectus abdominalis than in the left rectus f Is this re-
flex increase of tone due to some, as yet unexplained,
mild inflammation in the right quadrants of the
abdomen f
Should we not now study the physiology of these
reflex changes f As Sir James Mackenzie remarks,
in the normal processes of life, a stream of energy is
continually passing by the afferent nerves to the
spinal cord and continuously playing upon the effer-
ent nerves which run to muscles, blood vessels and
other parts, maintaining the normal. If a morbid
process in a viscus or a joint gives rise to an increased
stimulus of the nerves passing from the viscus or joint
to the spinal cord, this increased stimulation affects
neighboring centres and so stimulates sensory, motor
and other nerves that issue from this part of the cord.
If the increased stimulus affects a motor centre, then
a contraction of the skeletal muscle results and thus
is produced the viscero-motor or the articulo-motor
reflex.
Sir James Mackenzie asserts that it is in the muscles
forming the abdominal wall that the viscero-motor
and viscero-sensory reflexes can best be studied.
Listen to his words: "Some years ago I pointed out
that these muscles could be demonstrated to possess
the power of contracting in small sections in response
to visceral stimulation. Later I found that Sherring-
ton had described a difference in the reaction to nerve
stimulation between these flat muscles and the muscles
of the limbs. The fibres that constitute the nerve sup-
ply oi; any given muscle leave the spinal cord in
separate bundles. If one of these bundles be stimu-
lated the whole length of a limb muscle like the sar-
torius will contract. On the other hand if one of the
bundles that constitute the nerve supply of one of the
abdominal muscles be stimulated, only a portion of
the fibres of the muscles will contract
Contracted Ahitmimmi Mmtde Shmdatimg a Tnmee
"The contraction of a small portion of the abdom-
inal muscle, in response to a visceral stimulus may.
remain for an indefinite period. The limited hardness
thus arising gives to the palpating hand the impression
of an underlying tumor, and not only does it give the
impression, but it is often mistaken for a tumor. I
have, on several occasions, seen experienced surgeons
Phila., November, 1922]
Muscular Tone and Reflex Pain in Diagnosis — Forbes
791
and physicians make this mistake, and at the subse-
quent operation no tumor was found. This hard
contracted portion of a muscle is often hyperalgesia
and its tenderness is readily mistaken for an evidence
of the sensitiveness of ;the supposed 'abdominal
tumor*.
"The extent of this contraction of the abdominal
muscle is variable. In appendicitis it may be limited
to a few strands of muscle, which may be mistaken
for the appendix itself. It may be more extensive
and resemble a rounded tumor, and this, in appendi-
citis, is often mistaken for swelling in and around an
appendix (perityphitis of olden days). On the other
hand, the whole of the right side of the abdomen,
and even a portion of the left, may be found hard
and board-like.
The Pky$wlogy •/ ComtracUd MmscUm
"There are features in these contracted muscles
that have not been appreciated, and which open up
some new points in the physiology of contracted
muscle. As a rule the contraction is long continued,
lasting it may be for days or weeks — or it may be
months — as long as the visceral lesion keeps up an
adequate stimulus. As a rule it begins as a slight
increase in the tonicity of the muscles, and is de-
tected by one side of the abdomen or one portion of a
muscle being a little more resistant than other parts.
At this stage it is readily provoked to a strong and
firm contraction by palpation. If, as often happens,
the skin or muscle itself, is hyperalgesia this reflex
contraction is very readily induced, but after the con-
traction it remains for a time strongly contracted.
Thus, in palpating the epigastrium in cases of gastric
ulcer, if the part is not explored with gentleness the
muscles immediately become violently contracted, and
remain strongly contracted. On the other hand, if
^ery gently palpated all that can be detected is a re-
sistance slightly greater than normal and with the
slightest increase of pressure an increase in the hard-
ness of the muscle is produced.
"When this contracted muscle is examined under
chloroform certain characteristic features are found.
It is, as a rule, the last portion of the muscular sys-
tem to yield to the influence of the anaesthetic, re-
maining hard and contracted when all the other mus-
cles are limp and flaccid. The chloroform has often
to be pushed, and even in deep anaesthesia no relax-
ation may take place. In many cases the contraction
persists, however deep the anaesthesia, and however
long it may be pushed. In such instances when the
muscle is cut during an operation the fibres remain
stiff and unyielding, and one is much hampered in
forcing an opening through the cut muscle. Thus,
in one case of appendicitis the muscle was rigid and
hard, and gave the impression of an underlying tumor.
When cut, the fibers would not yield, and I had
much difficulty in getting my finger in to explore the
abdomen. There was no underlying tumor, and the
peritoneum and bowel in the neighborhood, were per-
fectly healthy. Deep down an inflamed and suppu-
rating appendix was found."
Once more applying our knowledge of these reflexes
to clinical diagnosis we quote from Mackenzie. Mus-
cular contraction may come on suddenly with the sud-
den onset of some visceral trouble. Thus, in a case of
renal calculus, the onset of pain was immediately suc-
ceeded by the contraction of the abdominal muscles
and the patient was also conscious of the contraction
of the cremaster muscle by the pulling of the testicle.
In angina pectoris the sudden onset of the powerful
contraction of the intercostal muscles is recognized
by the feeling of compression of the chest, so great
at times that the patient states that he feels as if his
breast-bone would break.
Mmmy ComKCmm Pfimce This Reitx
There are many conditions which produce this reflex.
Peritonitis causes it, and as the muscle is usually also
tender, these symptoms of hardness and tenderness of
the abdominal wall have come to be looked upon as
undoubted evidence of peritonitis. But these symp-
toms may be, and often are, present with absolutely
no peritonitis. Thus, I have found tenderness with
firm contraction of the lower part of the left rectus
abdominalis muscle in a case of stone in the bladder
without peritonitis. Hardness and tenderness of the
recti over the epigastrium is common in gastric ulcer,
and I have found these symptoms without any peri-
tonitis. I have also found hardness over a limited
area in the left lumbar region due to a tubercular
ulcer in the posterior wall of the descending colon
and there was no peritonitis underlying the hard
and tender muscles. In like manner wide-spread
tenderness of the abdominal wall with hard contrac-
tion of the whole abdominal muscles may occur with-
out any peritonitis. As illustrating the extensive mus-
cular contraction due to visceral stimluation I cite the
following case: I was summoned to operate upon a
fellow practitioner for obstruction of the bowels.
The symptoms were, no movement of the bowels for
two days nor had any flatus been passed, some vom-
iting but not faecal: considerable abdominal disten-
tion, with great hardness of the whole abdominal wall
and pain on the slightest pressure. Some difficulty
was experienced in passing the finger into the bowel
on account of the strong contraction of the sphincters.
The patient had severe attacks of pain every few mo-
ments. The pain began in the left lumbar region,
passing forwards and downwards towards the pubis.
Pain was felt on light pressure on the left testicle.
From the situation of the pain and the tenderness on
pressing the left testicle, I had no hesitation in recog-
nizing the condition as one of renal calculus. In my
experience the pain in obstruction of the bowel is
792
Muscular Tone and Reflex Pain in Diagnosis — Forbes
[The
never so distinctly one-sided. The inability to have
the bowels move was simply due to the violent con-
traction of the sphincters, such contraction, with the
contraction of the abdominal muscles, being due to the
renal calculus. The diagnosis was confirmed by the
passage of a calculus next day with immediate dis-
appearance of all the symptoms. This patient has
had two subsequent attacks with a repetition of all
the foregoing symptoms. The contraction of the
muscles was undoubtedly due to a violent stimulation
passing from the affected organ to the spinal cord.
There the irritation spreads, affecting not only the
centres of the sensory nerves, but also the centres of
the motor nerves. These stimulated, give rise to vio-
lent muscular contractions — the viscero-motor reflex."
The Mcckmim •# MtucmUr Tmm
The mechanism of the production of increased mus-
cular tone is extremely interesting. A stimulus reach-
ing the spinal cord from the skin may produce a reflex
contraction of the muscle whose centre in the spinal
cord is adjacent to that of the sensory nerve from the
skin. A stimulus reaching the spinal cord from an
organ may produce pain over the organ or, as ex-
plained by Mackenzie, pain referred some distance
from the organ. A stimulus from an organ, on the
other hand, may produce muscular contraction as
demonstrated by hypertonicity or spasm. Again a
stimulus reaching the spinal cord may, if of adequate
strength, stimulate other nerve cells in the neighbor-
hood, and these respond according to the nature of
their function, producing pain and muscular con-
traction as has been seen. Mackenzie draws attention
to a well-known phenomenon. The nerve supply of
a different organ may be stimulated and thus the
symptoms may be referred to this the unaffected organ
and give rise to various possible errors in diagnosis.
For instance, frequent micturation may be due to an
inflammation about the appendix. Inability to mic-
turate may follow operation by hemorrhoids and in-
creased flow of urine or saliva may be due to an attack
of angina pectoris. In lumbago the pain and stiff-
ness may be due to some pelvic trouble as endometritis,
or hemorrhoids. In angina pectoris the pain may
spread or be referred to the left arm. In many cases
of visceral disease pressure over the spines of certain
vertebra elicit pain, sometimes of a very acute char-
acter. These tender vertebrae ar usually associated
with areas of hyperalgesia in the skin and muscles of
certain definite areas, at some distance from the spinal
column. Such hyperalgesic areas are supplied by the
nerves that issue from the cord at the level of the
tender vertebrae. The skin over the vertebrae may not
be hyperalgesic, so that the pain is elicited from
deeper structures. The pain is referred to the region
of the vertebra that are tender. These tender ver-
tebrae must not be confused with the spinal tenderness
so common in certain neurotic cases. In these latter
the tenderness is not limited to a few vertebrae but the
whole spine is tender on pressure.
Am Emr m flinj— is Mmy ResmU
If the visceral origin of the tenderness of these
vertebrae be not kept in view, an error in dlagnosii
may result from the fact that the tender vertebra?
may be looked upon as evidence of disease of the
spinal column. This is all the more likely to be the
case if there is well-marked evidence of cutaneous
hyperalgesia. I have seen a patient encased in a
plaster of Paris jacket on the recommendation of a
distinguished neurologist, because of an extreme ten-
derness of the sixth and seventh dorsal vertebrae and
a band of marked hyperalgesia of the skin around
the left half of the upper part of the abdomen. At
the post-mortem examination no disease of the spinal
column could be detected, but there was a cancer of
the cardiac end of the stomach.*
Oiftcalrv m D**rmmmg faW We« •/ the Fmm Strnrn*
"On account of the fact that pain originating in
any part of a nerve in its course from the brain to
its periphery is referred to the peripheral distribution,
there is often a difficulty in determining the source
of the pain stimuli. The differential diagnosis must,
therefore, depend on a knowledge of how the pain
arises, the relationship of the nerve-supply of different
regions of the body to the central nerve-supply, and
its connection with the visceral nerve-supply. In the
absence of any demonstrable cause of stimulation at
the periphery it is necessary to consider the possi-
bility of stimulation at more central parts. The
symptoms which may arise from an irritation of a
nerve-trunk, as from pressure, neuritis, or herpes
zoster, resemble in a great many respects those which
arise from visceral disease. So great, indeed, is this
resemblance that even the most experienced may be
led astray. Thus, the pain and hyperalgesia of a
stomach affection may simulate the symptoms pro-
duced by caries of the spine, and the shoulder-pain
of gall-stone disease may be mistaken for a neuritis."
There is often great difficulty in determining the
source of pain. The differential diagnosis must, there-
fore, depend on the knowledge of how the pain arises,
the relationship of the nerve supply of different
regions of the body to the central supply and its
connection with the visceral nerve supply.
In the surgery of the joints it is often found most
difficult to differentiate between the normal and the
abnormal.
Pain stimuli originating in the joints may be re-
ferred to other parts and pain about joints may be
due to stimuli arising in a viscus.
'Mackenzie states that pain is sometimes felt in the 1st 2nd
3rd and even the 4th dorsal vertebra in cardiac affections; oter
the 5th, 6th, 7th and sometimes the 4th and 8th dorsal vertebr*
in affections of the stomach; in the 9th, 10th. 11th and some-
times the 8th in affections of the liver ; in the last lumbar and
upper sacral in affections of the rectum and the uterus.
Phila., November, 1922]
Cancer Therapy — Levin
793
Joint Pom Are Nearly Alwmys Fth at Samu Distance From the
A0ected Joint
The pains caused by joint affections are nearly all
felt at some distance from the joints. The best
example is the pain felt on the inner side of the knee
in disease of the hip joint. Pain in affections of the
shoulder may be felt down the arm as low as the
elbow and the pain from the knee joint may be re-
ferred over the head of the tibia. In many joint
affections the contractions of the muscles which move
the joint may be as strong as to lead to the idea that
the joint is ankylosed. This is particularly the case
with some affections of the shoulder joint. On the
other hand, hypertonicity, the arthrito-motor reflex, is
a very valuable sign which will cause us to focus all
our powers of diagnosis on one joint when there is
little else to aid us in our search for disease.
CANCER THERAPY
The Proper Co-ordination Between Surgery, Radium and the X-Ray$
By Isaac Levin, M.D., New York.
Clinical Professor of Cancer Research New York University and Bellevue
Hospital Medical College; Chief of the Cancer Division of Montefiore
Hospital; Chief of the Radiotherapy Division of St.
Bartholomew's Hospital; Consulting Radio-
therapeutist Lebanon Hospital
(From the Cancer Division of the Montefiore Hospital for Chronic Diseases.)
Second and Comclm&ng Section
This is the second and concluding section
of this notable contribution to the diagnosis
and treatment of cancer by means of a group
clinic management of the cases. The first
section was published in the October issue. —
Editors.
X-Ray Therm*? of Cancer
The development of the methods of X-ray therapy
may be roughly divided into three periods. In the
first period, which continued from the beginning to
about ten years ago, no attention was paid to the
quality of the radiations nor to the ratio between
the quanity of radiations which were directed upon
the surface of the body of the patient and the frac-
tion of these which reached into the depth. In the
second period, which began about ten years ago,
through the improvement in the X-ray machine
(higher voltage on the secondary) and in the quality
of X-ray tubes, particularly the development of the
Coolidge type of tube, and the use of filters, X-rays
of smaller wave length and consequently higher pene-
tration were obtained. Furthermore, by the use of
several small fields of entry and by cross-firing from
opposite directions an empirical attempt was made
to obtain in the depth a greater fraction of the quan-
tity entering through the skin without injuring the
latter. Nevertheless this fraction still remained very
small and its quantitative relation to the total entering
the skin could not be determined.
The latest developments in the X-ray therapy, which
have taken place in the course of the last five years,
consist, first, in the construction of X-ray machines
which produce 200,000 volts and more in the second-
ary, and of X-ray tubes which can withstand the
high voltage imput. Furthermore, the ionization
methods of measuring the intensity of X-rays were
perfected so that it is now possible to determine with
a fair amount of accuracy the percentage of the sur-
face amount which penetrates into a certain depth.
These measurements brought forth the following
striking result which even a priori supports the
writer's contention stated above as to the difference
of the action of radium and the X-rays. The per-
centage of the quantity of radiation entering the
depth of about 10 cm. even with the most powerful
machinery and tubes and with % mm. of zinc or 1
mm. of copper as filter, is comparatively small. In
order to improve this quotient of the depth dosage to
the intensity of the rays on the surface, not several
Cancer Therapy — Levin
small fields, but a large portal of skin entry must be machines for the treatment of Hodgkin's disease,
used. The reason for it lies in the fact that the leukaemias, splenomegalies, exophthalmic goiter, sur-
qnotient of the depth dosage can only be improved gical tuberculosis, etc For the treatment of cancer,
by the addition of secondary and scattered radiations however, the writer employs now only tbe high-volt-
which are formed within the tissues by the entering age machines. Fig. 7 shows the installation in the
beam of rays. The larger the portal of entry, the writer's private laboratories. The units of apparatus
greater the quantity of secondary and scattered radia- were built by Waite & Bartlett Company, and Dr.
tiona, and in order to obtain the necessary quantity Waite co-operated with the writer and used mueh
in the depth a large field must be used. ingenuity to create a set of machines which will lose
Kronlg and Frledrlch.,11 who
added more than any other group
of investigators to the progress
of the subject, have shown ex-
perimentally that while In ac-
cordance with theoretical calcu-
lations only 10% of the surface
Intensity of the X-rays reaches
Into the depth of 10 c m., even
with a TOltage of 20,000 and 1
mm. of copper flltratlonB, the
actual percentage as measured
by the Ionization method Is as
much as 43%. They further
show the following relationship
between the size of the Held of
entry and the quotient of the
dose in the depth. Given the
same conditions, namely, 20,000
volts, 50 cm. target skin dis-
tance, 1 mm. copper as filter, a
field 5 cm. square delivers 31%
of surface intensity into 10 cm.
depth, a field 10 cm. square de-
livers 38% and a field 15 cm.
square 43%. They have further ^
shown the existence of secondary labor
radiations at a considerable dls- aphe:
tance to the periphery of the
field of entry. Al] this means
that In order to direct the nec-
essary quantity of radiations to a deep seated tumor nothing in their efficiency and at the same time be
a large quantity or radiation will also be directed to so compact as to fit in any X-iay laboratory. The
the adjoining normal tissues, the blood and the blood- generating machine presents a double transformer
forming organs. Furthermore, If an attempt 1b made with a double cross arm mechanical rectifier operated
to send a very large dose in the depth from several by one synchronous motor. The X-ray tube is corn-
portals of entry, a cumulative effect may take place pletely incased in a rigid ray-proof box, tbe whole
at some point in the depth, with consequent serious room is leaded throughout, and photographic tests
" have shown that no rays penetrate beyond the room
T. The high voltage X-ray apparatus In tbe writer's
itorles. A shows tbe adjustable table; B tbe genera -
uaeblne; C tbe Coolidge filament transformer; D the
e gap; E the box containing the X-ray tube; F tbe
" 1; H toDtoquantlmeter ; I inau-
icope to the tonliatlon chamber
- '~ purify the air of the
-8SSL
r tbe pyramid; J exhaust fan [
injury of normal tissues.
Tin Nroltr X-Rltj Appumtnt
There is no doubt that technically the high-voltage
X-ray machines and the ionization method of measur-
ing the intensity of radiation mark a great progress
in X-ray therapy and are indispensable in the treat-
ment of cancer. The writer still uses the old type
ig unci W. Frledrlcb. Phyalt
lofc-tscbe Oru
and box, thus protecting the operating staff and the
people in the vicinity from the action of the rays. A
sphere gap measures and controls the voltage enter-
ing the tube. A controlling device connected with
the rheostat of the filament transformer keeps the
mi Hi amperage perfectly constant. Tbe table can oe
raised and lowered.
The writer had constructed a set of frames in tbe
form of pyramids which have at one end a lead
Cancer Therapy — Levin
diaphragm under which is attached the filter % mm. ionization chamber, -which is a small cylindrical tube
or 1 mm. of copper and 1 mm. of aluminum. At the built of horn and lined with graphite. This ioniza-
other end of the frame there is attached a plate of tion chamber is placed directly under the X-ray tube,
bakelite which fdters off the secondary radiations pro- as shown in Fig. 7. The ionization chamber is con-
duced by the metal filters. The respective square
dimensions of the opening in the lead diaphragm an "
the piece of bakelite at the base of the pyramids are
so arranged that the beam of X-rays passing through
the diaphragm has the square size of bakelite, when
it reaches it. Furthermore, the height of the pyra-
s such that when the bakelite touches the skin
of the patient, the distance between the skin and the
target of the X-ray tube is exactly 30 or 50 cm. This
device simplifies the arranging of the fields of treat-
ment. The proper sized pyramid is selected, placed
in the box under the tube and the table raised until
the skin of the patient touches the bakelite place of
the frame. If the skin does not touch the plate every-
where, then cotton padding is added, which absorbs
the rays in the same way as the tissues of the body.
Fig. 8 shows a schematic cross section drawing of
the arrangement. The writer uses comparatively
large fields, 10, 15 or 20 cm. square. The number
and size of fields is arranged in accordance with the
condition to be treated, the size and location of the
tumor and the size of the patient. Fig. 7 also shows
the relative position of the ionization measuring
apparatus to the X-ray tube. Fig. 9 shows a photo-
graph and schematic cross section drawing of the
same apparatus.
The apparatus used by the writer is one devised
by Dr. Solomon, of Paris. It is practically identical
with Friedrich's iontoquantimeter and consists of an
nected by the aid of graphite lined tubing with an
electroscope. The electroscope itself is again a large
ionization chamber within which there is placed a
metal rod, and affixed to it somewhere nearly midway
is a silver leaf. A small friction apparatus charges
the electroscope chamber with high- potential elec-
tricity (about 300 volts). This electrical charge de-
fleets the silver leaf from the rod. When X-rays or
gamma rays of radium enter the ionization chamber
the air within that chamber, as well as within the
connective tubing and the electroscope chamber, be-
comes ionized. As a result of this the high-potential
current within the electroscope chamber is discharged
and the silver leaf falls back to the rod. The rapidity
with which that fall takes place is in direct ratio to
the intensity of the radiations. There is arranged
within the electroscope chamber of the apparatus a
scale of numbers running between 10 and 60 and a
796
Cancer Therapy — Levin
reflecting glass. The measuring with this apparatus
proceeds in the following way: The electroscope is
charged until the leaf is deflected to 60; then gamma
rays of radium or X-rays are directed to the small
ionization chamber for as long as it takes the leaf
to drop to 10 on the scale. The time necessary for
it is measured by a stop watch. The apparatus is bo
standardized that the gamma rays from 1 gm. of
radium take one second to move the leaf from 60 to
10. The unknown intensity of the radiations acting
on the ionization chamber can consequently be meas-
ured when the time it takes the leaf to move from 60
to 10 is known. This ionization apparatus is very
similar to the one described above which is used for
measuring radium emanation.
When an X-ray machine and X-ray tube are so
constructed that the voltage on the secondary, or
rather to say, the voltage entering the tube and the
milliamperage do not fluctuate then given the same
distance from the target to skin and the same filter
the intensity of radiations delivered in a unit of time
will practically be always constant, and it is there-
fore not necessary to measure it frequently with the
ionization method, but it suffices to use the latter
only at intervals for proper control.
Thus, with the new methods and the modern
apparatus, an exactly calculated amount of radia-
tions may be delivered into the depth. Through a
large field of entry 43% of the skin dose may be
delivered to a deeply seated tumor and with several
portals of entry even more than a skin dose may
reach the tumor. However, too much emphasis can-
not be laid on the fact that such a large amount
must be accompanied by dangerously intensive ray-
ing of adjacent normal tissues. Attempts were made
in the gynecological clinics of Freiburg and Er-
langen not only to measure the quantity penetrating
into a certain depth, but also the exact quantity
needed to destroy a malignant tumor. A so-called
carcinoma dose is claimed to represent 110% of a
skin, dose, while a sarcoma dose represents 70% of
a skin dose. Such conceptions represent only a very
rough estimate of the true situation. The biological
behavior of a cell cannot be translated into an arith-
metical equation. A melanosarcoma is, for in-
stance, by far more resistant to irradiation than car-
cinoma, while a lymphosarcoma can be influenced by
a very small fraction of the quantity needed for any
other type of malignant tumors. Furthermore, no
account is taken of the fact that the efficiency of
radiotherapy in cancer is in inverse ratio to the mass
of the tumor. The greater the amount of the total
tumor mass within the organism, the more malignant
is the condition clinically and the lower is the power
of resistance of the organism. The writer has shown
in a previous publication11 that even metastases in
the bones may be clinically arrested when they are
not multiple and the primary tumor is removed, while
the existence of several metastatic tumors in the
skeleton make the condition hopeless. Moreover,
the measure of the true quotient of the depth dose
can never be made mathematically accurate.
Holfelder13 claims to have devised an accurate
method. He employs, in accordance with the tech-
nique of Seitz and Wintz, several not very large
fields of entry. A set of colored celluloid plates over-
lapping each other and laid over a flat schematic
Fig. 10. Prom Holfelder" a scben
drawing of the patient filled with dots, circles and
triangles, into which the tumor is drawn, arranges
the combination so that within the area of the tumor
all the figures on the paper are obliterated by the
depth of the color of the overlapping plates, and this
represents the required full carcinoma dose. This
device he calls a field selector. He then directs the
X-ray tube under the same angles to the surface of
the body as the celluloid plates. Fig. 10 shows, how-
ever, that the field over the abdomen is applied with
pressure which of necessity must change constantly
during the treatment. Furthermore, the slightest
Phila., November, 1922]
Cancer Therapy — Levin
797
movement of the patient changes constantly the rela-
tive positions of all the fields and consequently cre-
ates the danger of an overdose and severe injury to
the normal tissues.
What at X-Rmy Therapy Ahme?
Seitz and Wintz, of Erlangen, maintain that it is
possible to cure carcinomata of the cervix with
X-rays without the aid of any other agent. They
support their view by the fact that of twenty-four
eases so treated twenty-three remained well for one
year. This is a premature and ill-advised assertion.
Such an attitude does more harm than good, both to
X-ray therapy and, as well, to cancer therapy as a
whole.
It may be appropriate to cite a couple of facts
from the work of Freiburg and Erlangen to indicate
that X-ray therapy alone cannot be considered the
correct treatment of every cancer case. Friedrich
and Behme14 reported from Freiburg on a series
of seventeen cases of cervical carcinoma treated with
X-rays alone. Five cases were given a so-called full
carcinoma dose through the abdomen and back. All
the five patients suffered from X-ray cachexia and
severe blood changes as a result of the treatment,
and the cervical carcinoma was not influenced by the
treatment. The other twelve cases were treated
through the vagina with better local results and less
general effect on the blood, which was due to the
small field of entry. The authors conclude that the
general ill effect on the organism when large fields
of entry are used, influence unfavorably the local
effect of the rays on the tumor. Now, it stands to
reason, that X-ray treatment applied through the
vagina must be less efficient than radium applied
directly into the cervix or the endometrium. The
authors attempted to bring the rays nearer to the
cervix by making a deep perineal incision, but this
resulted in local implantation of carcinoma.
The X-Rmy flee Sargery
Seitz and Wintz1, who as stated above, claim to
have received good immediate results with treatment
of cervical carcinoma, presented in the sam§ publica-
tion a very instructive report on the treatment of
forty-two cases of ovarian carcinoma. Nine cases
were treated with surgery alone, ten cases with
X-rays alone and both without any results. Twenty-
three cases were operated, the main tumor masses
were removed and then X-ray treatment was insti-
tuted, and the result in these cases was a great deal
more favorable. They conclude that ovarian car-
cinoma cannot be irradiated without a previous opera-
tion since the full dose produces a "Roentgen-
cachexie." Apparently a full carcinoma dose in
cervical carcinoma and ovarian carcinoma are differ-
14 Friedrich nnd Behme. Strahlentheraple, 1920, XI, 85.
ent things. In this instance the difficulty is caused
by the mass of tumor, since ovarian carcinoma is
more radio-sensitive than cervical carcinoma.
Yungling,15 of the surgical clinic of Tubingen,
working with the exact Erlangen methods, found
that X-ray therapy alone, using a full carcinoma dose,
gave poor results in carcinoma of larynx, lip, tongue
or rectum.
The progress of X-ray therapy in the course of the
last decade is due to a large extent to the fact that
the German gynecologists became interested in the
subject. The weakness of their stand, however, lies
in their premature generalizations. Results obtained
on carcinoma of the cervix and uterus cannot be
transferred to cancer in other localities. The uterus
and cervix is a muscular organ, which is less radio-
sensitive than carcinoma and presents a good pro-
tection against insults of all kind. Carcinoma of
the rectum or esophagus, for instance, is very poorly
protected by the thin walls of these organs. Car-
cinoma of the larynx is situated immediately over
cartilage which is fully as radiosensitive as carci-
noma tissues, and so on. Though the newest methods
of X-ray therapy represent a great progress and
must supersede all the previous methods of X-ray
therapy, this agent cannot be considered an all-
sufficient method of cancer therapy and is undoubt-
edly not as efficient as surgery alone or radium
therapy alone.
Combmti Metheie et Cameer Therapy
There is no doubt that basic limitations to all the
three methods of cancer therapy exist, which will be
impossible to overcome by further progress in the
technique. The limitations of surgery were analysed
above. Both radium and the X-rays exert a truly
specific selective action on cancer tissue, and biologi-
cally they present the nearest approach to a specific
therapeutic measure. The limitations of both agents
are due mainly to the size and location of the tumors
and the comparative vulnerability of the normal tis-
sues. Radium can be placed in near approximation
to or within the tumor. The new method of buried
radium emanation capillaries obviates to a great
extent the difficulties created both by the size and
location of the tumor. However, the size and multi-
plicity of the malignant tumors make the quantities
of radium required prohibitive. Excessive quantities
may become injurious to the rest of the organism.
X-rays are less costly and may effectively cover
simultaneously many areas even in the depth of the
organism and influence the tumor nodules, provided
they are sufficiently small. Treatment of large tumor
masses is followed by severe general reaction of the
organism, and, as was seen above, even a so-called
full carcinoma dose does not destroy a large tumor.
Further progress in cancer therapy must be looked
*• Tangling. Muench. Med. Woch., 1920, no. 24, p. 690.
798
Cancer Therapy — Levin
[The American Physician
for in the development of proper methods of co-
ordination of the three therapeutic measures.
Correct Method* lUmttraUi
It may be well to illustrate in a few instances the
correct methods of combined therapy which may be
pursued.
The writer had under his care two cases of carci-
noma of the urethra in the female. In one case a
complete radical operation was done with block dis-
section of regional lymph glands and removal of
the whole urethra with sphincter. No other treat-
ment was instituted until three months later, when
a severe recurrence took place which did not react
to intensive irradiation and the patient died six
months after the operation. In another case the
writer was consulted before any treatment began.
At his suggestion preoperative radium treatment was
given and then an incomplete operation was done,
removing only the tumor and leaving the posterior
part of the urethra and sphincter intact, and this was
followed by surface application of radium. The
patient is well clinically and is so now, over two years
after the operation.
In co-operation with Dr. Seeligman, at his serv-
ice at the Lenox Hill Hospital, a number of cases of
carcinoma of the cervix, vagina, urethra and ovaries
were treated by the writer.
As was shown above, the idea of a certain number
of German clinicians that every case of carcinoma
or sarcoma of the pelvic organs in the female may
be cured by a so-called full carcinoma or sarcoma
X-ray dose administered through the abdomen and
back is not borne out by the results obtained. Best
results are obtained by applying a different plan of
treatment for each individual case.
Whenever the tumor could not be removed surgi-
cally the main reliance was placed on the intra-
tumoral application of buried capillary tubes of
radium emanation, which is aided by surface applica-
tion of radium into the vicinity of the tumor and by
X-ray therapy of the adjoining areas.
Carcinoma of the larynx is very difficult to handle
and the radical operation leaves a very marked de-
formity. In the great majority of cases the condi-
tion recurs promptly and X-ray therapy does not
influence the condition. The writer, in association
with S. Yankauer, treats these cases in the follow-
ing manner : Preoperative radium treatment is given
externally and intralaryngeally through an instru-
ment devised by Yankauer. Then a suspension opera-
tion is done, only the tumor without any adjacent
normal tissues is removed, and post-operative radium
therapy instituted. One of Yankauer's patients is
now well for over five years. Another is well a year
and remains with such a good speaking voice that
he pursues his occupation as a traveling salesman.
In border-line cases of carcinoma of the breast the
writer buries radium emanation needles into the
breast tumor and the axillary glands, places radium
boxes over the tumor and glands, three to six weeks
later a radical breast amputation is done, and this
is followed by radium treatment of the operative
field and supraclavicular region and X-ray treatment
of the chest and the parts of the skeleton into which
metastases may take place. Dr. Auchincloss, at his
service at the Presbyterian Hospital, co-operated
with the writer on some of his cases.
Carcinoma of the urinary bladder is treated by the
writer in co-operation with Dr. Leo Buerger in the
following manner: A cystotomy is done and if the
tumor is found to be operable then it is removed and
a surface applicator is placed in the bladder. If
Jhe tumor cannot be removed, then a sufficient amount
of radium emanation capillaries is placed into the
tumor and the bladder is allowed to close. This is
followed by surface application of radium over the
symphysis and per rectum and by X-ray therapy.
The results of this method are very gratifying and
an extensive report will be published shortly by the
two investigators.
In co-operation with Dr. J. Lynch, at his service
in St. Bartholomew's Hospital, and with Dr. L.
Buerger, the writer has treated carcinoma of the
gastrointestinal tract in the following way: A lapa-
rotomy is done, which is followed either by a radical
operation or by an exporation with or without some
palliative surgery. In all cases where the tumor is
not removed surgically, radium emanation capillaries
are placed into the tumor. All the operations are
followed by surface application of radium and by
X-ray therapy. A preliminary report on this work
is in press.
Conclnui
Cancer therapy requires a great deal of sound
judgment and experience in handling complex clini-
cal conditions. A radiotherapeutist should not under-
take to treat a cancer patient without the co-opera-
tion of surgeons within the different specialties, nor
should a surgeon operate on a cancer case without
having an experienced radiotherapeutist near to
hand. No man, be he a clinician or physicist, can
create a scheme which will fit all the cancer patients,
or, for that matter, any two consecutive cases.
The necessity for early diagnosis of cancer is an
axiom in medicine. But even in perfectly apparent
advanced cases a correct estimation must be made be-
fore a hasty attempt at therapy is made. The writer
had under observation a case at his service at the
Montefiore Hospital on which two laparotomies were
done, by a noted New York surgeon, on a diagnosis
of carcinoma of the intestines. When the patient
entered the Montefiore Hospital, two months later,
the writer made a clinical diagnosis of an ovarian
carcinoma which was subsequently confirmed by an
autopsy. If a correct diagnosis were made before
the operation and consequently the laparotomy in-
Phila., November, 1922]
Cancer Therapy — Levin
799
cision made below instead of above the umbilicus, a
radical removal of the tumor may have been possible.
Even in attempts at palliative treatment, the cor-
rect aim must be kept in mind and a course pursued
which will accomplish it. The following case may
well illustrate the point: Dr. Leo B. Meyer kindly
conferred with the writer in regard to this patient.
Mrs. G., a woman eighty-five years of age, the mother
of a physician, was suffering from a scirrhus carci-
noma of the left breast for several years. For the
last two months the tumor began to grow rapidly
and cause pain and discomfort. Since the age and
general condition of the patient precluded a radical
operation, Dr. Meyer thought that palliative radium
treatment would be the course to pursue. The
examination showed a tumor the size of an orange
occupying the middle of the left breast. The tumor
was soft and showed apparent fluctuations, the skin
over the tumor was thinned, of a bluish red color
and firmly adherent to the tumor. One large lymph
node could be felt in the left axilla. The writer
stated that the tumor would ulcerate very soon and
even more promptly if radium treatment were
attempted. This would be followed by foul discharge
and great discomfort to the patient and surround-
ings. He suggested, therefore, that an incomplete
excision of the tumor with the adherent skin be done
without any attempt at removal of breast or lymph
glands. The operation should then be followed by
surface application of radium. The palliative opera-
tion was performed and no attempt was made to
remove the tumor completely, the skin, however, was
excised widely, sutured, and healed by primary union.
Under subsequent radium treatment the remnants of
the tumor in the breast diminished in size and the
gland in the axilla disappeared. It is nearly two
years since* the operation, and the patient is free
of any local or general disturbance.
The writer has had occasion to observe so many
hopeless cases of cancer in which an error not only
in the diagnosis but also in the method of treatment
was made previous to their entering the cancer divi-
sion of the Montefiore Hospital that it was thought
that it would increase the efficiency of the service
of the institution to the community by organizing a
clinic for diagnosis and treatment of early cases of
cancer. This clinic is equipped with radium emana-
tion laboratories, high-voltage X-ray therapy appara-
tus, and is assisted by all the facilities of the surgical
and all other divisions of the hospital.
A group study is thus established in the clinic of
the complex diagnostic and therapeutic problems of
cancer, which is in the opinion of the writer the only
method of approaching the subject. Cancer research
today needs co-operation of physicists, chemists,
pathologists, biologists- and clinicians of all special-
ties in medicine and only teamwork may accomplish
results.
Ludwig's Angina
Requires Immediate Surgical Attention
CASE REPORT ILLUSTRATES FATALITY OF DELAY
By Mayer Shoyer, M.D.,
Soldier, Kansas.
Ta Smrgeam at Undertaker
When crossing a railroad you stop, look,
and listen. When crossing Ludwig's Angina
you do not; you rush your patient to the sur-
geon, or the patient will go to the undertaker,
as is emphasized in this short but illuminating
paper of Dr. Shoyer. — Editors.
ANGINA LUDOVICI is a rare acute phlegmo-
nous inflammation of the floor of the mouth.
It is said the condition is more common in the male,
and may be secondary to specific infections (diph-
theria, scarlet fever, mixed infection), insignificant
lesions in the mouth, carious teeth, ulcers, tonsillitis.
It may result from trauma. The specific organism is
generally the streptococci; bacillus coli or staphy-
lococci may be found.
Symptomatology ami Pathology
The symptoms are said to be intense at the onset
(but this is not always so), and begin with swelling
in the region of the submaxillary gland, with rapid
involvement of the cellular tissue of the floor of the
mouth, as well as of the anterior portion of the neck,
causing a brawny tense edema from jaw to clavicle
and sometimes involving both sides. The head is
held backwards; there is always fever, frequent de-
lirium, and later prostration, severe sweats and coma.
Early in the disease the swelling is not discolored
but later it becomes a deep red. These cases of
cellulitis of the neck do not tend to prompt suppura-
tion. In a severe case the patient dies from sepsis
before there is any external evidence of pus forma-
tion, but by going deep beneath the fascia pus is
found. Delay in operative interference in these cases
means death.
Diagmono ami Treatment.
Diagnosis from ordinary lymphadenitis is easy by
its extension outside of the gland, which cannot be
palpated nor moved about, glands and surrounding
tissue being in one brawny mass. The prognosis is
serious; cases left to nature die. Early operative
interference will save the majority.
Treatment is surgical, an incision in median line or
over submaxillary gland, respecting the large blood
vessels. No doubt early in these cases the pus is
very deep; yet by using the finger or a blunt instru-
ment, different areas in the neck may be explored with
800
Ludwig's Angina — Shoyer
[The
the hope of reaching pus. Incisions below the deep
fascia will serve as drains in case no pus is encoun-
tered; pus may flow later.
Late cases do not take a general anesthetic well
and must be operated on under local anesthesia. The
process is frequently bilateral and the finger can be
pushed across the median muscles to the other side,
which should also be drained. Hot moist compresses
are to be used for the dressings.
Am Iwkprtuivt Ccm
A strong healthy man complained of feeling badly,
about the first of April, the first symptom being a
sore throat. He was up and down for several days,
some days feeling better than others. There was some
swelling over the left submaxillary gland and a husky
redness, some difficulty in swallowing and fever. On
April 12, 1922, the neck swelled rapidly, and he was
delirious. Up to this time he had been treated for
tonsillitis. I saw the case, for the first time, on
April 15. The neck was then swollen nearly even
with the chin and extended to the clavicles, and was
bilateral. There was nearly constant delirium and
a rectal temperature of 106.5° F., a very profuse
perspiration, and dysphagia.
Ludwig's angina was diagnosed and immediate
operative measures advised, which were performed
that morning. A median incision just above the
thyroid cartilage and another over the lower border
of the left submaxillary gland was made; deep in the
neck pus was encountered in large quantities, of a
dark green color and colon bacillus odor; drainage
tubes were inserted and a hot pack of permangate
1-2000 was applied.
For a week the patient's temperature fluctuated
between 99 and 104%° F.; the sweats and delirium
continued, only milder in character, but at this time
patient was no better, though the neck was down to
normal size and tubes were draining well. As moist
rales now appeared in upper part of right lung,
he was sent to a hospital, where x-ray examination
showed pus cavities in lung and in pericardial sac.
These cavities were drained several times. The patient
died.
Necropsy showed abscesses throughout both lungs,
pericardial sac, destruction of part of thyroid gland
and other organs.
This case demonstrates the necessity of an early
diagnosis and early operative measures.
Cmdmsiom
Any swelling in the region of a submaxillary gland
and floor of the mouth, with constitutional symptoms
out of proportion, should be promptly explored be-
cause it may be Ludwig's angina.
The mortality is high and cases rare, so that ex-
ploratory incisions are justifiable in all patients
having a swelling in the region of the submaxillary
gland and floor of the mouth, with a tendency to
spread.
PHYSICIANS
SHOULD LEAD Patients to Right Living
and to
Children WELL Born
By E. T. Schheinee, M.D.,
190 Maplewood Avenue, Philadelphia, Pa.
Young people just entering maturity may be
readily impressed with high ideals and strong de-
sires to achieve great things. The amassing of
money — if only causing it to change hands — is, of
course, not creative work, and the wise spending of
money, although laudable, is also not necessarily
creative work. Greatness is not achieved along that
line. But the making of two blades of grass grow
where only one grew before is using creative energy
and this creative instinct of youth calls to you, Doc-
tor, for safe direction.
As man is the crowning creative work of God on
earth, the creation of a new human life is the
greatest creative work of which man is capable. As
far as our knowledge goes, God — I say it reverently
— cannot create a new human life without man's
help. The ending of life is inevitable, but the begin-
ning, the creation of life, depends upon the parents.
The Ptrents' Retponubdity to the Cfcfera CkM
What greater responsibility can be assumed than
the creation of a new lifef And what greater work
than giving to that new life a normal inheritance T
In order that a child be born well, the desire for it
should be mutual and both parents should be at then-
best at the time of conception. No restrictions or
reversals should be practiced — if a man got his ear
under way at highest speed and then jammed down
the brake or reversed the engine, it would not be
good for the machine, would itt Playing at cross
purposes is always injurious, and especially so in
birth control, so-called; how can it be other than
injurious to all concerned to follow creative effort
with destructive effort? Finer children or stronger
parents, through reducing the number of children in
that way, seems a fallacious hope.
The life of the Roman Emperor Nero has been used
as an illustration of the lowest degradation possible
to man. What did he do to distinguish himself in
wickedness f Cut off the heads of a few objec-
tionable relatives! Made torches of the Christians.
"Everybody did it," for it was then the customary
way of disposing of undesirable people. Emperor
Nero enjoyed his food so much that he took an
emetic after eating that he might sooner repeat that
pleasure! Are not very similar practices condoned
todav?
Phila., November, 1922]
Physicians, Patients and Right Living— Schreiner
801
Tkt OpfTtmmty ami Dmty eftk* PkymtU*
Where am I wandering, do you sayf I am not
wandering, but taking the straightest way I know
to impress the fact that to have babes born well
A*e must have parents living well. We cannot con-
trol the third or fourth past generations, but we
can bring to the present the accumulated knowledge
and wisdom of all the ages; and we of the medical
profession have that knowledge and authority. We
should not be content to condone wrong acts be-
cause "Everybody does it." Although following the
crowd is, perhaps, easier than leading, yet it is ours
in all things oertaining to health to lead.
Advice to stop and think may be worth more than
any drug prescribed. Give more time to impressing
on patients the necessity for right living, and less to
removing the effects of wrong living. We may not
thus become wealthy, but we will have a following
of those who are truly seeking the welfare of man-
kind, and what greater honor can there be than that
of improving our race!
Impress it on your patients that in order that
their babies be born well, the parents must live well,
must exercise mutual consideration, must each
breathe pure air, eat pure food, drink pure water
and abstain from drugs and toxics. They must take
abundance of physical exercise and full daily ablu-
tions. And they must wear comfortable clothing — I
wonder how many baby ills are due to the mother's
shoes f They must also spend their nights in sleep,
must exercise their minds with the best reading and
most aspiring thought, dwelling on — in thought — and
imitating — in action — their highest ideal. So shall the
"Flesh help Spirit, even as Spirit helps Flesh."
Physicians, it is your opportunity — not to follow
—but to LEAD.
Gonococcemia and Metastatic Gonorrhea
Stressing Gonorrheal Arthritis
By Hyman I. Goldstein, M.D.,
1425 Broadway, Camden, N. J.
Assistant Visiting Physician and Chief of the Medical
Clinic, Northwestern General Hospital, Philadel-
phia; Assistant in Medicine, Graduate Medical
School, University of Pennsylvania, Phila-
delphia; Assistant Visiting Physician,
Philadelphia General Hospital.
Freqmemt, Imtemse, Obsthmt*
Gonorrheal arthritis is too frequent, too
intense, too obstinate a disease to require in-
troduction or emphasis. Such being the case,
we know Dr. Goldstein's able presentation of
this subject will be fully appreciated by our
readers. — Editors.
THE OCCURRENCE, during the past twelve years
3f my practice, of a number of interesting
cases of gonorrhea, associated with various complica-
tions, the great prominence now being given to focal
infections, and the lack of any definite form of treat-
ment recommended in textbooks and recent literature,
have led me to gather together a few facts on this im-
portant class of infections that are too little em-
phasized and still less recognized. When we con-
sider that gonorrhea is the most prevalent of all in-
fectious diseases, that it leads to acute and chronic
complications of which gonorrheal arthritis is the
most serious and damaging, occurring in from 2 to
5 per cent of gonorrhea cases, the phase of this sub-
ject certainly deserves a prominent position. I will
deal principally with gonorrheal arthritis.
The first probable demonstration of the invasion of
the blood by gonococci was made by Wertheim. Ab-
solute proof rested with the cultivation of these or-
ganisms from the circulating blood by Thayer and
Blumer in 1895. Hewes, in 1894, succeeded in isolat-
ing the gonococcus from the blood of a patient in a
case of arthritis.
Ruf us Cole made a study of twenty-nine septicemia
cases collected by him, and he divides them into four
groups — (1) Cases with malignant endocarditis with
fever, sweating, chills and septic infarcts in some;
(2) Cases with local suppurative lesions in internal
organs or in subcutaneous tissue and features of
pyemia; (3) Cases with no metastatic local infec-
tions— all these cases recovered; (4) Cases of gon-
orrheal puerperal septicemia. Some authors state
that as many as 25 per cent of all cases of puerperal
fever are due to gonococci.
The prognosis is not necessarily hopeless when
gonococci are cultivated from the blood. The prog-
nosis is worse when endocarditis is present. Of Cole's
twenty-nine cafces, twelve died, sixteen recovered, and
one not stated. As far as (Cole) secondary metastatic
lesions are concerned, it seems probable that they are
usually due to the transmission of a very few bac-
teria through the blood and their localization in loci
minoris resistentiae. The most common primary focus
is a chronic prostatitis or vesiculitis in male, or sal-
pingitis in female. (Treatment of these foci along
with appropriate local treatment is necessary.)
802
Gonococcemia and Metastatic Gonorrhea — Goldstein
[The American Fhyndan
Gmwrrmtml Pouibtfities ami Motmttmsu
Gonorrhea is an acute infectious disease, and locally
is a contagious catarrhal inflammation of the genital
mucous membrane, chiefly propogated by illicit sexual
intercourse and due to the micrococcus gonorrhoeae
or gonococcus Neisser. We know too well that this
disease may limit itself to the mucous membrane of
the genitalia — (1) the local (primary) disease; (2)
it may invade the genito-urinary organs, bladder, kid-
neys, tubes, ovaries, etc., by direct continuity of struc-
ture, secondary local infection, and (3) it may enter
the blood stream and cause constitutional infection
with metastatic involvement. It is this la it group,
in particular, with which I wish to deal in this paper.
Very little has been written on this subject recently;
very little space is given to this serious complication
and its treatment in the textbooks of general medicine
and in special treatises on the genito-urinary organs.
Any case of local gonorrheal infection is liable to
systemic and metastatic disturbances, manifested by
symptoms of general toxemia and localized inflamma-
tion, especially in the joints, heart, meninges, chiefly
in and about the joints. The condition is probably
due to the entrance of the gonococcus into the blood
and to the absorption of toxins.
Gonorrheal "rheumatism" so-called, is the most
common localization in septicemia cases. It may oc-
cur in infants, as a complication of gonorrheal
ophthalmia neonatorum and in young children (vulvo-
vaginitis).
Angle cited a case of ophthalmia neonatorum occur-
ing forty-eight hours after birth, followed two weeks
later by an arthritis involving the left wrist and right
knee; also a second case which, infected in a similar
way, affected both wrists. C. Lucas collected twenty-
three such cases of gonorrheal rheumatism in infantile
subjects of ophthalmia. It is evident that gonorrheal
arthritis is not limited in its origin to the urinary and
genital tracts.
In these days, arthritis due to focal infections are
most frequently traced to tonsils and teeth — yes, and
patients have had their teeth and tonsils removed for
so-called rheumatism, when as a matter of fact they
were harboring gonococci in the urethra, vagina, tubes
or prostate. In such cases, of course, examinations
of the smears and a blood complement fixation test for
gonorrhea would have cleared up the diagnosis and,
with proper local and general treatment, the cases
would have been cured, without the needless removal
of good teeth and innocent tonsils.
Symptomatology ami Pathology of Gmwrrkaal Arthnti*
Gonorrheal arthritis most commonly begins in the
acute stage of a urethritis and may be associated with
a temporary subsidence of the discharge. It may not
occur until after the discharge has greatly diminished
or not for several weeks after the beginning of the
attack. It comes on usually during the third or
fourth week of the disease. Its onset is seldom ab-
rupt, and is usually unattended by chills or high
fever, though there may be a rise to 101°-102°. Most
frequent in men, rare in women.
It is often stated that it is monarticular; however,
although it may only affect a single large joint, more
often two or three or even four joints are involved.
The polyarticular involvement may last only a few
days. In almost all cases, more than one joint is
involved. In all but three of Cole's fifty eases, there
was polyarthritis. Of course, many cases seen in the
later stages, when the disease is frequently localized
in one or two larger joints, will show monarticular
involvement and, if the history is not considered, a
mistake is made.
The affection is not so migratory and fugacious as
acute polyarticlar rheumatism. The joints remain
inflamed and only improve slowly. The ankles, knees
and wrists seem to be especially liable to gonorrheal
inflammation. Often the vertebral, sacro-iliac, tem-
pero-maxillary and hip joints, may also become af-
fected.
Previous rheumatic diathesis has no bearing on this
disease and in the cases which I have seen, no such
connection could be traced — on the contrary, they
were usually patients who were young and healthy,
and have been remarkably free from muscular and
joint pains.
The joints remain inflamed and only improve
slowly. The inflammation is endo-articular and peri-
articular, and the tendon sheaths also become in-
volved with a resulting teno-synovitis. Serous or
sero-purulent effusion may appear. Relapses are
frequent, and disabling ankylosis may result This
disease was first noticed eoincidently by Selle and
Swediaur more than one hundred and twenty-five
years ago.
Often the disease expends its violence on the fibrous
and bursal structures about the knee, elbow or ankle.
The muscles and their tendons, the sheaths through
which they pass, the bursal sacs, and the nerves, may
also suffer. When gonorrheal "rheumatism" attacks
the synovial membrane of a joint, though there may
be little pain and an entire absence of surface red-
ness, there will generally be a considerable effusion
into the cavity of the (joint) articulation, which is
not easily removed.
Osier states that the knees and ankles are most apt
to be involved. Suppuration is unusual, and he sug-
gests that the non-suppurative cases are due to the
action of the gonococcic toxins taken up from the area
of primary infection, and that the suppurative cases
are due to mixed infection with pyogenic bacteria. In
most of my cases the inflammation was located around,
rather than in, the joints.
Blood Ckamges in Gmwrrmxi Arthritis — and EmUtmamm
Anemia is not so marked as in rheumatic fever. A
moderate grade of leukocytosis is the rule. There is
(Continued on page 806)
While surgery, the specialties, hospitals, People are to be served, the primary im- ordinate* in constructive co-operation nnth
institutional medicine, public health work, Portance of the function of the General the essential service of the Family Physician,
industrial medicine, etc., have their definite Practioner must be recognised. Other divi- This is an integral purpose of The American
functions, if the best health interests of the sions of medical service must be properly co- Physician.
One Reason Why We Lose Practice
FOOLISH QUESTIONS? NO, NOT TO THE PATIENT
A Vary Practice! Matter
This, at start, may seem mildly humorous.
To anyone who is concerned for the continued
success and prosperity of the regular pro-
fession, it is anything but humorous. An
intelligent understanding of human nature
and a reasonable capacity to adapt to it is
a very practical matter. And very impor-
tant to success in any kind of work where
contact is direct and personal, as it is in the
practice of medicine.
THE LAY MIND has never been plumbed to its
depths in things medical, as we often realize when
questions are asked of us, "Doctor, why does my right
eye twitch and my left one doesn't ? Why do I gurgle
inside at night and not in the daytime! Why do I
have gas on the stomach when I take a drink of
water, yet sleep all right on a heavy meal? Why is
my rheumatism always on the left side? What are
the specks I see floating before my eyes? Why is
my tongue always coated in the winter and not in
the summer? Why should wet feet give me a cold
in the head? Why does malted milk agree with one
twin and not with the other? How can I tell whether
a mosquito bite will give me malaria or not? Do
Doane's kidney pills have the same medicine in them
that you are giving me? Is it true that yeast pre-
vents appendicitis? Just what do vitamines look
like and do the different kinds look alike?" No
wonder we fainted after that seance and felt like we
had visited a psychanalyst and were just coming up
for air in deep water and did not know how to swim.
And the what-to-do questions are worse yet. "What
can I use to keep from getting sunburn? Please tell
me what to use to keep my hair from getting stringy
at the seashore. What simple remedy can I use for
bleeding piles? Had I better use aloe or aloes for
constipation? What sleeping medicine had I best
buy at the drugstore? What ready-made gland medi-
cine do you recommend as best? What simple medi-
cine do you recommend for sleepy spells in the day'
time? My chiropractor says my trouble is making
too much bile and he is giving me adjustments for
it; but what medicine had I better buy to keep me
from making bile?" This midsummer bombardment
gave ns an attack of hay fever.
Qmesti—s? No, Nat to the Fatkni
We all get that sort of thing, more or less, every
day, for people can ask thousands of such questions;
and the way we satisfy them or fail to do so has
much to do with our success or lack of it. The erst-
while family doctor of the back country could answer
the multitude of questions better than we can today,
for his patients were not booked up on pseudo-
science and they resorted to simple herbs instead of
more or less denatured poisons sold by the ton in the
drug stores.
This article is designed to help meet this situation.
Your patients are perfectly sincere when they bom-
bard you with such a string of profound questions
usually based on trifling symptoms from which they
suffer. If they have typhoid or pneumonia, or other
well defined disease, they call you to attend them, but
they are constantly advised in newspapers and maga-
zines, by health workers, etc., to ask their doctor
about their small troubles, and they expect to get
this information for nothing. Naturally, when the
doctor is busy and has profitable work waiting, he
snubs these people and chokes off their flow of ques-
tions. Then they go elsewhere and you lose their
practice.
Yet, don't forget this: the whole trend of medicine
is prevention, and the physician who hopes to suc-
ceed in practice must, per force of circumstances, get
in line. But he does not have to do it for nothing.
When a patient bombards you with a string of ques-
804
One Reason Why We Lose Practice
[The American Pbyncua
tions, take it calmly and analytically. Their very
questions give you an insight into the case, so let
them ask questions to the point where you get a
good lead. Now is the time to explain their need for
a thorough physical survey, after which you can
answer their questions intelligently. Then set a time
out of your usual hours to examine the patient thor-
oughly and elaborately, adding necessary laboratory
tests, and let it be understood it is for a substan-
tial fee on a giving-service basis. Usually the pa-
tient will be pleased and get his money's worth.
The TrtMmg C«#
After letting the patient run down with his string
of questions, then it is your turn. Almost invariably
you will find he will own up to doing foolish things,
neglecting personal hygiene, running after quacks and
faddists, etc. Nine times out of ten he needs no
medicine, but he does need guidance, especially hy-
gienic guidance. Almost always these annoying lit-
tle symptoms have a definite cause, traceable to
neglect of personal hygiene, defective living, taking
trash bought in the drug stores, or following fool
advice given by a pseudo-doctor, but the tenth case
shows a real pathology that, taken in time, may save
the patient's life.
A patient will listen to any line of fool talk if
the fool talker shows an interest in him and his affairs.
If an educated physician does not take an interest and
actually examine the patient, it is not at all to be
wondered at that he patronizes the pseudo-doctor;
it's the most natural thing in the world. But if the
educated physician does as above suggested, takes
a real heart interest in the patient, and actually
shows him by the findings of a painstaking examina-
tion just what is or is not wrong, then the patient
has confidence and is ready to listen to medical com-
mon sense and to forget what the fool talker said to
him. It is easy money to line up patients for mod-
ern medicine if we only go at it right.
Uteleu> Medication
We get into office after office of non-specializing
physicians and find a whole string of people wait-
ing, and it is surprising how quickly they are rail-
roaded through, diagnosed, given a box or envelope
of some one of the fifty-seven, more or less effective,
kinds of tablets on hand, and shoved courteously out,
their questions unanswered. Shame on such practice !
Any intelligent osteopath does better work and ice
may as well admit it.
There are thousands of osteopaths, chiropractors,
etc., making good livings out of doing work that
physicians have refused to do, viz., attend painstak-
ingly to the little aches and pains of humanity with-
out doping them. These faddists do not treat many
really serious cases, their work being with the very
class of justly dissatisfied patients we are here con-
sidering. The public is getting tired of little pink
envelopes of dope, most of it not needed, as we well
know. If you do not believe the osteopath, makes a
painstaking examination, go and consult one. There
is an eye-opening awaiting you. He may be dead
wrong in his theory, and all that sort of thing; but
he is on the job, and he believes in his job and make?
his patients believe in it. Doctor, if you can't satisfy
these patients as well as the osteopath satisfies them,
he will get them and it will be your fault. The idea
that practicing medicine consists of two parts, one
being, doing something as a specialist, and the other,
giving something as a general practitioner, is as dead
as any political platform of two decades ago.
Wt Need to Skmkt Up Omr Medicd 5dUW*
Our schools are giving splendid training in the
heavy work of medicine and the specialties; but they
are positively not turning out young practitioners who
intelligently handle the vastly more numerous small
things. These relatively easy cases are left more and
more to the so-called irregulars and faddists. After
while, after they have secured all the smaH cases,
they will get the big ones also. Then whose fault
will that bet
When we pursue this course we are not giving the
people the medical service they want and rightly
expect from their physician. Yet, we complain that
the people fail to support the regular profession as
once they did.— -T. S. B.
Heart Disease in Pregnancy
Selian Neuhof (/. A. M. A., Sept. 9, 1922) says we
possess at present no instrumental guide or tolerance
test which can adequately measure the cardiac reserve
of the diseased heart of the pregnant woman. Each case
must be individualized, and the presence or absence of
heart failure noted. The best clinical guide for heart
failure is a detailed study of the patient's symptoms, to-
gether with a detailed study of the physical signs. Cardiac
neurosis, decompensation and endocarditis recurrences
seem the best inclusive grouping of all types of
cardiac symptoms that occur in pregnancy with heart
disease. The degree of decompensation and the month
of pregnancy together determine the type of procedure.
Decompensation that does not quickly and permanently
react to medication requires interruption of pregnancy at
any stage. When viability has been reached and decom-
pensation is moderate or absent, cesarean section, when
skillfully and rapidly performed, seems to be well with-
stood by the diseased hearts of pregnant women. It pre-
vents the cardiac strain incidental to labor ; it may like-
wise prevent a lingering, cardiac recuperation following
labor. Should the woman come to term, the labor should
be shortened as much as possible. Ether is the anesthetic
of choice.
Do not be unduly elated over a case of syphilis which
never shows a skin or other visible lesion. A false sense
of security may be developed in such cases. Cerebro-
spinal syphilis is all too often a consequence of a false
sense of security.
November, 1922]
The American Physician Advertising Service
805
Constipation in Young Girls and Women —
especially those who spend much time indoors engaged in sedentary pursuits — is
almost invariably attended by a retention of waste and toxic substances. Sooner
or later these make their way from the bowel into the general system and give rise
to a host of autotoxic ills.
Correction of this condition is imperative, and the safest, simplest and most effect-
ive remedy for the purpose is
INTEROL
Directions:
To relieve the constipa-
tion of young girls and
women, give two to four
taaspoonfuls of INTEROL
morning and night, in-
creasing or decreasing the
quantity as conditions re-
quire. As the bowels yield
to the action of INTEROL
gradually cut down the
dose to the least amount
that — taken at bedtime —
will assure a daily evac-
uation.
a pure mineral oil of the proper density and viscosity to
assure satisfactory lubrication of the intestinal canal, and
thus relieve and correct bowel inactivity without the usual
disagreeable effects of cathartics as commonly employed.
Besides lubricating the canal, INTEROL renders the
feces soft and plastic, thereby promoting their easy passage
and evacuation with gratifying freedom from discomfort
and distress.
It would indeed be difficult to suggest any more service-
able and agreeable medium for the correction of constipation,
with its attending autotoxemic conditions, than INTEROL.
Sample and Inter ol Brochure on Request
Allied Drug and Chemical Corporation
2413 Third At*. New York City
Manufacturers of
ORASEPTINE— Internal and External Antiseptic, Wash, Spray and Douche.
ADACCO SALT— Effervescent Saline Loxatire and Uric Acid Solvent
VELOGEN— "The Doctor's Hand-maid and Household Emollient"
44
99
xHe who puts up at the first Inn he
comes to, very often passes a bad night
Proverb of Italy —
The same holds true of the physician who does not carefully
discriminate in his choice of a drug, or combination of drugs,
for each individual case.
For the removal of effused fluid — dropsy — in loss of cardiac
compensation in valvular disease — in chronic Brights, in Post-
Scarlatinal Nephritis, or in ascites from Hepatic disease,
ANASARCIN TABLETS secure prompt and satisfactory
results, because ANASARCIN is a carefully worked out, scien-
tifically tested and proven combination of agents, which over-
come circulatory stasis, bring about resorption of effused fluid
and elimination of both urinary solids and fluids.
ANASARCIN TABLETS are designed to act specifically.
That they do so act can easily be established by
clinical test Convince yourself, Doctor
Sample, literature, case reports, etc., on request
The Anasarcin Chemical Company Winchester, Tenn.
Mentioning The American Physician Insures Prompt, Careful Service
806
Is Medical Education Becoming Impracticable?
[The American Physician
1$ Medical Education Becoming ImpraSical?
IS OUR FORCED STANDARDIZATION AND MULTI-
SPECIALIST TYPE OF EDUCATION PROVIDING
THE MEDICAL SERVICE THE PEOPLE NEED?
SUCH CONCERN is being expressed in medical
circles over the future supply of physicians for
small communities, due, so it is claimed, to over-
educated young graduates not caring for anything
but a city location, but really due to the fact that
most small communities provide no hospital or labora-
tory facilities, and the further fact that the more in-
telligent residents go to the city for most of the
work yielding good fees. It is a difficult thing, in the
average small community, for an up-to-date practi-
tioner to develop himself, and hence these communities
are avoided by the new graduate. The problem is
to educate the communities up to the modern stand-
ard, not to educate doctors down to the communitv
standard.
Yet, it is a fact that a forced standardization does
not work any too well in medical education, and the
American plan of conferring the doctorate before a
man is allowed to practice has certain disadvantages,
one of them being that the expense and time inci-
dent to the modern curriculum is a heavy weight,
and it compels a multi-specialist type of education
that does not produce general practitioners of a kind
sadly needed.
The writer, like many other physicians, has had
to face the problem of educating a son. The boy
would not study medicine, so he went to a state agri-
cultural college direct from technical high school,
where a four-years' course gave the B. S. degree and
also a profession, which offers more income to him
from the start than he could expect to get for several
years in medical practice and saves him five years in
medical school and hospital. Dad also has five years'
less freight to pay, though he realizes that his boy
is not a doctor of agriculture, which probably is no
disadvantage to the boy.
Tke Lmw of Fr*U$sional Grmvitation
A man does not come out of college as a doctor
of chemistry, engineering, theology, law or mining,
but our notion of things is that osteopaths, chiroprac-
tors, chiropodists, dentists and physicians must be
called "Doctor." This purely academic degree has
lost its academic significance and has become cheap,
no longer definitely standing for advanced scholar-
ship or professional attainment.
The average doctor of medicine has no academic
incentive to progress, and most of these doctors do not
progress in scientific attainment. Rather, the law
of professional gravitation tends gradually to poll
them down to lower scientific standards, and there
is no provision made for keeping physicians up to
standard except for the individual physician who is
so placed that he can do it to take what we fondly
call post-graduate instruction, but which rarely is
more than a mere jacking-up course for old graduates.
This is a sad way to produce advanced students and
usually amounts merely to sending a worn practi-
tioner in for repairs.
MeAicd Simmdmrdt
Considered from the standpoint of the doctorate,
medical standards are low at present, but considered
from the standpoint of training a man to begin medi-
cal practice, the present standardization is top-
heavy. Even a four-years' course in medical school
is utterly inadequate to cover the subject completely,
even as all branches of engineering could not be
taught in this period. Engineering schools know bet-
ter than to try to give such an all-inclusive course.
Then why not rearrange the medical course, grant-
ing the degree of B. S. in medicine, sending the men
out to practice general medicine, and providing for
a master and a doctor degree by really earning the
first one by study and the second by practical
attainment?
Gonorrheal Arthritis — Goldstein
(CmtHumtJ fnm pmgt 6t2)
no apparent relationship between the degree of leuko-
cytosis and the severity of the lesions.
The association of endocarditis with gonorrheal
arthritis was recognized as early as 1847 by Ricord.
Thayer and Blumer, in 1895, proved this with blood
cultures during life and in smears from the thrombus
on the heart valve after death. Kulbs collected forty-
nine cases (thirty-six in men and thirteen in women)
of endocarditis; twenty-eight cases were aortic and
eight mitral. Thayer found seven aortic and two
mitral lesions in fifteen eases collected. The right
heart was affected more frequently in gonococcal than
in simple endocarditis. Von Leyden first described a
case of genuine gonorrheal endocarditis. Later, Fin-
ger, Schlagenhaufer, Lenhartz and Ghon described
cases of gonorrheal endocarditis.
rmtwtttM IM dJRR Cl'ipflMf
Heller has collected twenty-six cases of gonococcal
phlebitis, in fifteen of which arthritis was also present.
Gonorrheal skin eruption may occur in cases of
arthritis. Buschke divides them into four groups—
(1) simple erythema, the most frequent form; (2)
urticaria and erythema nodosum; (3) hemorrhagic
and bullous eruptions, probably embolic in origin in
very septicemic cases, and (4) hyperkeratosis. This
is a most interesting group because the lesions are
(Continued one leaf over)
November, 1922] The American Physician Advertising Service 807
Is Mineral Starvation a
Primary Cause of Disease?
PHYSIOLOGISTS now generally con-
cede that a demineralized diet reduces
the supply of vital energy, and helps pre-
pare a tissue-soil favorable to the growth
of pathogenic germs.
Since mineral deprivation may be con-
sidered an actual cause of disease, Grape-
Nuts is valuable in conditions of malnu-
trition resulting from demineralized foods.
Grape-Nuts contains all the mineral salts
of whole wheat flour and malted barley.
And its 20-hours baking facilitates the
ready digestion of the starches.
In fact, the qualitative tests of the self-
developed sugar in Grape-Nuts indicate
this food contains a notable proportion of
dextrose — the end product of carbohydrate
conversion.
In addition, Grape-Nuts is deliciously
satisfying as a cereal — served with cream
or milk it is a complete food.
Samples of Grape-Nuts, with full information,
for personal or clinical trial will be sent upon
request to any physician who will write for them.
Postum Cereal Co., Inc., Battle Creek, Michigan, U. S. A.
Mentioning The American Physician Insures Prompt, Careful Service
808
apparently specific. They have been extensively <Ie-
fieri bed by Baermann. Thin follows a severe general
infection with joint Ie*ion*. Emaciation and anemia
are quite pronounced. They appear suddenly on
palmar and plantar surfaces or about the nails. The
French writers consider the condition a trophoneurosis
due to toxic changes in the nerve endings. Baermann
does not think the crust formation a true keratosis,
but a dermatitis papillaris parakeratotica.
Koth thinks them "angiopathic" skin eruptions. It
m to be remembered that exanthemata may develop
in gonorrhea that are not due to drugs or sera.
Buschke thinks they are due to gonorrheal toxins.
Vidal and Besnier consider them trophic myelopathic
toxicodermata.
Herpes labialis has been observed by Lenhartz,
Irons, Thayer and others.
Other complications such as iritis, pericarditis, and
pleurisy may occur.
Ctmm W CtmnUd Arthritis
There are two views as to the direct cause of the
most frequent and also the most important complica-
tion of gonorrhea — namely arthritis : 1, that it is due
to the action of soluble toxins elaborated at the seat
of local infection and 2, that it is due to localization
in the joints of gonococci, which have gained ac-
cess to the general circulation or have passed from
the local lesions to the joints through the lymphatic
channels. The view that the lesion is due to the
localization of gonococci in the joints is now well
established by the cultivation of these organisms from
the joints in a large number of cases. The organisms
are often present in the tissues, even where the ex-
amination shows the exudate to be sterile. The gono-
cocci probably reach the joints through the blood
current. A slight injury to a joint may so render
them loci minoris resistentiae as to predispose these
joints to such localization of infection. Wm. H. Park
says the pathogenic effects exerted by gonococci are
chiefly due to endotoxins.
Ffwu W GmmttiW Artkritk
Koeiiig classifies these joint conditions— 1, Hydrops
ffoiiorrhoicus; 2, arthritis sero-fibrinosa et catarrhalis;
8, arthritis purulenta (empyema of joints) ; 4, arthri-
tis phlcgmonosa (essentially the peri -articular or
para-articular form).
1. Arthritis with serious effusion— with little struc-
tural change in synovial membrane, and the joint is
more or less distended with a clear, serous fluid.
'J. Arthritis with sero-tihrinous and catarrhal exu-
date synovial membrane is more decidedly infiltrated
and the fluid contains floccnlent masses of fibrin.
3. Suppurative variety—- joint cavity is filled with
pus, Osier says mixed infection is rare.
4, Phlegmonous — rarest — causes the greatest dam-
age K> the joint and surrounding structures, and re-
sults in the greatest functional disturbances.
According to Osier, gonorrheal arthritis is classified
aa 1, arthralgie — wandering pains about the joints,
without redness or swelling, persisting for a long time;
2, polyarthritie — several joints become affected,
fever is slight, local inflammation may fix itself in
one joint, but more commonly several become swollen
and tender, cerebral and cardiac complications may
occur; 3, acute gonococcus arthritis, in which a joint,
usually the knee, becomes suddenly involved, the pain
is severe, the swelling extensive, due chiefly to peri-
articular edema, the general fever is not at all pro-
portionate to the intensity of the local signs, the exu-
date usually resolves, though suppuration occasionally
supervenes; 4, chronic hydrarthrosis — usually mono-
articular and is particularly apt to involve the knee,
comes on often without pain, redness or swelling, pos
is rare; 5, bursal and synovial form — attacks chiefly
the tendons and their sheaths, the bursae, and the
periosteum, the articulations may not be affected, the
bursae of the patella, the olecranon and the tendo-
achilles are most apt to be involved; 6, septicemic
form, in which, with an acute arthritis, the gonococci
invade the blood, and the picture is that of an intense
septico-pyemia, usually with endocarditis; 7, painful
heel of gonorrhea — a remarkable form of pododynia,
due to local periosteal thickening and exostosis on the
os calcis, at the insertion of the tendon of achilles and
the plantar aponeurosis, causing pain and great dis-
ability. Baer has demonstrated the gonococcus in the
periosteal lesion. Retro-calcaneal bursitis may be
present, giving a cystic enlargement, along with the
periostitis and exostosis. The achilodynia (or pied
blennorrhagique) manifests itself as a painful swell-
ing below the insertion of the tendon achilles and
interferes with walking.
According to Robert W. Lovett, of Boston, the
types of gonorrheal joint affection are as follows: 1,
arthralgia without definite lesions in the joint ; 2, acute
serous synovitis with much peri-articular swelling:
3. acute fibrinous or plastic synovitis with slight
effusion; 4, chronic serous or purulent synovitis; 5,
involvement of peri-articular structures, such as bur-
sae and tendon sheaths.
Peripheral nerves may become affected. A. Fraen-
kel, Fournier, Lesser and others have observed ischial-
gia. Engle-Reimers has described cases of neuralgia
of gonorrheal origin in the region of the isefcia:i-\
obturator, crural and auditory nerves.
Roswell Park was among the first to report a «****
of typical pyemia following gonorrhea and to recog-
nize it as such.
(Continued in December issued
To protect himself, a physician should warn s pa-
tient recently broken out with erythema muhii- rrx thst
temporary changes in type and degree oi irTf've-
ment arc part of the nature of the disease arc ~ft
due to medicines he may prescribe.
The American Phytician Advertising Stroke
VALUABLE properties to be found in bran
nave increased professional regard for this
important cereal. It is used in increasing quanti-
ties in well-organized households where diet and
health are given thoughtful consideration.
The deliciousness of Kellogg's Bran, in its
cooked and krumbled form, has overcome objec-
tions found to common bran. Bran, as manu-
factured under the Kellogg process, is a delight
to eat as a cereal, with other cereal, and in
appetizing bakery batches. At least two table-
spoonfuls daily are recommended; as much with
each meal in severe cases. It can be prescribed
with confidence.
The action of Kellogg's Bran is entirely natural
and mechanical. Bran, as you know, adds to the
indigestible residue in the bowel tract, its bulk
serving to distend the intestine, thereby induc-
ing better peristaltic action.
It *fll pleaie in very much to lend phriicieni
■ full-aUed packicc of Kelloci** Bran, without
liny obligation. 11*11 nqiuil card to Kcllott'*
Teamed Cora Flake Co., Battle Creek, Mich.
An Analytu of
KMogg't BRAN
coo lead and krumbled
Aaide from in refulatory
■aloe, KellofE-e Bran torn-
the moat valuable food.
known. Read tbla enalyeie:
lloieture
MINERAL SALT*
the original EiSAR* cooked and bumbled
Mentioning The A:
Physician Insures Prompt, Careful Service
810
Book Reviews
[PhflaiWpfck
"Book tReUews
The Vitamins
6y H. C. Sherman, Professor of Food Chemistry, Co-
lumbia University, and S. L. Smith, Specialist in
Biological and Food Chemistry, U. S. Dept. of
Agriculture. Issued under the auspices of the
American Chemical Society. Cloth, illustrated, 273
patres. The Chemical Catalog Company, Inc., 1
Madison Ave., New York City.
This authoritative presentation of the subject of the
vitamins details the historical development of the vita-
min theory, the various researches leading to our present
knowledge of the subject, and, as well, gives a wealth
of practical detail that makes of the work an especially
satisfying treatise. Especially valuable to the physician
is the clear outline of the clinical phases of the subject.
We wish to commend this book as of the highest value.
joined medical officer in a mental hospital, as concisely
as possible, those methods of treating the insane Which
experience has proved to be satisfactory. Nothing in the
way of treatment has been recommended which has not
stood the test of experience, and the opinions of practical
men only have been sought" This purpose has been
adequately accomplished in the publication of this modest
little work.
Mental Hospital Manual
Oxford Medical Publications. By John Mac Arthur,
M.R.C.S, L.R.C.P., Senior Assistant Medical Officer,
London Mental Hospital, Colney Hatch; Lecturer
on Mental Diseases to the North -East London Post-
Graduate College. London. Henry Frowtle and
Hodder & Stoughton, The Lancet Building, 1 and 2
Bedford Street. Strand, W.C. 2.
The object of this book is "to place before the newly
Studies in Influenza and Its Pulmonary Complications
By D. Barty King, O.B.E., M.A., M.D. (Edin.),
M.R.C.P. (Lond. and Edin.), Physician to the
Royal Chest Hospital, London; Consulting and
Examining Physician to' the Church Army Sana-
torium for Children Suffering from Pulmonary
Tuberculosis, Fleet, Hants; Honorary Consult-
ing Physician to the Royal Caledonian Schools,
Bushey, Herts; Late Major R.A.M.C (Temp.),
in charge of the Medical Division, County of
London (Horton) War Hospital, Epsom. With
31 illustrations. Paul B. Hoeber, 69 East 59th
Street, New York City, 1922. $2.00.
The aftermath of the late influenza epidemic is still
with us. We are still reaping a considerable harvest
in weakened, debilitated and devitalized individuals.
*
(Continued one leaf over)
EVEN NATURE WATERS THE MILK!
The fact that at least 86% of milk is represented by water justifies die advantage
of using the milk solids in powdered form, — i.e., as DRYCO.
DRYCO is powdered milk, obtained by die rapid drying of fluid milk on polished
steel cylinders heated to 212° F. The process occupies only two seconds. Cara-
melization of the milk sugar is avoided. Casein is changed into a colloidal form, and
its digestion rendered prompt and easy, without large tough curd formation. The fat
emulsion is broken up, — fat is present as a free fatty acid.
Hence Dryco is an Ideal Food for Sick and Invalid Feeding
DRYCO is easily prepared, pleasant to take, digestible in cases that cannot take
ordinary milk, produces prompt gain in strength and weight, is bacteria free.
DRYCO HAS SOLVED THE PROBLEM. TRY IT.
Sample, literature, case reports, etc* on request
THE DRY MILK COMPANY
14 Park Row New Yoric City
"An International Institution for the Study and Production of Pure Milk Products"
You can buy with Confidence — See "Service Guarantee to Readers" on page 830
November, 1922] The Americn Physician Advertising Service gi i
Pluriglandular Therapy in
DIABETES MELLITUS
COR SOME YEARS we have been developing
an effective polycrine formula for increas-
ing glycolysis and sugar tolerance in pancreatic
diabetes.
After much clinical and laboratory testing we now offer to the
medical profession
List No. 44
PAN-SECRETIN CO.
(Harrow«r)
An endocrine combination embodying —
( 1 ) A specially prepared extract of islets of Langerhans (pan-
creas tail), rich in its incretory glycolytic product.
(2) An acid extract of the duodenal mucosa containing the
pancreatic activator, secretin, and
(3) A small dose of desiccated calves tonsil.
PAN-SECRETIN CO. (HarrowerJ is clinically useful in
many cases of diabetes mellitus, favoring the reduction
of the glycosuria, increasing the dietetic latitude said
modifying the deranged endocrine balance.
The dose at first is one Sanitablet t. i. d., later an additional dose
is taken at bedtime and still later the amount may be advantageously
increased to as much as 2, q. i. d.
Practical
Organotherapy
A 416-page, cloth
bound book of ref-
erence, should be hi
your hands.
A copy will be
sent to any physician
of record for one dol-
lar postpaid — and it
may be returned if
desired and both the
dollar and the post-
age will be re-
funded.
Prescribe this formula— over 200 jobbers
in the U. S. carry it. Literature to physicians
from any of our offices mentioned below.
THE HARROWER LABORATORY
Home Office: G LEND ALE, Calif.
New York City Chicago Baltimore
31 Park PL 186 N. La Salle St. 316 Equitable Bldg.
Denver Kansas City Portland, Ore.
Cent. Say. Bk. Bldg. 712 K. C. Life Bldg. 707 Pittock Blk.
Dallas, Tex.
180S Vi Commerce St
Mentioning The American Physician Insures Prompt, Careful Service
812
Book R«Ti«W8
[Pfciladdpkii
The disease, then, its outbreak, its ravages, compli-
cations and after-effects, so excellently presented in
this small but compact modest work, will prove, we
feel certain, of unusual value and interest.
Tkt Flme* W Venhm in OhMric*
By Irving W. Potter, M.D., F.A.C.S., Obstetrician-
in-chief, Deaconess Hospital and St. Mary's Matern-
ity Hospital; Attending Obstetrician, City Hospital
and Buffalo Homeopathic Hospital. Cloth, 138 pages,
42 plates. C. V. Mosby Company, St. Louis, Mo.
Price $5.00.
Dr. Potter has long advocated the more free em-
ployment of version and has reported over 4,000
cases so delivered. In one series of 1,113 cases of
labor of all types he employed version in 920 cases.
His mortality record, both maternal and fetal, is
exceptionally favorable. It is undoubtedly the case
that, in his own hands, the author of this book has
justified his practice, so far as results are concerned.
Furthermore, he has developed the technic of version
in a way creditable to himself and safe for the com-
petent obstetrician to copy.
But when it comes to the recommendation that
version may with advantage be employed in 90 per
cent, of all cases by other competent obstetricians, and
simply to eliminate the second stage of labor and to
shorten cases, the profession is not apt to follow his
teaching. Undoubtedly it is true that version should
often be employed where the forceps are used, and
as preferable to the latter; but the reviewer, having
done many versions himself and knowing the great
value of the maneuver, would advise caution. The
book is an excellent instance of special pleading, pos-
sesses many good features, but it fails to show valid
reasons for stressing version to the extent that the
author does.
A Mmmd W Climcai Ubtmfry Methods
By Clyde Lottridge Cummer, Ph.B., M.D., Asso-
ciate Professor of Clinical Pathology, School of
Medicine, Western Reserve University. Cloth, 4&
pages, 144 illustrations, eight in color. Lea & Febi-
ger, 706-10 Sansom Street, Philadelphia, Pa. Priee
$5.50.
Dr. Cummer is an experienced teacher who hai
exceptional opportunity to apply clinically all of the
modern laboratory methods of diagnosis, hence he is
in position to prepare a text that is a safe and reli-
able guide for student and practitioner. There is a
minimum of "The Author's Method," which is a
blessed relief, since too many books have this as an
excuse for being, and Dr. Cummer modestly proceeds
to tell clearly just what the reader wants to know,
and having told it quits. The book is creditable a'ike
to author and publisher and can be commended on iti
merits.
@Pil. Cascara Compound— Robins@
g^ MILD, 1 GR— STRONG, 4 GRS. Jg*
5^ It is the failure of the secretory function of the bowel, together 2^
Itw with a poor bile secretion, which, in nine cases out of ten, 'i*mtv
^nw responsible for constipation. #^
^Bp Most cathartics altogether overlook this factor and address %$
©themselves solely to a stimulation of the musculature. Some even^^
inhibit intestinal secretion. The result is a rapid, unsatisfactory^^
e bowel movement, followed by paralytic reaction. f&
_ Pil. Cascara Comp. (Robins) is a rational therapeutic formula, ^5^
mSm which promotes a natural flow of secretions, which is, in turn, the/|A
e^i^ physiologic stimulant of peristalsis. Thus a normal evacuation i*^£
produced, without subsequent inhibition. mfW
^»w Samples and descriptive literature on request ^^
f+P A. H. ROBINS COMPANY Richmond, Virginia fM
You can buy with Confidence — See "Service Guarantee to Readers" on page 830
November, 1922] The American Physician Advertising Service 813
i
i
1
ANNOUNCING
A n«» NON-NARCOTIC Drug
"Roche
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which is both
Hypnotic^ an algesic
AUQNAL which a administered orally in tablet'
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many conditions in which Morphine and other
narcotics have hitherto been the only recourse
Supplies and Literature will be
furnished on request
TheHOfFHAIWlAReCHtCHtMICAlWoftKS
NewYork
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Mentioning The American Physician Insures Prompt, Careful Service
Helpful Pointo
NATURE'S RELIEF
FOR PAIN
ORDINARY HOT APPLICATIONS,
such SB hot water, poultices, etc., while
helpful, act slowly, cool rapidly, are sel-
dom available when needed and hare bat
little penetrative power.
RADIANT HEAT, as Id Sunlight or
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tissues, acts quickly, does not cool, la al-
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LIGHT, Is far superior for bodily appll-
Natnre are reproduced electrically In tb>
tJBeniiQ|it§,
II OUT AND BEAT APPLICATOR
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The Value of Yeast
Noted authorities agree that yeast is rich in "B"
vitamin, and that also the food value of yeast does
not rest alone upon the vitamin present. The pro-
tein of the yeast is itself a very satisfactory type of
protein, so far as the nutrition of mammals is con-
cerned. It is made use of in the tissues of man to
as great an extent as is the protein of milk or
meat, two of our most staple foods.
„VA Pr;omin«it professor of therapeutics writes:
least is more or less of a gastro -intestinal antisep-
tic, increases the movements of the bowels, cleans
a coated tongue, stimulates the production o£ white
corpuscles, and often seems to aid in combating vari-
ous streptococcic and staphylococcic infections.
Hence it is a valuable treatment for septicemia and
for boils and carbuncles.
"Besides the laxative effect of yeast, it has the
ability to change the flora in the intestine, and to
more or less check fermentation. It should be much
more frequently given in illness in which there is
intestinal disturbance, especially if it is associated
with constipation."
You will be interested in the new brochure on
''Yeast Therapy," copy of which will be sent free.
Turn to page 767 and send in the coupon now.
Organotherapy in Diabetes
Unusual attention is being given by the medical
profession these days to the problem of developing an
organotherapy for diabetes. Contrary to an impres-
sion gained from reading some of the articles, this is
not a new subject The recent "discoveries" really
should be called "developments," for a number have
been at work on this very problem these many years.
An interesting development of very considerable
promise was recently announced by Doctor Henry R.
Harrower, who states that he has perfected in his
laboratory in Glendale, California, a pluriglandular
formula directed at the pancreatic deficiency, which is
known to be so important in connection with this
Pan-Secretin Co. (Harrower) is a combination of
the extract of the pancreas (rich in the incretory
cells), secretin, the well-known pancreatic hormone
stimulant, and tonsillar extract. This new product
is worthy of close attention, for it is rendering effi-
cient service in many serious cases of diabetes.
Philo Burt Appliance of Proven Value
The Philo Burt Appliance is designed on correct
anatomical principles. It is not rigid, yet gives the
required support and extension. It is light in weigh'
and comfortable to wear. It is perfectly adjustable
and is made to fit each individual patient. The meas-
urements can be easily taken by any physician and
the company stands right back of the doctor taking
the measurements. A perfect fitting appliance is as-
sured for; should alterations be found necessary they
are cheerfully and promptly made.
The Philo Burt Appliance, while primarily in-
tended for the benefit of cases of spinal deformity,
scoliosis, lordosis and kyphosis, has been used with
similar success in cases of spinal tuberculosis, spinal
irritation, and general neurasthenia arising from pres-
sure upon emerging spinal nerves. Wherever there is
an inflamed, injured, defective or relaxed condition,
the need of support is indicated and results have
proved it to be the proper method of relief or cur*
in such conditions.
(Continued one leaf over)
l buy with Confidence— See "Service Guarantee to Readers"
November, 1922)
The American Physician Advertising Service
815
Catarrh and Gommon Golds
For prevention and treatment use
Catarrh "Cold" Sero-
bacterin Mixed, Typho-
Serobacterin Mixed, and
Pertussis Serobacterin
Mixed are now supplied
InMulford Hypo-Units,
ready for immediate
injection. No assembling ,
no sterilizing, no abutt-
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Insert the needle and
compress the tube.
Foot myectic
toot doluirs*
Catarrh "Cold" Serobaoterin Mixed
in Mnllord Hypo-Unite
FORMULA: A B G D
M. catarrhalls 126 250 500 1000 million
Pnenmooooous* 126 250 600 1000 million
Frtadlander Baa 126 250 600 1000 million
Staphylococcus aureus 126 260 600 1000 million
Staphylococcus albus . 126 260 600 1000 million
Streptococcus** 126 260 600 1000 million
•Tjrpw I, n and UL
•* Hemolytic and non-bemoiytlc, including vtrtdans.
A sensitized bacterial vaccine, prepared
from cultures usually found in respira-
tory organs of patients suffering from
catarrh, colds, etc.
According to laboratory tests, this sero-
bacterin imparts immediately a degree of
passive immunity against pneumococci and
other infecting organisms.
Susceptible patients should receive an im-
munizing treatment of four injections, and
the maximum or "D" injection should be
repeated every ninety days thereafter.
When this routine is followed, relief from
acute respiratory infection usually results.
Physicians desirous of including strains of iufluensa
bacillus should specify "Influenza Serobaoterin
Mixed," which is the same formula with the addition
of the Pfeiffer bacillus. This is the formula which
was so extensively used during the pandemic of 1918
and has given universally good results for more than
ten;
H. K. MULFORD COMPANY, Philadelphia, U. S. A.
Mentioning The American Physician Insures Prompt, Careful Service
n
816
Helpful Points
CPUbdeJpUi
DRIED MILK
PLUS +
DURING the war, a
British Commission,
appointed to investigate
dried milk reported:
<rWhen breast feeding is im-
possible, dried milk is a very
valuable food for infant
feeding. . . .
The physical and chemical
changes produced by the pro-
cess used in the preparation
so alter its character that it
is better borne in the infant's
stomach than ordinary cow's
milk whether raw, cooked or
sterilized. . . • The effect on
nutrition is marked."
NESTLE'S MILK FOOD
is dried milk plus cereals,
malt, and sugar. It is a com-
plete Food, presenting in
digestible form everything
that the infant needs to as-
sure normal growth.
Write Nestle's Food Com-
pany, Nestle Building, New
York, for complimentary
packages.
NESTLE'S
MILK
FOOD
For Babies and Invalids
Correct adjustment with the remedial advice and
methods of practitioners is very necessary in con-
junction with the right kind of support. It very
often happens that a slight readjustment of the static,
skeletal and semi-voluntary muscles and the relief
of intra-articular pressure will produce the utmost
relief. If held in the corrected position by a proper
supporter, the case will continue to improve and the
pathological condition will be overcome. Localized
rest through support or temporary fixation serves a
very valuable purpose and is applicable to a wide
variety of disabilities, sensory or motor.
Many practitioners are of the opinion that no form
of artificial support should be used in any case, bat
the weight of evidence goes to show the absolute
necessity of proper support and fixation in a great
percentage of cases. That this is correct pro-
cedure is manifest if for no other reason than to
enable the practitioner to retain a result accom-
plished through treatment or by proper exercise.
The end results attained through the use of ap-
paratus for relief and benefit in spinal conditions
often indicated that, had proper treatment and sup-
port of the right kind been used, many conditions
might have been cured which after a long period of
neglect have become incurable. The future care in all
such cases is very important and the improvement
depends much upon the right procedure and treat-
ment, with attention looking toward benefit of the
general health.
For descriptive book, interesting literature and plan
of co-operation with the physicians, address: The
Philo Burt Company, 115-23 Odd Fellows' Building,
Jamestown, N. Y.
A Starch-Free Flour for the Diabetic
Every physician realizes the serious nature of
diabetes and that the utmost care must be em-
ployed to see that dietary directions are followed to
the minutest detail. The physician is aided in giv-
ing the best he can to his diabetic patient by em-
ploying Lister's Diabetic Flour. This is strictly
starch- free and makes bread, muffins, pastry, etc,
which will please the patient and at the same time
be strictly on the diet.
Lister's (prepared casein) Diabetic Flour is self-
rising and is put up in convenient form — a month's
supply, 30 boxes, $4.85. You will find that with
its use the distressing features of diabetes will grow
less and less, and your patient will appreciate your
care. For further information, or for supplies, ad-
dress: Lister Bros., Inc., 405 Lexington Avenue, New
York City.
Promote Health and Strength of the Feet
It is a well-known fact that abnormal conditions of
the foot structures are often brought about by shoes
with hard, rigid heels and lacking in flexibility. Free
movement of the muscles is prevented, muscular tone
is lost and sagging of the arch naturally tends to
follow.
O'Sullivan Heels, however, by reason of their elas-
ticity and springiness, assure a greater latitude of
muscular action. The foot muscles thus receive more
exercise, the local circulation is increased and the
foot structures are kept in a nearer normal condi-
tion. The use of O'Sullivan's Heels, therefore, is a
simple but exceedingly effective means of promoting
the health and strength of the feet.
{Continued one leaf over)
You can buy with Confidence — See "Service Guarantee to Readers'* on page 830
November, 1922]
The American Physician Advertising Service
For Respiratory Ailments
Don't forget thin remarkable compound of iodine with calcium. More re-
liable than the tincture for internal ute. Better than the iodides. Not likely
to cause gantritia or acne. Promptly assimilated. Signally effective in bronchitis
and other acute respiratory ailment!. In catarrhal croup. The beet preparation
for goitre patienti. For syphilis. For glandular enlargement*, etc.
Calcidin Trochee. Flavored lozenges, with extract of licorice, for local uae.
Dissolved in the mouth, they afford an iodine-carrying solution with which the
congested parte are continually bathed, with telling effect.
Anesthcsin-Calcidin Troches. These have the same ingredients in addition to
Anesthesin, an analgesic like cocaine, but practically harmless. They quickly
relieve throat irritations, hacking coughs, dysphagia.
Order now for your fall and winter needs; or have your druggist do so
Net Prices
1000 Calcidin, gr. 1, tablets $2.55
1000 Calcidin Troches 4.31
1000 Anesthesin-Calcidin Troches 6.3ft
THE ABBOTT LABORATORIES
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
A Product of Unusual Merit
Lavoris — the original zinc chloride mouth wash —
has unusual merit, as evidenced by the success it
has had during fifteen years of wide usage.
Lavoris is a healing antiseptic, combining with
well-known antiseptics in pleasing form the thera-
peutic properties of zinc chloride. The physician
should not be content to tell his patient to use any
good mouth wash. When he knows of a product
of superior merit he should give his patients the
benefit of his knowledge with specific directions.
If you are not acquainted with Lavoris, a com-
plimentary supply will be sent to you. Then you can
judge for yourself of the merit of this product, which
is finding more and more favor with careful physi-
cians. Address: Lavoris Chemical Co., Minne-
apolis, Minn.
Haa a Merited Place
The physician who prescribes Hydroleine can rely
upon its action as an energy producer, tonic, builder
and blood maker, as well as for its action upon the
respiratory tract. Because Hydroleine is a pleasant,
permanent and potent emulsion of Cod Liver Oil.
Physicians of the older generation learned to de-
pend on Hydroleine, because most of them were firm
believers in the value of cod liver oil, and this was a
dependable and effective preparation. Today cod liver
oil is just as useful in the hands of the physician; and
modern science explains its merit partly on the ground
of its vitamin content.
Sample and literature will be sent to American
Physician readers on request Address: The Century
National Chemical Company, 80 Warren Street, New
York City.
Scientific Basis of Intravenous Therapy
Loeser, in an article entitled, "A New Field for
Pharmacological and Therapeutic Research," K. Y.
M. J., October 19, 1921, states the basic, scientific
principles on which his pharmaceutical work is
founded. He draws attention to the fact that the
therapeutic value and pharmacologic action of certain
remedies are based on the effect upon the colloidal
state of the blood stream and body fluids, which in
turn effect the respiratory and chemical exchange be-
tween the tissue cells of the body. He compares
the effect of remedies introduced to the effect of
bacterial and elementary proteins on the colloidal
state of the blood stream and body fluids.
Loeser, for the first time in medicinal literature,
demonstrates the establishment of scientific facts
underlying the action of certain remedies which obey
the laws recently established in the study of colloids.
Briefly, that remedies of elemental substances act
as electrolytes on the blood, which he points out is
a typical colloid fluid, with the erythrocytes in ins-
pension in the plasma, a hydrophile colloid; and
that the intensity of the activity of these elemental
remedies is based on their valence.
He demonstrates that the monads such as iodides,
are tolerated in large doses; the diads such as cal-
cium are more active; and that the triads, arsenic,
antimony and iron are the most toxic group, and
produce profound changes in the colloidal state of
the blood and tissues.
Complete reprints will be sent to American Phy-
sicians readers on request. Address: "Journal of
Intravenous Therapy," 100 West Twenty-first Street.
New York City.
(Continued one leaf over)
f tftborotorlos Qln
Prompt Worth- While
Results
follow the administration. 0/
Injection Clin
S b-j cli noph o Jp harsinet
This powerful, stable, painless
and effective combination sup-
plies phosphorus, arsenic and
strychnine in a therapeutically
active form.
Indicated in Neurasthenia,
convalescence, nervous depres-
sion, cachexia*, etc.
Supplied in ampoules for in-
tramuscular and subcutaneous
injection.
Wntt for samplci and literature.
E. Fougera &. Company, Inc.
90-92 Beekau Street, N«w T«k, N. T.
erican Agents
;.' Fs/rj^j-.M.^oni
The Obstetrical "Shoe Horn"
Anatomically Correct as
Who
* the
oatal head en-
.gainst
ent 1*
nay be
eadUy deflected
el. Eliminates
f suffering and danger
EQUISETENE IS BETTER
Never snarls: (2) No infection: (3) Many ttai«
tensile strength of hone hair; (4) Not *o stiff as
•ilk-worm But: (51 Not so pliable ae silk; better
than either; (6) Uniformly smooth; (7) Can be
boiled many times; (8) Very economical. Send
SI. 20 for two Urge sample packages, or *5.M
for 250 feet.
HUSTON BROTHERS
Adas American Bid,. CHICAGO
Compter Lints of Physician* Smpplits
You can buy with Confidence — See "Service Guarantee to Readers" on page 830
November, 1922] The Americn Physician Advertising Service 819
NERVES"
When you have a plain case of "nerves" with the patient irritable,
unhappy, over-excited, with nerves all on edge, prescribe
PENTABROMIDES
This is a combination of the five bromides in a palatable form; it is well borne
by the most irritable stomach and is less apt to produce gastric derangement and
bromism than the same quantity of any single bromide when given in larger doses
over a long period.
Pentabromides is of value wherever there is irritation of the nerves, as in hys-
teria, epilepsy, insomnia, or headache of nervous origin, uterine derangements,
dysmenorrhoea, monorrhagia, acute laryngitis, etc.; in fact, in all the conditions in
which the bromides are indicated, its advantages over the ordinary bromides being
that it is better borne by the system, is less apt to produce bromism and is much
more palatable.
Prescribe as "Pentabromides Merrell"
H POUNDED !•*•
ERRELLcoMMmr
CnfcmiMJI.ILS.A.
100 TABLETS FREE
ACTIVE CATHARTICS OR PURGATIVES THAT PRODUCE A WATERY
STOOL DO NOT GIVE GOOD RESULTS IN
Habitual Constipation
as the digestive secretions are carried off and a period of constipation follows until
the secretions again accumulate and the natural process of digestion and assimila-
tion is resumed.
A mild tonic laxative gives the best result and you can obtain this with Cascara
Comp. Tablets (Killgore's), as they stimulate the secretions, give an easy natural
movement without griping and do not become ineffective by continued use.
Dose: One or two tablets at night.
100 Tablets and Formula Sent to Physicians on Request
CHARLES KILLGORE
Manufacturing Chemist Established 1874
55 WEST THIRD ST., COR. WEST BROADWAY NEW YORK
Mentioning The American Physician Insures Prompt, Careful Service
820
Hdpful Points
[Philsddpfaa
Atophan Gives the Patient Relief
The patient, of course, wants relief, first, last and
all the time. And in no class of conditions is this
more so than in the painful cases of rheumatism,
gout, neuralgia, neuritis, sciatica, lumbago and mi-
graine.
It is indeed fortunate that the physician has at
hand a therapeutic remedy, Atophan, that does give
relief in these cases. To the patient the relief is the
patent fact. The physician, however, will realize
that Atophan accomplishes a definite, scientifically
and clinically established, physiologic stimulation of
the uric acid excretion. Performed innocuously and
controllable to a nicety by dosage and by urine and
blood tests.
Information, literature and ample trial quantity
will be sent to American Physician readers. Address :
Sobering & Glatz, Inc., 150 Maiden Lane, New York.
American Synthetics
The Fordney-McCumber Tariff Bill, recently passed
by Congress, unfortunately does not provide suffi-
cient protection for American-made medicinal chemi-
cals, nor does it compensate for the extensive re-
search work which has been done by American
chemists.
The rates on medicinal chemicals were passed over
the protest of the medical profession. It is now pos-
sible for the physicians to follow up their protest by
using only American-made synthetics, and referring
to them at all times by their American names, as
suggested by the Council on Pharmacy and Chem-
istry of the American Medical Association.
Among the important American-made medicinals,
which should receive the support of all American
doctors, are Arsphenamine, Barbital, Cinchophen and
Procaine. Literature on these products may be ob-
tained by writing to The Abbott Laboratories,
Chicago.
Salvarols
For the convenience of the physician who is dis-
inclined to employ arsphenamine intravenously, The
Drug Products Co., Inc., supplies this agent in sup-
pository form under the ethical trade name of
Salvarols. Numerous medical authorities have called
attention to the safety, convenience and efficiency of
the rectal route for the administration of arsphena-
mine. Salvarols, which are rectal suppositories, con-
tain an adequate dose of arsphenamine which has
been properly made under the control of the Chemical
Foundation and the U. S. Public Health Service.
The 606 is incorporated in a specially prepared base,
which assures its being absorbed promptly by the
mucous mebrane without any irritation. Since the
introduction of Salvarols, the use of this form of
medicament has been steadily increasing and the
clinical evidence which has accumulated proves un-
mistakably that in presenting this pharmaceutical
specialty the D. P. Co has met a long-felt want.
Salvarols is supplied in two sizes, for use in adults
and children. Interesting literature, case reports,
etc., will be sent free to any physician on request
Address: The Drug Products Co., Inc., 150 Meadow
Street, Long Island City, N. Y.
(Continued one leaf over)
>*^*vs^e->*^
The Management of an Infant's Diet
Malnutrition,
Marasmus or Atrophy
Mellin's Food
4 level tablespoonfuls
Skimmed Milk
8 fluidounces .
Water
8 fluidounces .
Analysis :
Fat
.49
Protein
2.28
Carbohydrates
6.59
Salts
.58
Water
90.06
The principal carbohydrate in Mellin's Food is maltose, which seems to be
particularly well adapted in the feeding of poorly nourished infanta. Marked benefit
may be expected by beginning with the above formula and gradually increasing the
Mellin's Food until a gain in weight is observed. Relatively large amounts of Mellin's
Food may be given, as maltose is immediately available nutrition. The limit of
assimilation for maltose is much higher than other sugars, and the reason for increas-
ing this energy-giving carbohydrate is the minimum amount of fat in the diet made
necessary from the well-known inability of marasmic infants to digest enough fat to
satisfy their nutritive needs.
;e[-^^>J^.^J^
Mellin's Food Company, Boston, Mass.
100.00
$*i-^j*i->*»iv
You can buy with Confidence — See "Service Guarantee to Readers" on page 830
November, 1922]
The America Physician Advertising Servio
Surprised Her Doctor with
Wonderful Improvement
We off.
himself
t to every physician and practitioner, ample opportunity to prove to
and his patient, the superiority of the Philo Burt Spinal Appliance
IT is because the Philo Burt Spinal Appliance is built upon sound, cor-
rect and advanced scientific, physiological principles that it is such a
great success in the hands of conscientious physicians. Here is a
strong proof from a doctor who, despite his knowledge of the many
remarkable benefits obtained by use of our appliance, was astonished at
the results attained in a fitting he made himself.
"About
s for
PHILO
i you for your help
the caw. 1 am per-
improvement. The round shoulders appliances." '""' ™
Each Order is Accepted Subject to a 30 Day Trial
It has been our privilege to Physician's Portfolio without charge and explain
lysidans, surgeon!, ortho- appliance for any caw and send it on 30 days' trial.
Ln.0-. ?v™™£™» "3,. TTnW w« guarantee a perfect fit and refund the money
oners throughout tne united ., . . . , . . j. ..=_,, w.
ier observation and will send him our comidtr it • privilege Is »nd von our HtermMt*.
BURT MANUFACTURING CO., 115-23 Odd Fellow* Bid*., JAMESTOWN, N. Y.
A Danger Signal
There remains no question as to the wisdom of employing suitable means to
reduce hypertension and counteract or prevent it.
It is safe to regard high blood pressure always as a danger signal. It is wise
always to treat it intelligently and safely by means of
PULVOIDS No. 373 NATRIUM CO.
which is essentially the famous formula of Sir Lauder Brunton, modified and
proven by Dr. M, C. Thrush.
PULVOIDS NO. 373 NATRIUM CO. contain Sodium Nitrite, Potassium
Nitrate, Sodium Bicarbonate, Nitroglycerin and" Crataegus Oxycantha. Sugar
coated white or green with a special coating to disintegrate in the intestinal
tract, thus avoiding gastric disturbance.
A safe, non-toxic, effective combination which is prompt in action and pro-
longed in effect.
A clinical test will demonstrate its superiority and service.
Bottles of 1000 Pulvoids $5.00, direct to Physicians and Hospitals only,
mailed free when cash accompanies order. Trade bottles of 100s, per
dozen $9.00.
Literature, case reports, etc., free on request
If tou diipenie. auk for complete price list, including Eadocrim Capiulen and Salvarola
(606 Suppositoriei)
THE DRUG PRODUCTS CO., Inc.
Pharmaceutical Manufacturers
150 MEADOW STREET LONG ISLAND CITY. N. Y.
Mentioning The Am
i Physician Insures Prompt, Careful Service
820
Helpful Points
[Phikwklpka
Atophan Gives the Patient Relief
The patient, of course, wants relief, first, last and
all the time. And in no class of conditions is this
more so than in the painful cases of rheumatism,
gout, neuralgia, neuritis, sciatica, lumbago and mi-
graine.
It is indeed fortunate that the physician has at
hand a therapeutic remedy, Atophan, that does give
relief in these cases. To the patient the relief is the
patent fact. The physician, however, will realize
that Atophan accomplishes a definite, scientifically
and clinically established, physiologic stimulation of
the uric acid excretion. Performed innocuously and
controllable to a nicety by dosage and by urine and
blood tests.
Information, literature and ample trial quantity
will be sent to American Physician readers. Address :
Schering & Glatz, Inc., 150 Maiden Lane, New York.
American Synthetics
The Fordney-McCumber Tariff Bill, recently passed
by Congress, unfortunately does not provide suffi-
cient protection for American -made medicinal chemi-
cals, nor does it compensate for the extensive re-
search work which has been done by American
chemists.
The rates on medicinal chemicals were passed over
the protest of the medical profession. It is now pos-
sible for the physicians to follow up their protest by
using only American-made synthetics, and referring
to them at all times by their American names, as
suggested by the Council on Pharmacy and Chem-
istry of the American Medical Association.
Among the important American-made medicinals,
which should receive the support of all American
doctors, are Arsphenamine, Barbital, Cinchophen and
Procaine. Literature on these products may be ob-
tained by writing to The Abbott Laboratories,
Chicago.
Salvarols
For the convenience of the physician who is dis-
inclined to employ arsphenamine intravenously, The
Drug Products Co., Inc., supplies this agent in sup-
pository form under the ethical trade name of
Salvarols. Numerous medical authorities have called
attention to the safety, convenience and efficiency of
the rectal route for the administration of arsphena-
mine. Salvarols, which are rectal suppositories, con-
tain an adequate dose of arsphenamine which has
been properly made under the control of the Chemical
Foundation and the U. S. Public Health Service.
The 606 is incorporated in a specially prepared base,
which assures its being absorbed promptly by the
mucous mebrane without any irritation. Since the
introduction of Salvarols, the use of this form of
medicament has been steadily increasing and the
clinical evidence which has accumulated proves un-
mistakably that in presenting this pharmaceutical
specialty the D. P. Co has met a long-felt want
Salvarols is supplied in two sizes, for use in adults
and children. Interesting literature, case reports,
etc., will be sent free to any physician on request
Address: The Drug Products Co., Inc., 150 Meadow
Street, Long Island City, N. Y.
(Continued one leaf over)
:~P<*~r*<*:->*=Ci
The Management of an Infant's Diet
Malnutrition,
Marasmus or Atrophy
Mellin's Food
4 level tablespoonfuls
Skimmed Milk
8 fluidounces .
Water
8 fluidounces .
Analysis :
Fat
.49
Protein
2.28
Carbohydrates
6.59
Salts
.58
Water
90.06
100.00
The principal carbohydrate in Mellin's Food is maltose, which seems to be
particularly well adapted in the feeding of poorly nourished infants. Marked benefit
may be expected by beginning with the above formula and gradually increasing the
Mellin's Food until a gain in weight is observed. Relatively large amounts of Mellin's
Food may be given, as maltose is immediately available nutrition. The limit of
assimilation for maltose is much higher than other sugars, and the reason for increas-
ing this energy-giving carbohydrate is the minimum amount of fat in the diet made
necessary from the well-known inability of marasmic infants to digest enough fat to
satisfy their nutritive needs.
-:^4frvis*fr*-*s£:
Mellin's Food Company, Boston, Mass.
You can buy with Confidence — See "Service Guarantee to Readers" on page 830
Hoiembet. 1922] The Americn Physician Advertising Stroke
Surprised Her Doctor with
Wonderful Improvement
We offer to every physician end practitioner, ample opportunity to prove to
fainiaelf and hU patient, the superiority of the Philo Burt Spinal Appliance
IT is because the Philo Burt Spinal Appliance is built upon sound, cor-
rect and advanced scientific, physiological principles that it is such a
great success in the hands of conscientious physicians. Here is a
. strong proof from a doctor who, despite his knowledge of the many
k remarkable benefits obtained by use of our appliance, was astonished at
I the results attained in a fitting he made himself.
I of your appliances for Connie B. I straighter. 'and her health so very much
■ had not seen her for six months when better. 1 thank you for your help
I 1 was very much surprised at her fectly satisfied with your' method! and
f improvement. The round thoulders appliances."
Each Order ii Accepted Subject to a 30 Day Trial
It has been our privilege to Physician's Portfolio without charge and explain
co-operate with thousands of to him our plan of co-operation. We will make an
-_- , physicians, surgeons, ortho- appliance for any case and send it on 30 daya" tri*l.
Parmlti Absolut* pedic specialists and practi- ... ___ „, „ , „ fi, , „i„„j tH „,„„,.
Fr«dom of Action tioner. throughout the Cniled * \$g **f fl^« **£*££ wSLSUT^Ifc
countries. We will gUdfy' rrfer^any phy«c^" hove followed this plan for more than 20 year,
some of his contemporaries We are anxious to co- *"& have treated successfully oyer 45,000 cases of
operate with any focal physician who has _ bad a spinal curvature, diseases and weaknesses. We will
PHILO BURT MANUFACTURING CO., 115-23 Odd Fellows Bid*., JAMESTOWN, N. Y.
A Danger Signal
There remains no question as to the wisdom of employing suitable means to
reduce hypertension and counteract or prevent it.
It is safe to regard high blood pressure always as a danger signal. It is wise
always to treat it intelligently and safely by means of
PULVOIDS No. 373 NATRIUM CO.
which is essentially the famous formula of Sir Lauder Brunt on, modified and
proven by Dr. M. C. Thrush.
PULVOIDS NO. 373 NATRIUM CO. contain Sodium Nitrite, Potassium
Nitrate, Sodium Bicarbonate, Nitroglycerin and" Crataegus Oxycantha. Sugar
coated white or green with a special coating to disintegrate in the intestinal
tract, thus avoiding gastric disturbance.
A safe, non-toxic, effective combination which is prompt in action and pro-
longed in effect.
A clinical test will demonstrate its superiority and service.
Bottles of 1000 Pulvoids $5.00, direct to Physicians and Hospitals only,
mailed free when cash accompanies order. Trade bottles of 1 00s, pei
dozen $9.00.
Literature, cate reports, etc., free on request
If von disiiRniR, aak for complete price list, including Endocrin Capsules and Salvaruls
(606 Suppositories)
THE DRUG PRODUCTS CO., Inc.
Pharmaceutical Manufacturer*
150 MEADOW STREET LONG ISLAND CITY, N. Y.
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
To Relieve Pain
The patient usually wants relief of pain; that is all
that matters to him, and it is fortunate that the
physician has at hand a means of relieving pain —
nature's own way. Heat is our best first aid in pain
and sunlight our best stimulant in convalescence.
Radiant Heat produced by the Thermolite Light
and Heat Applicator furnishes this power in the most
" " ; Heat
without unpleasant sequelae; it may be given intraven-
ously without incidental injury to the vessel walls.
The reader is referred to
manufacturers in our advertising pages.
most available and effective manner. Radial
and Light penetrates, as the ordinary appli
heat have not the power to.
You will find this applicator — at a moderate cosi
— will have many uses in your practice. Your pa-
tients will appreciate your having the means at
hand to relieve pain in the natural and effective way
For interesting and instructive literature, address
H. G. McFaddin & Co., 34 Warren Street, New
York.
A Dependable Antiluetic
In considering a new remedy, physicians nowa-
days very pertinently inquire as to the clinical data
acquired before the product is offered to the pro-
fession at large.
We understand that proposed additions to the
specialty list of Parke, Davis & Co. are put through
a rigid preliminary clinical test, and that it was only
after a trial lasting eighteen months, during which
time upwards of ten thousand doses were adminis-
tered to no less than four hundred patients, that
Mercurosal, the new synthetic mercurial compound,
was made available by Parke, Davis & Company to
the profession in general.
The distinction claimed for this preparation is
that it enables the physician to inject large doses
of mercury, either intravenously or intramuscularly
A Complete Food
The British commiss.on appointed during the war
to investigate dried milk, reported:
"When breast-feeding is impossible, dried milk is a
very valuable food for infant feeding. The physical
and chemical changes produced by the process used
in the preparation so alter its character that it is
better borne in the infant's stomach than ordinary
cow's milk, whether raw, cooked or sterilized. The
effect on nutrition is marked."
Nestle's Milk Food is dried milk plus cereals, resit
and sugar. It is a complete food, presenting in digest-
ible form everything that the infant needs to assure
normal growth. Complimentary packages will be
sent to American Physician readers on request Ad-
dress: Nestle's Food Company, Nestle Building,
New York.
Sherman'H Polyvalent Vaccines
Recovery from infectious disease is due to the de-
velopment of immune substances or anti-bodies, as
they are frequently called, by the defense mechanism
of the tissue cells. Therefore, the main factor in
preventing bacterial invasion or the development of
infectious disease consists in having tissue cells ade-
quately trained for immu no-pro duct ion. Sherman's
Vaccines are adequate immuno -producers.
Sherman's Vaccines are recognized antigens for de-
stroying or digesting disease germs with which they
{Continued <me leaf over)
Jr
%,
Glycocholate. Sodium Tiuiocholuc with Can
Siffida ind Phenol phthilkn
TAUROCOL COMPOUND TABLETS
THE PAUL PLESSNER CO.
Operative
Surgery
Special course in general
surgery, operative
technique and gynecologic
surgery given to physicians
of both sexes. Enrollment
limited to THREE.
First iuiunbhip-No cadaver or dtg-wwfc
For particular! address,
DR. MAX THOREK
AMERICAN HOSPITAL
846-856 Irvinuj Park Boulevard, CHICAGO
You can buy with Confidence— See "Service Guarantee to Readers" on page 830
The American Phytkhn Advertising Stroke
"Sedatole" — "Linctus Comp" — "Hyotole"
three admirable demulcent expectorants of which
we are now shipping large quantities to the drug-
trade in anticipation of your urgent requirements
this fall and winter when, owing to the shortage of
coal, "flu," pneumonia, bronchitis, etc., are liable to
occur in your practice, perhaps epidemically. If
you send in for samples please mention your Fed.
Lie. No. — this only for our records. None needed ,
when you prescribe them; just keep records.
Ethical
S .
Conscientious Chemists mice 60
Expectorants sharp * D"1""*-"!"—
Mentioning The American Physician Insures Prompt, Careful Service
Helpful PoinU
No foreign substance
LOCAL ANAESTHETIC
You can't make
equal to Waite'i Antiseptic »
Local Anaesthetic because you „(
have limited facilities So why '
try, when you can get Waile "■
ready-to-use anaesthetic much
cheaper when you figure the
value of your time.
Sold in bottles and ampuls,
The ampules are hermetically
sealed — won't deteriorate — will
keep Indefinitely. Are ready to
Antidolor Mfg. Company
32 Main St.. Sprin grille, N. Y. """^Jl,
Send for Free Sample
Let your own experi-
ence prove the supe-
riority of Dr. R. B.
Waite'i Local Anaes-
thetic. Send iii the
coupon with your pro-
fessional care! and we
will s
11 fre.
Caeek, Burn ana Hall Thi. Coupon
ANTIDOLOR MFG. CO.,
Springville, Erie County, N. Y., U. S. A,
Attached End my professional card. Please »
me free sample box of Waite'i Antiseptic I.o
It was through the scientific study of ii
and the experience gained in producing bacterial vac-
cines that the Sherman Laboratories have found t hit
heat sterilization decidedly impairs the efficacy of
bacterial vaccines. A method of chemical sterilisa-
tion has been developed which insures for Sherman'?.
Vaccines a uniform content of unchanged bacterial
protoplasm "so essential for adequate immune-pro-
duction. For interesting literature address: Tht
Laboratories of G. H. Sherman, M.D., Detroit, Mich.
Clinical Results Prove It Effective
Pluto Water has been successfully employed and
endorsed by many able clinicians as a uric acid sol-
vent and eliminating agent in renal disorders. It
is prompt, safe and efficient and is well retained by
the most delicate stomach.
In cases of habitual constipation, gout and rheu-
matism, the clinical evidence proves the most satis-
factory results are to be obtained by prescribing
Pluto Water. Many practitioners direct convales-
cent patients to the spring for rest and complete
treatment. Pluto Water is bottled from the famous
spring by the French Lick Springs Hotel Co., French
Lick, Ind.
A Normal Element of the Diet
The entrance of bran into the national diet is directly
traceable to the modern methods of living, which Dr.
Harvey W. Wiley accredits to "the exigencies of
modern business and recreation." Dr. Wiley de-
plores the prevalence of careless habits in cleansing
the human system and recommends bran as one of
th' food adjuncts which should be used at home to
correct the evil. "Bran is a normal constituent oi
cereals," he states. "It carries particularly one oi
the health factors, or vitamines, namely, the one
soluble in water. It is particularly rich in minerals
which are normal and necessary. Bran, therefore,
(ends to restore the natural functions of Ihe intes-
tines, which have become impaired by reason of
a too concentrated diet."
Dr. Wiley does not stand alone in thus recommend-
ing bran; more and more physicians generally are
coming to realize its value as a part of the every-
day diet, and are recommending its use.
Kelloee's Bran is the product generally used ant)
recommended by physicians because of its purity.
cleanliness and its distinctive savory taste — it is not
only easy to take, but delightful. A large package
of Kellogg's Bran will be sent complimentary to
American Physician readers. Address: Kellogg
Toasted Corn Flakes Co.. Battle Creek, Mich.
Hormotone in Menstrual Disorder
A large proportion of the patients treated in a
physician's practice are women suffering with some
derangement of menstrual or generative function.
These disorders are due in a large measure to dimin-
ished or disturbed function of the glands of internal
secretion. Owing to the reciprocal relationship that
exists between these glands, a functional disorder of
them is, in its last analysis, always a pluriglandular
disturbance — never a monoglandular malady.
It is now recognized that pluriglandular combina-
tions give better results than single gland prodncts-
(Continued one leaf over)
t buy with Confidence — See "Service Guarantee to Readers"
The Ameriat Physician Adcertuing Service
MORPHINE
Treated by the "Quayle 3fethocL"
A lafe and easy way. Results guaranteed.
Tr— imm it pi i nli— and ■apaowiw, wdur dan
abo furailh • Horn* Tnmtmcwl forP^ickn. ID
DR. QUAYLB SANITARIUM
a>m H. Ciuylt, M.D., Medial Dinaar
Dcpt. 505 Madnon, Ohio
« STORM «
Binder and Abdominal Supporter
For Men, Women and Children
Far Ptoais, Hernia. Obeiity, Pregnancy,
Relaxed Sacro- Iliac Articulation*, High
and Low Operation!, etc
A>kf<*36 page De*crlplle» Folder
{Catherine L. Storm, M. D.
Or**-**, rahnta. Smh Omm *W Ma("
1701 Diamond St. Philadelphia, P«.
To ALLEVIATE PAIN, to PROMOTE DIURESIS
and to PROTECT die membrane of the urethra, especially
THE POSTERIOR PORTION- -these are the important
object* of the treatment of acute cases of Gonorrhea.
The entire urinary tract should be influenced by means
•f proper internal medication. Local injections alone win
not be sufficient
This it the rationale of GONOSAN.
RIEDEL ft CO., Inc.
104-114 South Fourth St. Brooklyn, N. T.
LISTERS DIABETIC FLOUR
I
Strictly Starch-free. Produces Bread,
Muffins. Pastry that makes the
distressingfeatures
Litter, prepMed cuem Diabetic Flow — tell ruing. A month'. Ripply of 30 boxes $4.85
LISTER BROS. Inc., 405 Islington Avenge. New York City
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
A Stand-By in
Uterine Troubles
VIBURNO
(BEACH)
The best evidence of this is the
repeat orders received from physi-
cians and druggists.
Nervine-Tonic and Anticongeat-
ive, with calmative and corrective
action on the bladder. Employed
with much satisfaction in ovarian
congestion and congestive dysmenor-
rhea; weak pregnancy and deficient
lactation; menopause and its phe-
nomena, including hallucinations, hot
flushes, etc.; nervous and menstrual
derangements after "flu," and the
troubles of adolescent girl*. Sterility
often responds after 2 or 3 bottles if
no lesion exists.
i, VIBURNO
inctilutod) LU.
before auaU.
Put up in 11 oa. bottlM
Sample mid Formula on Rtautit
THE VIBURNO COMPANY
116 Matdea Lane, New York
J Sal Hepatica
THE
STANDARD SALINE
LAXATIVE
Bristol-Myers Co.
NEW YORK
Clinical results emphasize this. Hormotonc is usually
effective in these cases. Where there is a tendency
toward high blood pressure use Hormotone without
Post-Pituitary.
Interesting literature will be sent on request Ad-
dress: G. W. Carnrick Co., 419 Canal Street, Ne»
York.
A Beneficial Spray and Gargle
The stinging pain and distress that attend the con-
gestion of acute nasal colds can be promptly re-
lieved by spraying the nasal passages every boor
or so with a solution of Pond's Extract — one or tiro
tablespoonsful to a half glass of warm water. And
used quite hot, this is also an excellent gargle for
tonsillitis and sore throat.
Yeastone for Medicinal Use
Yeastone offers the purified active principles and vita-
mines of yeast, and is reliable, pleasant to take and
keeps well.
Sample and literature will be sent to American Phy-
sician readers on request. Address: Merck & Co, 45
Park Place, New York.
Woodlawn
Maternity Home
A strictly private and ethical Bow ~
for unmarried girls «td women dor — _ ,
nancy and confinement, with beat — aifl
ore, nursing and protection. A hoot* food
for the infant by adoption — • -
'ended. Piiees n
SMFFITn'S COMPOUND MIXTURE
of Guaiae, Stillingia, etc.
A Powerful Alterative— Competed of Gnaiac,
Stilling*. Prickly Ash, Turkey Com, Colchicine!.
Black Cohosh, SanapaHUa. Salicylates of the Alka-
lies, Iodide of Potassa and other well known reme-
dies, combined in such a manner that it ii tolerated
by all patient! suffering from Rheumatism, Gout,
Lumbago, Neuralgia, Sciatica, etc.
Prescribe it for "That Stubborn Caao"
To Physicians only — we will upon request, send a
regular eight ounce botUe ($1.25 size), for trial,
upon receipt of 25 cents for express charges.
Griffith's Rheumatic Remedy Compu*
Newburgh, New York
\
Pond's Extract- --
Few remedies are so dependably use
the acute diicomfort and pain of Tom
Extract, lied as a gargle every hout
fnl to ■ half glass of hot water— it* cfi
Tonsillitis
Si, u PonH'm
. .. __.. (lata ol
id gratifying.
POND'S EXTRACT CO., New Yoaa
I
l buy with Confidence — See "Service Guarantee to Readers"
E
The American Ph&ium AdvaHting Service
VERY DAY doctors are advising a rest, a trip to a sanitarium, a visit to
'a specialist, an operation — anything to get rid of their old, stubborn cases of
Prostatic Disease and Impotence
Maybe you are doing, or ire about to do thil very thing. You arc losing possibilities of dollars and prestige,
to iot nothing of the satisfaction of having won a, hard fight.
Too many of these cases are passed up by good doctor!, only to fall into the bandi of unscrupulous men who
offer nothing but promise* and frequently give less.
YOU CAN GET RESULTS
in many of tbese eases. If you will try SUPPOS. PROSTANS thoroughly in one or two cases you will surely
convince yourself and will thereafter kitp tht buswtsi yon'vt btm turning sway.
There is nothing secret about Suppci. Proitatu — formula with each box.
If after a fair clinical teat you feel that the results do not more than meet all your expectations, we hereby
agree to refund your money upon request. This offer place* the burden of proof upon us it our own expense.
Remember, Doctor, that j>our immediate order means a clear saving of |4 to you. It seems a duty to
your patients to mail this before other nutters cause you to lay it aside, and save that much time for other
thi ngs— tomorrow.
Pill out the coupon now. Sincerely,
REGENT DRUG COMPANY
Thii Coupon Miant Sncetti ant Monty Savtt ei Will, fill It out. Stnd Today.
REGENT DRUG COMPANY. The Burd™ of Prool Rests Upset Us.
3152 Woodward A*<)., Detroit, Mick.
I enclose $5.00, send me six boxes of Name
Suppo*. Proitan* (worth $9.00) also
the above book and "Successful Proita-
tic Therapy" — tree. AddreSS—~~
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
Remits Are What Count
Worldwide clinical results extending over
thirty years past should be conclusive evi-
dence to the most skeptical, that a palatable
combination of the alkaloid -amino acid prin-
ciples of pure Cod Liver Oil with a Creo-
sote rich in guaiacol, such as represented in
Ch&poteaut's
MORRHUOL CREOSOTE
(Captulet of t mi*. Atorrkuol and I mi*. CrMosoU)
is the only practical way to confirm the
favorable results obtained from the use of
these well known therapeutic agents in the
routine treatment of i
T. B. — Influenza and Branchial Catarrh
In all cases where Creosote is contra-
indicated :
MORRHUOL PLAIN
tfeptulu at 1 mi*. Morrhatl Chap ettt.t)
exerts its alterative tonic and stimulant
action alone upon metabolism by virtue of
its constituents and will be found of great
service in: — Rickets, Scrofulosia and simi-
lar "deficiency diseases."
DR. PH. CHAPELLE
Pun New York
E. Fniitn & Co., Inc. Lrmnw, Lindtad
U. 3. Agf , N.w Yorfc Canadian AgtS« Mom
, 11th to Nov. Z3u>, 1922
These Advertising Pages are
A Constructive Market
A C MlhUI, T-OmDmtWm Cimidmtm mdmtm
Our Advertising Standards
Advertisements must give honest service to mi
readers and their patients is the basic principle for the*
standards and for the conduct of The Amiucai
Physician's advertising pages.
Our attitude in applying these standards is not one
of narrow technicality but of practical service.
Advertisements of the following classes are *1
acceptable for the pages of The American Physiose:
Fraudulent pharmaceuticals; those making dishonest
Pharmaceuticals charging excessive price; price sot
warranted by content and by trade conditions.
Pharmaceuticals and other mixtures for internal ns*
and containing narcotics or other habit- inducing drup
in quantities sufficient to promote their improper repel*
tiou on prescription (chloral-bearing proprietaries, etc).
Potent pharmaceuticals which justly merit prefcs-
sional disapproval because of their lay advertising or
manifestly unethical exploitation.
Financial advertisements that claim returns not com-
patible with conservative investment Only cousin*
e advertised.
Further
Advertising copy is subject to revision by the editornl
staff.
The American Physician agrees heartily with tne
principles of the Council on Pharmacy and Chemistry
of the American Medical Association and we "d"*
from our advertising pages such pharmaceutical prod-
ucts as they have definitely shown to be unworthy «
professional confidence and the manufacturers of ww*
have not removed the cause of objection; but we ■ *
not accept such findings as are based on academic dan
without due recognition of general clinical experience.
Concerning formula. The American Physics** *
urging pharmaceutical manufacturers to give full thera-
peutic data regarding formt»la\ stating quantitatntti
active medicinal content, in order that physicians n«F
intelligently prescribe. We do not accept advertising «
secret pharmaceuticals.
Bui We do not Decline
Advertising of original drugs, compoonds or P"?>ai*riomi«>
tated in current edition* of the U. S. Phsrmacoponn or «•*■■'
Formulary (except habit-inducing preparations ;; new I"™
tbst aeem to b* honest «nd valuable, lint which ham ^TZ
reported upon by the Council on Pharmacy and ChOBuOT. «J
similar products whose manofarturers hare not yet snbanKtJ ■»
same to them for approval or rejection. We use oar WW
men! in these cases, but will always consider proper eaarf"
Preparations containing a limited 1
0« W o
imber o
You can buy with Confidence— See "Service Guarantee to Readers" on page 830
The American Phyttcian Adieertuing Service
A Logical Sequence of Events:
THE Premises: Infection, Inflammation,
Swelling, Fever, Pain.
THE Argument:
The Conclusion: Result, Relief from
Pain, Reduction of Swelling and Fever. Resolution
of Inflammation.
Read the Formula
Pneumo-Phthysine Chemical Co. Chicago
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
Advise Its Use
Marvel Whirling Spray
MARVEL COMPANY
25 W. 45th StrMt N.w York
Onr Advertising Sfaadirdi
ICoMinntd mn from ("lading p*gt]
lure and in iuch form ■■ but parallel
qualified physician who i> aeeking in ll
Product! composed of rain
doaege, provided tbe>e drug* b
uoda of pbviiciana encem
to both phybiciana and Uyrcie
men!; honeatlv edvertiicd mi
food products, etc
Service Guarantee to Readers
IF YOU HAVE ANY UNSATISFACTORY
DEAUNG WITH AN ADVERTISER IS THE
AMERICAN PHYSICIAN, WRITE US THE
PARTICULARS AT ONCE.
WE WILL IMMEDIATELY TAKE THE MAT-
TER UP WITH THE ADVERTISER AND SEE
THAT THE ADVERTISER EITHER HAKES
GOOD, OR HIS ADVERTISEMENT IS ELIMI-
NATED FROM THE AMERICAN PHYSICIAN'S
PAGES.
Neosalvarsan
le-Metr)
HA
is unsurpassed in reliability,
trypanocidal efficiency and
ease of administration.
I Neosalvarsan is manu-
factured by the process
2J used in preparing the orig-
inal Ehrlich product and
offers the physician the
ideal means for treating
the luetic.
IffMarrz iaborjwoiues u
Oaf-7uWi/y-7u»n Hudson Stmt , N-K> %»*.
""THE older member* of
1 the Medical Profession
have found
Pluto Water
excellent for the counter-
action of those drugs
which suppress secretions
and in prescribing this
valuable water in small
doses the action is to flush
the intestinal canal and
stimulate the liver to re-
move from the ducts the
accumulated secretions.
Many practitioners direct
convalescent patients to
the spring for rest and
complete treatment
French Lick Springs Hotel Co.
French Lick, Ind.
i buy with confidence — See "'Service Guarantee to Readers" top of this page-
The American Physician Advertising Sctuic.
Mentioning The American Physician Insures Prompt, Careful Service
December
THI
1922
i iiiuoiy juupuiuuit-c ui uic vicucrai i ujsitioii
ANNUAL ANNOUNCEMENTS AND SERVICE PROSPECTUS FOR 1923
The Service of the Genera/ Phytician Cannot fie Adequately 'Performed by Any Other Agentp.
The Bed Health IntmiU of the People EmphaUcolfy •Demand Recognition of ihil
Fundamental Fact. It b High Time to Fight for thtt Worthy Caiae.
(pmge,tW4,S,$*7)
Surgeons, Hospitals and Teachers
AN INSPIRING PAPER; A FITTING CLIMAX TO DR. FORBES' NOTABLE SERIES OF CLINKS, (page 863)
The Etiology of the
Symptom Complex Called Asthma
IS ASTHMA A DISEASE OR A SYMPTOM f (page 857)
Visceral Prolapse Surgically Considered
EXTERNAL MECHANICAL SUPPORTS SHOULD ALWAYS BE GIVEN A
LONC TRIAL BEFORE SURGICAL MEASURES, (page 859)
Early Diagnosis of Tuberculosis in Children
THE VITAL ESSENTIALS IN A VERY BRIEF. "PRACTICAL PAPER
(page 583)
Full Content* on Page 836
(2.00 The Year "Most Widely Circulated Medical Monthly " 50c The Copy
I 42q ^atnut St, PhiUitelptil*, U. S. A
A Coiufrucfoc Market for Buyer and Seller
Rheumatism
Gout
Neuralgia
Neuritis
Sciatica
Lumbago
Migraine
"Twice gives he, who
gives promptly"
says a Latin proverb. The remarkably
prompt pain and inflammation relief be-
stowed by ATOPHAN, ia truly such a two-
fold gift.
What's more, it's rational, safe and reliable
relief.
Genuine ATOPHAN ia manufactured
at our Bloomfield. N. J., plant by a
special procen, precluding the poa-
i> lii lily of even tracea of irritating
empyreumatjc admixtures.
Ccuiplimeiitarf Trial Pac^af* and Information from
Schering & Glatz, Inc.
150 Maiden Lane NEW YORK
REDUCED PRICES
NEOD1ARSENOL
0.6 Gnn. Amp..
SODIUM D1ARSENOL
Orders for 50 ampoules — 10% discount.
Ihii date ■ Terr «ub,
Dade. They will no*
United Statea Public Health Service.
Diiraenol brand product* are Dow unexcelled for lolubOi
power. All are toted at ilandardl »ery much higher than Gove
terted and paued by the U. S. P. H. S. before being ihipped
a and therapeutic
ch lot ia offiiaally
DIARSENOL COMPANY, Inc.
ATLANTA, GA. BUFFALO, N. Y. BOSTON, MASS.
Fonyth Bid*. Ellicott Square 53 State St.
You can buy with Confidence — See "Service Guarantee to Readers" on page 906
December, 1922]
The American Physician Advertising Service
835
Acute Respiratory Diseases offer
an excellent opportunity to dem-
onstrate the value of Therapeutic
Immunization with Bacterial
V
accines
DATA FURNISHED ON REQUEST
Bacteriological Laboratories of
G. H. SHERMAN, M.D.
DETROIT
The combination of tonics and stimulants ex-
plains the clinical results obtained in the
treatment of nervous disorders by the use of
FELLOWS' COMPOUND SYRUP
OF HYPOPHOSPHITES
"A true stabilizer of shaken nerves?'
It contains the "mineral foods", Sodium, Potassium, Calcium, Manganese,
Iron and Phosphorous, and the stimulating agents, Quinine and Strychnine.
Samples and Literature sent upon request.
FELLOWS MEDICAL MANUFACTURING CO., Inc.
26 Chrutopher Street, New York, N. Y.
VmU *7, No. 12, Published monthly— The Taylors; C. C. Taylor, Publisher; Mrs. J. J. Taylor, Ed. Mgr. Entered as
second-class matter Feb. 13, 1896, at the post office at Philadelphia, Pa., under Act of March 3, 1870. Continuing
ths Characteristic Service of, The Medical Council. "Most Widely Circulated Medical Monthly, established in 1806.
COPYRIGHT 1922, by The Taylors, Publishers, 4*0 Walnut St., Philadelphia, U. S. A. All rights reserved.
MEDICiL CQUSCL
A Centtructioe Market for Bayer and Seller
THE CRITICAL AGE
The age of
GROWTH— of STRAIN
— of INFECTION
THE importance of a correct
diet during the age of growth
cannot be overestimated. For the
injury resulting from insufficient
or inadequate food may be perma-
nent in its effects.
VIROL is of especial value in the
diet of School Children because it
is digestible and easily absorbed.
It contains the vitamins essential to growth, and
enriches the diet in those elements essential to
MAINTENANCE OF HEALTH IN WINTER
It has been established by Independent scientific
tests that VlROL increases the power of resistance to
disease of bacterial origin.
At all stages of Growth and Development VlROL
is a food of very great value. Whether for the
School Child, the Growing Babe, or the Expectant
and Nursing Mother.
VIROL
Bone Marrow, Beef
Riit, Lemon Juice Used in more than 2 J>00 hospitals and_ infant clinics
end S*lti of Lime tn Great Britain
and Iron.
SOLE AGENTS FOR U. S. A.
Geo. C. Cook & Co., Inc., 59 Bank Street, New York
You can buy with Confidence— See "Service Guarantee to Reader? on page 906
The American Physician Advertising Service
[l^y^fT-agtg^^^^t^P^rs^i^iH^^gqpSi'lpraglg^^^gl
"Aegrata dum anana est, spes esse diettur"
AIpha-Lobelin
Incomparable stimulant in
subnormal respiration due to
accidents and diseases.
Cadechol
(Comphor-choleinic acid)
Indicated in disturbances
of the circulation and heart
insufficiency due to functional
and organic changes.
Laudanon
Scopolamine
Unexcelled analgesic in
labor and inoffensive hypnotic
in prolonged deep X-ray treat-
ment.
Laudanon
Universally accepted
ard for morphine med
during long periods v
danger of habit format
Perichol
(Cadechol and papover
Efficacious Cadechol
bination especially im
in the treatment of
pectoris.
Laudanon
Atropine
Indispensable analgesic and
hypnotic for overcoming hy-
persensibility and tendency to
vomit.
For Literature or Further Information Address
Ernst Bischoff Co., he, 85 West Broadway, New York, N. Y.
m:
1KB
nrjirr.
Mentioning The American Physician Insures Prompt, Careful Service
838
Contents
C*tyrigH, 19**, hy Ths Tiyhr*. AU rights rs&rvtd.
Editorial*
Th« Professional Difficulties In Group Practice 849
What of That Persistent Rheumatism? 860
Use of Opium In Influenza and Tuberculosis 861
Infectious Diseases a Combination of Units 862
Original Articles
Early Diagnosis of Tuberculosis In Children.
By J. Rosenthal, M.D 863
To write a voluminous treatise on the early diagnosis
of tuberculosis in children is usual and natural. To
write a short paper on such an extensive subject and
still cover the vital essentials of this common disorder,
is an achievement worthy of note. Dr. Rosenthal has
accomplished it — and accomplished it remarkably well.
A Radically Different View of Cancer Therapy.
By L. Duncan Bulk ley, A.M., M.D 866
This paper presents another side of this imperative
question. Dr. Bulkley says: "Inasmuch as thorough,
rigorous and prolonged dietetic, hygienic and medicinal
measures yield such far better results, Is it no,t wise
for the profession and laity to give heed to the signs
of the times?"
The Etiology of the Symptom Complex Called Asthma.
By Henry I. Leviton, M.D 867
Is asthma a disease or a symptom T Is it caused by a
food, pollen or micro-organism? Is an asthmatic a
tubercular or a tubercular an asthmatic — is it one or
the other; if neither, what is the relation between
them? All these questions are thoroughly discussed in
(Contents
this paper, a paper on a disease which has punted and
is still pusxling the medical profession as to its etiology,
pathology and treatment.
Visceral Prolapse Surgically Considered.
By A. Wlese Hammer, M.D., F.A.C.S.
• •■••<
.80
Dr. Hammer says that while the stomach is the orgin
most usually prolapsed, wandering liver or spleen,
movable kidney or displaced uterus, may each or
severally be found in association. This is especially
true in females, the result of tight lacing, repeated
pregnancies, or — again depending upon the latter cause
—engendered through muscular strain. Before using
surgical measures, treatment by external mechanical
supports should be given a thorough trial.
Surgery and Tuberculous Peritonitis.
By Robert T. Morris, M.D., F.A.C.S. ...
■ • • • • • i
Surgeons, Hospitals and Teachers— Thirtieth Clinic
By A. Mackensle Forbes, M.D 863
This last paper is a fitting climax to the notable series
of clinics by Dr. Forbes, which has stimulated so mnch
Interest among progressive physicians. We belierc
you will find it an inspiration, as we did.
The Successful Treatment of Chronic Diseases.
By Albert C. Geyser, M.D 867
"The average chronic patient does not suffer so much
from his original disease as he does from perverted or
arrested physiological function. Our effort must be
directed toward restoring to as near normal as possible
the individual's physiology. And we must remember
It is not the agent, but the physiological response of
living cells to an agent that must be our guide in
therapeutics."
confswssf #n pagm 840)
Chinosol
"A POWERFUL ANTISEPTIC, SOMEWHAT STRONGER IN
THIS RESPECT THAN MERCURIC CHLORIDE AND CONSID-
ERABLY STRONGER THAN PHENOL."
(COUNCIL ON PHARM. AND CHEM. A. BL A.)
iVSEPTIKONS (su PPOSITOR I es)
producing complete antisepsis
But
Non-poisonous, Non-irritating and No injury to membranes
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December, 1922]
The American Ph&cim Ad*ertimg Service
839
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A definite increase in the
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A laxative effect more mark-
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Contents — ««f™*j u
•e838
_ and Metastatic Gonorrhea, Strewing
Gonorrheal Arthritis.
By Hyman I. Goldstein, M.D 870
This is the second section of this practical paper, pub-
lished In tbree sections. This section covers particu-
larly diagnosis and prognosis. Tbe Brut section, glTlof
symptomatology and pathology, appeared In tbe Sotem-
Primary Importance of the General Physician — Annual
Announcement! and Service Prospectus for 1923. .(74
Tbe service of the general physician cannot be ade-
quately performed by any other agency. The best
health Interests of the people emphatically demand
recognition of tbla fundamental fact. It la blgh time
to fight for tbla worthy cause.
Tuberculous Abscess of the Chest, with Report of a
By Lonls W. Joergens, M.D. t7|
Efficient Future of Medical Practice
Should Minimum Standards Be Eatabllshad for Private
Hospitals? m
The Patient First— The Clinical Golden Rule 890
The Bhappard-Towner Maternity Act SB
Beat Current Medical Thought
Evidences of Tonsillar Infection ae
Chronic Appendicitis M4
Physiological Adjuvant In Rest Cure of Tuberculosis. 884
The Percy Method of Treating Cancer of the Uterus
Applied to Treatment of Cancer of the Rectum. ...SM
Book Renews
Manual of Psychiatry n
Hughes' Practice of Medicine. Including a Section on
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Mental Diseases a
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Consequently, ALKALOL is the ideal agent for use in the Eye, Ear, Nose,
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The best proof of the efficiency of ALKALOL is the steadily increasing
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Sample and Literature to any physician on request
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THE CRITICAL AGE
The menopause is not due simply to insufficiency of the genital
glands, but is the expression of an "endocrine crisis" complex,
varying in different persons, of which the said insufficiency of the
genital glands is the central factor, but, with it, other glandular
disturbances play an essential part. — Maranon.
The menopause, therefore,
is a functional plurigland-
ular derangement and is
best treated by plurigland-
ular therapy.
In hypotensive cases use
Hormotone
and in high blood pressure
cases
Hormotone Without
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The Professional Difficulties in Group Practice
Only Seasoned Specialists Are Qualified to Succeed
SMALLER COMMUNITIES BETTER SERVED BY COMMUNITY HOSPITALS
ETHICAL relationships, as appeared in a pre-
vious paper, are necessary to success in a
group-practice undertaking, whether viewed from
the professional, human or business standpoint.
This being conceded and that skill is equally im-
portant, it is not necessary to discuss these primary
matters here. But there is a professional considera-
tion to which attention must be drawn.
A group clinic will not succeed unless the mem-
bers composing it are, each of them, real specialists.
When a number of middle-aged practitioners start
a group clinic in the expectation of becoming spe-
cialists through, one at a time, taking short post-
graduate courses, failure stares them in the face.
After a man has practiced general medicine for fif-
teen or twenty years a three-months' course will not
make a true specialist of him. The profession is
overcrowded now with that sort of so-called special-
ists. After a physician is forty years old or more he
has certain handicaps to overcome to become a special-
ist in the modern sense ; he fails to let go of the past,
and to grasp the recent conceptions as younger men
do. To make a specialist of such a man takes one
full year of college work in the diagnostic and
medical specialties and two years in the surgical
ones; and to this must be added a year or two of
practice as a specialist. This may not parallel the
views of some gentlemen, but those most competent
to judge from actual experience in teaching the spe-
cialties will, most of them, agree.
So, then, if a number of you aim to start a group
clinic without being already seasoned specialists, take
our advice and give up the project. This opinion is
based on considerable observation, and while dis-
couraging it is sound. Even if you are specialists,
do not fill up your group wholly with middle-aged
men.
Very Hmri Work
Don't forget that group-clinic work is most ex-
acting and is wearing from the professional point of
view and is hard work from any angle. Your indi-
vidual profit is less than with a similar number of
cases wholly your own, and as a consequence you
must see more patients in a day than you are accus-
tomed to examining if you keep your income on the
old basis. Most men who enter such work fail to
realize that the fees are divided among several, and
the consequence is that they must do considerable
work in their private ofiices when already wearied
from their hours at the group clinic and their regular
outside visits. There is considerable professional
satisfaction in well-done group clinic activities, but
one can't get away from the fact that it involves
considerable strain and more work than you are
accustomed to doing.
People expect more in a group clinic than they do
when consulting a physician in his office; they view
the clinic somewhat as they do a dinner served in
courses and expect all of the trimmings, from soup
to ice cream, nuts and coffee. A physician cannot
get away from individualism, even in a group clinic.
There are several physicians in the group; each an
individualist, only they are doing team work for the
time being. No cheap labor is working making
money for you, as might be the case were you run-
ning a factory; you still must make your own fees
by skilled personal professional service. It is all
very wearing and is hard work, especially when you
have the constant worry of making the heavy overhead
850
Professional Difficulties in Group Practice
[The American
of the establishment in addition to your professional
work.
In tke Urge City
Certainly not over ten to twenty per cent, of cases
of illness need the services of a group clinic; it is
the chronic and involved cases that are available, and
there must be a large population to supply a sufficient
number of these cases to justify the establishment of
a clinic. In a large city there is an actual field for
such a clinic, seasoned specialists are available to
man the work, and there is apt to be sufficient money
among them to carry on such a project without
undue financial strain. Under these conditions there
is no reason why group clinic work should not be a
very satisfactory line of activity to the staff member.
/■ the SmtU Ctmmmnity
Here conditions are very different, the difficulties
having been already set forth in a previous paper.
Many physicians in small places have suffered heavy
losses through the breaking down of group projects.
From some considerable observation it impresses us
that the logical plan to meet the needs of the small
places and rural districts is the establishment of
community hospitals. We have in mind one such
of only eight beds in a town of 1,500 people, yet it is
well equipped and is doing splendid work. The money
was raised by the community itself, which is full of
enthusiasm over the work. Practically everybody in
town feels that "Our Hospital" is a fine thing. We
talked with the physicians in the place and they are
much relieved that now they have a proper place to
take cases for special examination, laboratory diag-
nosis and ward treatment. Good surgical work is
done, the minor cases being handled by local men
and involved cases by surgeons called from the city,
twenty miles away. The writer wants to go on record
in hearty commendation of the community hospital
idea for the small place as against the group clinic.
— T. S. B.
What of That Persistent Rheumatism ?
FOCAL INFECTION may or may not account for
a persistent arthritis. There is a tendency to
forget this fact in the search for foci. It is a mis-
take to sacrifice teeth or undergo surgical procedure,
in the absence of definite diagnosis or surgical indi-
cation, on the assumption that through some mys-
terious influence a persistent rheumatism will be
cured. This matter has been overdone, as many of
us know who have under care persistent cases of
rheumatism that have been "focused" without result.
Personal hygiene has a vast bearing on this sub-
ject. Insufficient clothing is responsible for many
cases of myalgia and for some acute attacks of
arthritis. Bad housing — dark rooms, poor ventilation,
leaking sewer traps or gas pipes, damp walls and
cellars, and especially living on a ground floor with
no cellar under it — is a large factor. Wet feet neg-
lected, lack of sufficient exercise to promote skin
diction, neglected constipation, heavy eating, too much
coffee or caffeine-bearing soda drinks, using tobacco
in excessive amount, or an improperly balanced diet,
all may be factors in producing and maintaining a
persistent rheumatism.
The Newer Drug*
There is a tendency to decry the use of drugs in the
treatment of rheumatism. This is unwise, and espe-
cially to be deprecated is the neglect of the old drugs
in favor of the newer ones. These newer drugs have
advantages and disadvantages. Acetyl-salicylic acid
•undoubtedly relieves the pain of rheumatism more
•effectively than does sodium salicylate, and as long
as it is kept up the patient may get along fairly
•comfortably; but it does not eliminate as well as
does sodium salicylate and is more depressing than
the latter drug. The combination of sodium salicylate,
colchicum and cascara is unequalled as an eliminant
in rheumatism. Try this on a case that becomes very
uncomfortable soon as he drops the use of acetyl-
salicylic acid.
Seme ei the Old Draft
In chronic cases in which the salicylates appear to
have little value, medication with iodides may be
quite effective provided the dosage is heavy enough.
Here, too, cascara combines well with the more potent
drug. Some physicians believe that cascara has some
specific action in rheumatism, and sometimes we have
felt inclined to believe that this is true. With the
cascara may be combined small doses of bryoma,
being careful not to give enough to elicit its drastic
and irritant effect.
The now all but obsolete plan of giving quinine
and blue mass in chronic rheumatism is being re-
vived by some discriminating clinicians. Just why
these drugs should be effective in such conditions does
not appear very clear, but it is a fact that they
oftentimes clear up an old case most beautifully.
Some physicians who employ this treatment insist
on a purely milk diet for a time, giving milk in large
quantities.
The old vegetable alteratives, especially phytolacca
and stillingia, may be combined with more active
drugs often with marked advantage.
Don't conclude there is nothing to do in a case of
persistent rheumatism, except keep on hunting f°r
the elusive "focus," as long as the above suggestions
are available. Perhaps there is no focus to find.
Phila., December 1922]
Opium in Influenza and Tuberculosis
851
Use of Opium
in
Influenza and Tuberculosis
EXPERIMENT PROVES NON-MEDICINAL MEASURES MORE IMPORTANT THAN NARCOTICS
DR. JOHN DILL ROBERTSON, former Com-
missioner of Health in Chicago, interested in
statements made in a meeting of the Morals Com-
mission, by physicians from various sections of the
country who testified to certain facts concerning drug
addiction, in 1918 ordered an inspection of drug-
gists' prescription files in Chicago and ascertained
that nearly a fourth of the prescriptions for influenza
contained narcotics, as follows : chloral, 3,866 ; opium,
17,504; morphine, 10,003; codeine, 50,081; heroin,
17,812; cocaine, 1,383; other, 3,331; a total of 103,-
980. Such use of narcotics, it was contended by able
sanitarians, is dangerous, some of them going so far
as to say that to give opium in influenza was to invite
pneumonia. Clinicians do not go that far, but very
able clinical authorities are very conservative in rec-
ommending opiates in this disease. That all sanitar-
ians did not view the matter in the same light was
testified to by the fact that the Government relaxed
the narcotic regulations during the influenza epidemic
of I9i8-'i9.
In December, 1918, Dr. Robertson, as head of the
municipal tuberculosis sanitarium, which treats over
a thousand patients a year, issued an order to dis-
continue the use of narcotic drugs in the institution
in the treatment of the symptoms of tuberculosis,
and for three years after that none was used. This
order was designed to prevent inmates from becoming
drug addicts and to prove that, if physicians studied
hard and took trouble with individual cases, nar-
cotics are not necessary in meeting these symptoms.
Whmt Hmpptmed
For the first few weeks the patients, accustomed
to their narcotics, suffered much general distress and
coughing was intensified. The attending physicians
were up in arms against the order; but in due time
matters improved and most of the patients seemed to
get along very well without the opiate medication.
Meanwhile the staff was busy devising substitutes,
with the following results, which are very suggestive
in general practice. Extensive use was made of hot
packs and baths, massage, fixation with plaster casts,
adhesive plaster splints, dietotherapy, heliotherapy,
etc.
Cmgk
Patients were taught how to cough with the teeth
tightly closed and this had a good effect. Drugs
used were cannabis, dilute hydrocyanic acid, lobelia
and chloroform, always in suitable mixture.
Jl€M9fTIMUJ6
Nervousness and restlessness were allayed by psy-
chotherapy and this was thought to reduce the inci-
dence of hemorrhage. Drugs used were thromboplas-
tin, emetin, amyl nitrite, and horse serum.
Dmtrrkmm
Colonic irrigations and proper diet wiere effective
in the great majority of cases. The proper diet for
each case was made a study. Drugs used were bis-
muth subgallate and subnitrate, betanaphthol, kino,
gambir, etc.
Pmm Dm* to LmrymgkU
The prone, face-down position gives relief, and in
this position liquid diet can be taken through a tube.
Heat and cold, the ultra-violet and the X-ray, and
reflected sun rays were used to relieve the distress.
Drugs used were phenol and menthol oily sprays,
alcohol injections along the recurrent laryngeal nerve,
and insufflations of orthoform and anesthesin.
Pmm Dm* to PUmrity
Fixation by strapping of the chest, in the absence
of effusion, was used, as well as local applications.
Benzyl benzoate and lobelia were used when the pain
was due to smooth-muscle spasm.
The RemiU
The principal thing proved by the experiment con-
ducted under Dr. Robertson's orders is that non-
medicinal measures are more important than are
drugs in the treatment of tuberculosis ; and the second
thing grows out of it, that is, if the physician is
denied the use of narcotics in handling these cases
he is forced to use the non-medicinal measures that
might be neglected if he depends on the use of opiates
to keep the patient comfortable, thus accomplishing
better results,' and not so much by denying a pos-
sibly harmful drug as by actually using something
better.
The experiment does not prove that, aside from
escaping the incubus of a drug addiction, the ad-
vanced or even definitely developed case of tubercu-
losis lives any longer without opium than with it or
that the mortality rate is reduced by omitting nar-
cotic drugs.
852
Opium in Influenxa and Tuberculosis
[The American Pkytictaa
While cordially in agreement with the main con-
tention of Dr. Robertson, especially as to the value of
non-medicinal measures and the effectiveness of the
drugs noted in meeting most indications heretofore
met with opiates, we venture a word of comment.
Cough may induce hemorrhage in tuberculosis; it
may seriously embarrass a weak heart, and it may
make the terminal stage of the disease exceedingly dis-
tressing. Ordinarily narcotics should be avoided, but
in the conditions noted above their use may be entirely
justified. It is our opinion that small doses of co-
deine, even though long used, will do less harm than
will cannabis, lobelia, chloroform or hydrocyanic acid.
Codeine rarely induces an addiction, and it is effective
in the cough of tuberculosis if the case is not spoiled
by first using morphine or heroin. The latter drug,
we feel, should not be resorted to and morphine
should be avoided except in the presence of serious
cardiac lesions aggravated by cough.
The ordinary hemorrhage in tuberculosis does not
require the use of an opiate, the remedies suggested
by Dr. Robertson serving every purpose; but we see
alarming hemorrhages with the patient wrought up
and exceedingly nervous, and in such cases we would
hesitate in denying a hypodermic dose of morphine
as an emergency measure. It is also true that the
ordinary diarrhea, just as in other diseases, does not
justify the use of an opiate; but when a diarrhea
gives rise to intense pain nothing serves the purpose
of relief as does a dose or two of an opiate.
Then, too, take an acute pleurisy arising in the
course of tuberculosis, an opiate may be urgently
indicated. Laryngeal cases have persistent pain that
is relieved only for a time by opiates unless given
in ascending dosage, and orthoform or other anes-
thetic agent may be preferable to morphine.
It is, unfortunately, the case that many physicians,
regarding tuberculosis as an incurable disease, are
too free to start their patients on opiates, masking
the symptoms and neglecting the non-medicinal meas-
ures so useful in all cases. Many of these cases
would recover under proper treatment.
No one knows better than the writer how opiates
are abused, as it is his duty to enforce the narcotic
laws in Pennsylvania; but he fails to see why a
serious disease like tuberculosis should be made the
shining mark for a no-narcotics propaganda that is
lived up to despite the condition of the patient. If
it is necessary, or logical, to do away utterly with
narcotics in the treatment of tuberculosis it is equally
logical to do away with them in nearly all other dis-
eases. Who is to draw the line? Then, too, think of
the patient! Let us not be extreme with our propa-
gandas.— T. S. B.
Coming
Turn to pages 874, 5, 6, and 7, further over in this
issue. Here you will find the annual announcements for
the coming year.
A year of exceedingly practical, useful service is in
store for you in the 1923 issues of The American
Physician. Read over the list of papers to be pub-
lished. It is one of the best lists we have ever an-
nounced.
A vital service must be performed in medicine, and
performed now. To reassert the fundamental impor-
tance of the general physician-. He is the key man in
medicine. Medical service must be built around him.
Read in this annual announcement the position of this
journal in this important matter.
We are with you and after reading this announcement
we know you're going to say — "And by the eternal Fm
with them. The 'A. P.* is one journal I simply can't
do without." Turn now to pages 874, 5, 6 and 7.
Infectious Diseases a Combination of Units
L. PANETH, in one of the German medical jour-
nals, differentiates between the systemic and
local processes in diphtheria, the former yielding to
antitoxin but the latter streptococcic local sepsis re-
quiring separate treatment. He asserts, therefore,
that the problem of diphtheria is not as simple as
many assume it to be. Furthermore, he asserts that
infectious diseases are seldom pure units, but repre-
sent a combination of biologic units.
Some years ago this journal presented an edi-
torial entitled "Tuberculosis Plus," taking the view
that Paneth now enunciates. Experience has served
to confirm us in the view that mixed and cross infec-
tions are common, not only in tuberculosis, but also
in other infectious diseases.
We apprehend the matter to be of importance in
clinical medicine and occasion is here taken to empha-
size the point that so-called specific treatment has
distinct limitations, the at-present neglected sympto-
matic medication being required in many cases, and,
as well, a case-management involving several factors.
Certainly we see this matter constantly illustrated as
regards syphilis.
The so-called complications of measles, scarlet fever,
etc., may not be complications, as such; they may be
manifestations of a combination of biologic units
producing an illness that must be viewed in toto and
not as a complicated case of some infectious unit
All of this tends to confirm the older school of
clinicians in the view that we are treating diseases
too much and sick people too little.
Ths following papers
are contributed exclu-
sively to this journal.
Republication is Per*
mitted if credited as
follows: AMERICAN
PHYSICIAN, Phila-
delphia.
Original Articles
SntucMt tti submit tan nn%A **> ■* certeMU"
We are not respon-
sible for the views ex-
pressed by contribu-
tors; but every effort
is made to eliminate
errors by careful edit-
ing, thus helping the
reader.
Early Diagnosis
of
Tuberculosis in Children
EARLY DISCOVERY IS OP THE GREATEST BENEFIT, FOR AT THIS STAGE MUCH CAN BE DONE
IN PREVENTION AND TREATMENT
By J. Rosenthal, M.D.,
1001 Stroh Building, Detroit, Mich.
Essential Paints in n
To write a voluminous treatise on the early
diagnosis of tuberculosis in children is usual
and natural. To write a short paper on such
an extensive subject and still cover the vital
essentials of this common disorder is an
achievement worthy of note. Dr. Rosenthal
has accomplished it — and accomplished it
remarkably well. — Editors.
MY EXCUSE for presenting a subject so ex-
tensively written on and discussed in the past
few years is that I consider it one of vast importance
to our future and the general well being of our
communities. Our present knowledge of its treat-
ment and prevention depends so much on its early
discovery that all our efforts are expended in means
to that end.
No one method of examination can give definite
enough data to make a positive diagnosis in its early
stages, but it is necessary to use every means at our
command, and to take results as they appear and
consider them as spokes in a wheel, the whole to
give us a working basis from which to draw con-
clusions. Even then there is opportunity for error.
History
No attempt for diagnosis in this condition should
be made without taking a careful history, especially
for any possible exposure to open tuberculosis. The
mere fact that one or both of the parents, grand-
parents, uncles, aunts, or any other member of the
family may have had tuberculosis means nothing ex-
cept in so far as there is a chance for exposure to
infection. Many cases may be traced even to visitors
or perhaps moving into a home in which there has
been a case of tuberculosis. Again I say, much in-
formation may be obtained by careful and painstak-
ing questioning, and we cannot go too deeply into this.
The past personal history may give us much in-
formation. The child may have always been a weak-
ling easily infected with all the prevalent diseases.
May have had measles, whooping cough, etc., and
never fully recovered. The whole trouble may be
traced to a pneumonia in which the cough never fully
left. It is quite common following whooping cough
and measles, and when you have a history like this
you may be justified in suspecting tuberculosis until
you can satisfactorily explain the condition as due to
something else.
Present Comi'dian
When you have this information you may now look
to the present condition. Is the child weak? Has
he lost his "pep"? Does he cough t Does he run an
elevated temperature especially in the afternoon t Is
he easily exhausted? Does play make him feverish?
Has he lost his appetite? Is he getting thinner?
These are some of the questions, if answered affirm-
atively, would naturally make one suspect tuberculosis.
Pkyucet Examination
As to the physical examination much can often be
obtained, and frequently there may be grave pathology
with no physical signs. The size and shape of the
chest may be abnormal, there may be lagging of
motion on one side. The general contour of the
child's body may be thin, scrawny, pale, weak and
undernourished, yet a plump, well-nourished, healthy-
looking child may have tuberculosis. You will, in all
854
Early Diagnosis of Tuberculosis in Children — Rosenthal
[The American Physician
probability, have some enlargement of the cervical
lymphatic glands.
Auscultation and percussion may give us nothing,
but in some cases we may find areas of impaired
resonance, prolonged expiratory murmur, and a few
inspiratory rales. On this latter I lay more stress
than on either of the other. Tubercular rales are
almost always inspiratory and persistent, that is, they
do not disappear on coughing. In percussing, do not
forget that in childhood most areas of infection are
in the mediastinum, and in some cases can be found
on percussing along the spine between the scapulae.
If you find intrascapular dullness down to the fourth
to seventh cervical vertebra, and if in this area you
get on ausculation a whispering prolongation of the
vocal resonance, D'Espin Sign, you may be assured
you have mediastinal pathology and probably tuber-
cular. But don't get the idea this is always the case.
On the other hand, you may have tubercular lesions
in the mediastinum, and this fairly well pronounced,
yet get a negative D'Espin Sign. One thing that will
show up in these cases is inspiratory rales, especially
if there is an active lesion.
What I am especially trying to make clear is, that
from the standpoint of physical examination alone,
lesions of tuberculosis in their early stages are easily
overlooked, and even after very careful, repeated,
painstaking examinations nothing definite may be
found, or signs may be found that will lead us to
make a diagnosis of tubercular lesion, and on further
investigation prove to be non-tubercular.
X-JUy
X-ray is a valuable aid in our diagnostic routine,
yet too much reliance cannot be put on this alone.
The more experience I have with their interpretation
by men whom I know are skilled in reading plates,
the less reliance I can put in their reports. Two
men, both skilled, may read the plate differently. A
great deal of help can be given to our X-ray con-
freres, and in this way get more satisfactory results,
if we go over with them, at the time of the reading,
what we have found on our examinations, together
working out the information shown on the plate. It
is also advisable to take both anteroposterior and lat-
eral views of the chest. We can in this way get a more
satisfactory view of the relation of any pathology
found.
There are cases of tubercular chest infections, espe-
cially active ones, in which the lesion or lesions are
too small to throw a shadow and will entirely escape
the picture. There are cases, though, in which the
picture is so characteristic that all may see, skilled
or unskilled; but these cases usually have such well-
marked physical findings that all our picture does is
to corroborate them.
M 1W I \ HUH M Till
We now come to tuberculin tests, which, to my way
of thinking, are the most positive diagnostic method
we have. If one gets a positive tuberculin reaction,
either from a Pirquet, intradermal, or subdermal
method, we may rest assured there is some foeus of
tuberculosis somewhere in the body. Whether it is
an active process or not is not the question. But, on
the other hand, if the tuberculin test is negative, in
a small proportion of cases it does not mean that a
tubercular process is not present, depending a great
deal on what method of test is made.
I do not wish, at this time, to go into a lengthy
discussion on the merits or demerits of any of the
various methods of making tuberculin tests, but simply
state that for universal use in all ages and forms of
tubercular infections, in my experience, the intra-
dermal test has proven the most satisfactory, and I
feel fairly confident that if it proves negative or very
faintly, questionably positive. I can rule out tuber-
culosis, that is, if I have been true in my technique,
and have done it repeatedly with different strengths
of tuberculin dilutions.
Now let me recapitulate. If you have a child at
any age who shows symptoms of lack of "pep," poor
appetite, tires easily, with or without a cough, with
or without an afternoon temperature, always weak or
may seem fairly well nourished, a history of some
possible exposure to infection, some cervical gland
enlargement not necessarily large in size, perhaps
just palpable, and with or without demonstrable chest
involvement especially in the mediastinum which may
or may not be proven by X-ray, and you get a posi-
tive intradermal tuberculin reaction, either to 1-1000,
1-500, or 1-100 dilution old tuberculin, or if these
prove negative I use the same in bovine tuberculosis,
you may suspect and feel confident that this child
has tuberculosis. But as to the severity, activity,
etc., that is another question, and one which requires
prolonged study of each individual case with the exer-
cise of good judgment. All information obtained
must be considered in its correlation of each with the
other, and your final and honest opinion given.
If you yourself have been honest with your reasoning
you have done all that can be asked of yon. The
best of us make errors in judgment. I make it a rule
in these cases, if I feel confident there is tuberculosis
and I suspect an active process, I treat it as active.
If my judgment has been in error, I have erred for
the child's good and will be doing more good than
harm.
If, in this short article, I have impressed upon you
the importance of not overlooking any possible tuber-
cular case, and if I have impressed on you the im-
portance of the necessity of correlation of all symp-
toms, physical signs, X-ray pictures, and tuberculin
tests, and even then the possibility of error, so that
you may not be discouraged when you fail to find a
tubercular infection easily, I have accomplished its
mission, and perhaps renewed your interest in thii
important subject, and helped you to diagnose it earlj
when so much can be done for it.
Phila., December 1922]
Radically Different View of Cancer Therapy — Bulkley
855
A Radically Different View of
CANCER THERAPY
Is There a Cancer Therapy Which Yields Far Better Results Than
Surgery , X-Ra$ or Radium?
THE FIRST OF TWO BRIEF PAPERS GIVING AN INTENSELY INTERESTING AND
VERY DIFFERENT POINT OF VIEW OF THIS SUBJECT
By L. Duncan Bulkley, A.M., M.D.,
5 East 53rd Street, New York City.
Senior Physician to the New York Skin and Cancer
Hospital, Member of the American Society
for Cancer Research, etc.
Amkktr SUt *f the Qwtttfn
This paper presents another side of this
imperative question. Dr. Bulkley says: "In-
asmuch as thorough, rigorous and prolonged
dietetic, hygienic and medicinal measures
yield such far better results, is it not wise
for the profession and laity to give heed to
the signs of the times?" — Editors.
F THERE NO cancer therapy except the knife,
X-rays, and radium f This question is continually
asked, but surgical dominancy answers "No," while
dozens of • physicians, and some surgeons, answer
"Yes, and one which yields far better results.,,
Which are right t
Cmrnctt Mm* Btmt m C
Everything has a cause, and cancer can be no
exception. Deaver* says: "The nature of carcinoma
is unknown." Speaking of laboratory researches,
he says, "a generation of workers have labored, with
great industry, intelligence, and patience, and a
mass of information has been collected, but when it
is carefully sifted out we find ourselves very much
where our forefathers were, so far as any clear idea
of the cause and nature of cancer are concerned.
But what is most disappointing, we are precisely
where they were, so far as treatment is concerned.
All that they knew was. that the proper thing for
cancer of the breast was to remove it. All that we
know is to remove it. We do it with less pain than
they, thanks to the anesthetist ; we do it with greater
safety than they, thanks to antiseptics and asepsis;
we do it with less probability of return than they,
thanks to better technic, but we still do nothing to
a — Deaver, MacFarland and Herman; The Breast and Its
Its Anomalies, Phlla., 1917, p. 476.
cure it." All surgeons are not as honest as Dr. Deaver,
but in their hearts they know that this is the truth.
And so the surgeons go on, as they always have
done, cutting out the products or manifestations of
a disease of which they profess to be totally ignorant,
which is quite as sensible as it would be to thus
remove surgically the manifestations of gout, tuber-
culosis, or late syphilis, without rectifying the real
cause of the lesions. Latterly they have added X-
rays, radium, thermo-therapy, and the older meth-
ods of caustics, but still leave the cause of the
carcinosis unchecked, which produces recurrences
again and again till the patient dies, not from the
local lesion, as they regard it, but from the con-
tinuance and increase of the systemic or consti-
tutional condition which was the basic cause of the
first mass, and reproduces ethers.
FiWs of the C*w*tofamd Nmtmrt mi Cmmctr
Time and space do not permit of elaborating
here just what elements are concerned in the pro-
duction of this carcinosis, which have been abundantly
presented elsewhere,1 so that he who runs may read,
if only he would. The proofs of the constitutional
nature of cancer have been presented before scien-
tific societies,2 and not a word has been raised against
them, only surgeons have said they did not believe
in them, and that they had cured cancer by surgery,
but whatever may be said of individual cases it
cannot be gainsaid that all surgical efforts have not
sufficed to stay the alarming increase in the mortality
of cancer, which has risen over 30 per cent, since
1900, under surgical dominancy, while under wise
medical direction that of turberculosis has fallen
43 per cent.
It may be well to present some of the reasons for
the lamentable condition in which carcinosis stands
today as a disease, and the ultimate results of its
treatment; they are briefly as follows:
1. The glamour of surgery, and latterly of X-rays
and radium, and the craze for immediate and spec-
tacular apparent and temporary results.
1 Bulkley. Cancer and its Non-Surgical Treatment. New
York; 1921.
2 Bulkley. Proofs of the Constitutional nature of Cancer.
New York Medical Journal. July 20, 1921.
856
Radically Different View of Cancer Therapy — Bulkley
[The American Physicist
2. The claim of surgeons as to the success of
operations, and the failure to investigate and report
results after the lapse of years.
3. The results of laboratory and research work,
wrongly supporting surgeons as to the local nature
of cancer, and advocating the desirability of the im-
mediate removal of the results or products of carcino-
sis, now called cancer.
4. Ignorance on the part of the general medical
profession as to the true facts concerning cancer.
5. The many fake cancer cures which have been
foisted on innocent sufferers, together with the many
failures of remedies and measures which have been
advocated by the regular medical profession.
The proofs of the constitutional nature of cancer
fall under four heads: 1, Laboratory findings, nega-
tive and positive; 2, Statistical evidence; 3, Bio-
chemical evidence; 4, Clinical evidence.
1. The laboratory and experience have shown that
cancer is not parasitic, is not contagious nor in-
fectious, and is not hereditary, but that cancer cells
are but altered, normal body cells. In other words,
the mass which is called cancer consists of body
cells, once healthy, which have thrown off their
allegiance to normal, physiological control, and,
leaving their natural function of secretion, etc.,
have expended and continue to expend their whole
energy upon growth, which we call malignant be-
cause of the ultimate harm observed to result from
their action. They are like mutinous soldiers1 re-
belling at the quality or quantity of food furnished,
for the cells get their pabulum or nutriment from
the blood, which is replenished by food; when all
the dietary and systemic errors are corrected the
rebellious cells return to their allegiance, as would
the soldiers, if an intelligent and sympathetic officer
removed all their causes of complaint.
Not m Local Dumm
The late history of cancer, especially of recurrent
cancer, should be sufficient to convince anyone that
it is not a local disease, although it may be granted
that the first external manifestation of the "neoplas-
tic diathesis/' as a great Frenchman once called it,
may occur from a local irritation, even as a gout-
may be first recognized when the great toe is stepped
on, a late syphilitic gumma develop in the site of an
injury, etc. etc. But how any rational human being
who has watched the whole course of many can-
cer cases, till death, as some of us have, can think
or believe that cancer, as a disease, is a local affec-
tion, is very difficult to comprehend. None so blind
as those who will not see, none so deaf as those
who will not listen attentively and heed what is said.
There is plenty of evidence in literature of those
1 Bulkley. Cancer a mutiny of body cells. Med. Record, Oct.
1. 1921.
who knew cancer well in regard to its systemic nature,
dating back to the great English surgeon, Aber-
nethy, who over a hundred years ago wrote strongly
of the constitutional nature of cancer and of the
value of a vegetarian diet. Ever since that time
there have been men of prominence, including
Walshe, Lambe, Sir Astley Cooper, Sir James Paget,
Dr. Hughes Bennett, Dr. Willard Parker, Sir Arbuth-
not Lane, Dr. Robert Bell, Dr. Forbes Ross, Dr.
John B. Murphy and even Dr. Wm. J. Mayo, who
have expresed such views, often very strongly, in
support of the constitutional nature of cancer. The
latest is Sauerbruch, the famous German pioneer in
thoracic surgery. He is reported as saying, "Cancer
is the local manifestation of a constitutional disease.
We must go back to the humoral conception of life
Virchow, who on a solidistic basis, taught that all
the constitutional manifestations of cancer were
secondary to the local lesion, is shown to be wrong,
and that the old humorists are in line with modern
progress." If medical literature were more studied
and assimilated and acted upon, there would be
fewer mistakes made in regard to cancer, and its
mortality would be reduced, instead of constantly
rising.
Surgery, X-rays, and radium have undoubtedly
been of some temporary benefit in some cases of
cancer, but they have also done much harm, as all
of us who are seeing much of the disease can tes-
tify. And inasmuch as thorough, rigorous and pro-
longed dietetic, hygienic and medicinal measures
yield such far better results, is it not wise for the
profession and laity to give heed to the signs of
the times f
SECOND PAPER
The second of these two brief but intensely interesting
papers will be published in the January issue. Keep it
in mind or make a memo, so you will be sure not to
miss it. The importance to the general physician of
being fully cognisant of this radically different view of
cancer therapy need hardly be statid.
Infant Feeding
E. G. Padfield (Jour Kan. Med. Society, April, *22),
emphasizes the importance of starting the baby properly.
If you can so regulate the child's diet that you have a
healthy child at two years of age with no digestive
trouble, this same child will continue to advance and be
healthier and less likely to the ordinary troubles of child-
hood than the child not so taken care of in the early
period of its life.
Phila., December 1922]
Etiology of Symptom Complex Called Asthma — Leviton
857
The Etiology of the Symptom Complex
Called Asthma
By Henry I. Leviton, M.D.,
1015 Story Building, Los Angeles, Cal.
Wk* h AiOmm?
Is asthma a disease or a symptom? Is it
caused by a food, pollen or micro-organism?
Is an asthmatic a tubercular or a tubercular
an asthmatic — is it one or the other; if
neither, what is the relation between them?
AU these questions are thoroughly discussed
in this paper, a paper on a disease which has
puzzled and is still puzzling the medical pro-
fession as to its etiology, pathology and treat-
ment. — hjditors.
THE ETIOLOGY of asthma, particularly its re-
lation to tuberculosis, has been studied by the
most eminent students of the respiratory diseases,
even long before tuberculosis became a definite dis-
ease entity.
The opinions expressed on the subject by all those
students, especially on the relation of asthma to
tuberculosis, are so contradictory, that one is act-
ually confused, and is at a loss to form a definite
opinion.
On a perusal of the literature on this subject, it
occurred to me that of late certain definite principles
are being worked out, principles leading to an in-
telligent and scientific understanding of this symptom
complex, with all its various etiological factors.
In the light of recent research on this subject,
asthma, as a definite disease entity, became obsolete —
it does not mean any more what it formerly meant.
It has been placed in the class of those indefinite
conditions called indigestion, rheumatism, fever,
neurasthenia, etc. All of them including asthma have
been relegated to the rubbish heap, where they prop-
erly belong, being indefinite and meaningless. There
was a time when asthma was considered a definite
disease entity, but it is not so any more. We all know
now that asthma is nothing else but a symptom, it is
a manifestation of a host of conditions, some defi-
nite, but most of them indefinite and obscure.
•Read before th*» T"fc~i-culoeia Section of the L. A. County
Med. Ais'n, January, 1922.
Not very long ago, that is, before the era of protein
sensitization secured a stronghold of the profession,
asthma was considered an affection due to some form
of respiratory disorder, that is, it was an affection of
the lungs or bronchial tubes, and nothing else. To
those of us interested in tuberculosis, this theory
seemed plausible; it was evidently due to our ac-
quaintance with the respiratory disorders, with their
frequent asthmatic manifestations and complications.
In many of our patients, these manifestations seem to
be a respiratory disorder of a possible bacterial
origin. Of late, the pendulum as to the etiology of
asthma began to swing very strongly towards the
side of pollen protein sensitization.
Food PnUm, PoUtm wr BmcUrim, As PtsibU Camse*
The object of this paper is to discuss, and pos-
sibly question, the over-enthusiasm in this direction.
The exponents of the protein sensitization theory
claim that asthma is a manifestation of the patient's
sensitiveness to various proteins both of endogenous
and exogenous origin, that is, an absorption from a
focal infection within the body, which is quite plaus-
ible, as well as an ingestion and inspiration from
without. Three groups of etiologic agents have been
definitely worked out as being possibly responsible
for the asthmatic manifestations; they are: the food
proteins, pollens and bacteria, with the emphasis on
proteins and pollens.
While it is true that the food proteins and pollens
are responsible for a number of asthmatic outbursts,
it is still a question whether they are the real cause
of it, or only the exciting cause! Is there no deeper
pathology, possibly even more obscure, than the
pollen and protein anaphylaxis theory? Norris and
Landis state "Spasmodic dyspnea in which the chief
difficulty is emptying of the lungs, the obstruction is
in the upper respiratory tract, due to infection or
mechanical process, as well as heart disease and
nephritis are capable of causing dyspnea of a sudden
onset."
Caulfield states: "If one regards bacteria as cap-
able of causing the symptoms of bronchial asthma,
then this conception is not to my knowledge sup-
ported by any experimental data, being merely based
858
Etiology of Symptom Complex Called Asthma— Leviton IThe AmerUM ******
on theoretical grounds, and the clinical evidence of
bronchial asthma may disappear after the removal or
the successful treatment of areas harboring foci of
infection." By this we may understand, once the foci
of infection were removed there were no more asth-
matic outbursts.
Here it is quite clear that it is the bacteria that
are responsible in such cases. He further states,
"Many cases that were negative to protein showed
fairly constant bacteriological findings and were asth-
matic clinically."
Piness in his personal observation of 150 cases
states that 14 per cent of these cases were of a bac-
terial origin; some patients of this group were also
sensitive to other than bacterial proteins.
Brown, after thoroughly discussing the anaphylaxis
of asthma, comes to the following conclusion: "It
seems to me we must conclude that anaphylaxis is in
some cases a predisposing or contributing factor only,
and not the common or direct etiologic factor. In
many cases, however, it may be the one element with-
out which there is no asthma. The foreign proteins
when present, cause circulatory changes, swelling and
a lowered resistance of the part affected. Bacterial
invasion occurs and pharyngitis tracheitis, bronchitis,
etc., soon result." He further states that asthma
usually develops secondarily to bronchitis, tuber-
culosis and nasal disease, and in this connection it
should be considered merely as a symptom.
Theoretically, asthma may originate independently
of an inflammatory state of the bronchial mucosa,
and structural changes may be temporary or even
permanent. They are surely not to be denied.
From all these observations we can easily deduct
that bronchial asthma is a syndrome with very wide
variations. It requires a very broad type of investi-
gation if all the possible bacterial etiological factors
are to be taken into consideration, and it is most
important not to ignore the possible bacterial etiology.
Even the greatest enthusiasts of the protein pollen
sensitization theory admit, that there are a number
of cases that are negative to all their known proteins.
AtAmm mml Tmberaiom
Now, as to the relation of asthma to tuberculosis,
tuberculosis being the most probable bacterial factor.
Trousseau has always considered asthma and tuber-
culosis as being of the same diathesis. We all well
know that asthmatic people are very frequently the
parents of tubercular children, as well as asthmatic
children being the offspring of tubercular parents.
Landouzy suggests that asthma may be an an-
aphylactic reaction to the tubercle bacilli.
Roboule spoke of pretuberculous asthma, meaning,
that there are individuals with a nearly inactive tuber-
culosis manifesting itself in producing asthma.
Osier observed that one of the early signs of tuber-
culosis might be asthma with its wheezing and sibiliant
rales.
Soca studied 140 cases of asthma, especially to dis-
cover the presence or absence of tuberculosis. He
concludes that 120 cases were positively tuberculous.
Later he reported on a series of 700 cases of asthma
and his opinion was, that nearly all of these were
tuberculous. His convictions are that all cases of
asthma are tuberculous.
frankfurter uses tuberculin in asthma, with pa-
tients showing much improvement, and concludes that
tuberculosis and asthma are interdependent.
Brown in his chapter on tuberculosis and asthma/
after naming many authorities pro and con, comes to
the following conclusion: "By a thorough study of
case histories, careful physical examination and a
conscientious course of reasoning, I believe one will
be led positively to conclude that many asthmatics/
not only have tuberculosis foci but that these foci are
very slightly active — sufficiently so to instigate and
contribute to chronic bronchitis" In his own series
of 50 cases, nearly all of them were tuberculous and
10 per cent showed tubercle bacilli present.
In my own experience as examining physician for
the admittance of patients to the Jewish Comsump-
tive Relief Association Sanitorium at Duarte, I have
found- that more than 25 per cent of patients who are
positive tuberculars are asthmatics as well. This
is also true in my private practice. Quite a number
of so-called ex-patients, that is old fibroid cases, have
frequent outburst of asthmatic paroxysms.
Of course, there are a great number of prominent
authorities who do not accept this view, but in this
paper I am interested primarily in the bacterial
origin of asthma and the authorities mentioned are
all of this opinion.
Grippe mml Bnmchku as Factors
Accepting the bacterial theory of asthma as being
a plausible one it would stand to reason that in most
of the patients who are subject to frequent attacks
of influenza and bronchitis there should be patholog-
ical changes in the respiratory mucous membrane.
This debilitated condition of the mucous membrane
will render it sensitive to a great number of food
proteins, and pollens, these proteins and pollens act-
ing merely as exciting factors. The pollens and pro-
teins possibly act only in cases where there are
pathological conditions in the respiratory organs,
caused by bacteria or their toxins.
The bacteria and their toxins evidently prepare
the ground, so to speak, for the pollens and proteins;
the latter act merely as irritants on a wounded dis-
eased surface, in the same sense as smoke causes
paroxysms of cough in people who suffer from some
sort of catarrhal inflammation of the respiratory
organs, while in people without catarrhal inflamma-
tion smoke has no effect. A great number of cases
showing sensitization to a number of proteins, espe-
Phila., December 1922]
Visceral Prolapse Surgically Considered — Hammer
859
daily those of the dermal variety such as hair, dander,
and feathers, are at the same time also showing, on
repeated sputum examination, strains of streptococcus
pyogenes and micrococcus catarrhalis, as well as
tubercle bacilli.
In some cases the bacteria found are evidently the
primary factors in these asthmatic cases, being later
augmented by the dermal proteins, as Caulfield states,
"In most of the patients with a co-existing infection
which has led to pathologic changes, repetition of the
cutaneous tests has shown that sensitization tends to
reappear"
I believe more research in the direction of the
pathology of the respiratory tract, will throw more
light on the etiology of asthma, irrespective as to the
number of poUens and food proteins a victim may be
sensitive to.
The real origin of the asthmatic syndrome is in
all probability of a bacterial nature. The tendency
in many quarters to believe that the majority of cases
of asthma are due to food protein and pollen sen*
sitization is stimulated by an honest over-enthusiasm.
The tendency of the present time is in the direction of
the pollen and food protein theory. To some extent,
this is the fashion and style of the day. We all re-
member the time when tuberculin was pronounced a
sure cure for tuberculosis by Koch himself, and we
certainly do remember the great outburst of over-
enthusiasm when salvarsan was declared a "one shot"
cure for syphilis, by Erlich himself.
New theories on obscure diseases seem like rapid
rivers — they carry everything met on their way, they
run for quite some time and distance until the proper
levels are found and there they rest.
The proper level of the status of the etiology of
asthma, as well as its treatment, will be found only
then, when its sensitization theory will run through
its course and pass through the same stages as tuber-
culin and salvarsan did. The enthusiast will cool
down to calm thinking and healthy reasoning, based
on the only positive standard — experience.
Visceral Prolapse Surgically Considered
External Mechanical Supports Should Always Be Cben a Long Trial Before Surgical Measures
By A. Wiese Hammer, M.D., F.A.C.S.,
218 S. Fifteenth Street, Philadelphia, Pa.
Dr. Hammer says that while the stomach
is the organ most usually prolapsed, wander-
ing liver or spleen, movable kidney or dis-
placed uterus, may each or severally be found
in association. This is especially true in fe-
males— the result of tight lacing, repeated
pregnancies, or — again depending upon the
latter cause — engendered through muscular
strain. Before using surgical measures, treat-
ment by external mechanical supports should
be given a thorough trial. — Editors.
THE TERMS, "visceral prolapse," "visceral
ptosis," "splanchnoptosis," and "Glenard's dis-
sease" are interchangeably employed to indicate that
condition of the abdominal viscera in which there
occurs a lengthening of the peritoneum or the liga-
ments supporting the various organs, allowing of a
lowering from their normal position, together with
a range of motion exceeding by far that which is
regarded as normal.
It is not our purpose to dwell upon the familiar
facts laid down in text-books, but rather to em-
phasize certain selected thoughts that will appeal to
the general clinician as well as to the operating
surgeon.
While the stomach is by far the organ most
usually prolapsed, wandering liver or spleen, mov-
able kidney or displaced uterus may each, or sev-
erally, be found in association. This is especially
true of females, be it the result of tight lacing, of
repeated pregnancies or, again, depending upon the
latter cause, be engendered through muscular strain.
The small bowel may be prolapsed into the lower
abdomen and the pelvis. Coloptosis or prolapse oi
the colon is the portion of the large intestine most
frequently prolapsed, especially the transverse por-
tion, as it is the most freely movable, the most de-
pendent part lying at the public symphysis. The
frequency of gastroptosis in cases of young chlorotic
girls is regarded by not a few investigators as a
cause of chlorosis, they insisting that its occurrence
860
Visceral Prolapse Surgically Considered — Hammer
[The American Physician
is due to the use of corsets during the developmental
changes at puberty.
Glenard found gastroptosis to occur 400 times in
1300 patients he examined. No symptoms were com-
plained of and these cases were discovered in the
course of clinical investigation for other diseases.
Although Glenard emphasized the fact that the
condition was usually found in neurotic females,
tall and scraggy, who complained of various dys-
peptic symptoms, fulness after meals, flatulency and
a tendency to faintness, when distension of the
stomach took place. He found in association with
gastroptosis, a inarked mobility of the kidneys,
especially the right.
Rovsing offers the following as his method: He
gastric prolapse. In the one form, the abdominal
muscles are firm and strong, allowing of operation.
This form comprises a minority of cases; to this
rarer group, Rovsing applies the name, "virginal."
The larger group of cases occurs in multiparous
wpmen, with thin, flabby belly walls, associated with
prolapse of several viscera and which is relieved by
bandage, belt or some other abdominal mechanical
appliance. In the virginal form, such pressure de-
vices are ineffective, because the robust, firm mus-
culature does not permit of external pressure offer-
ing any impression upon the powerfully contracting
abdominal walls.
Jtomif'f Method
Rovsing offers the following as his method. He
passes three stout sutures of silk transversely through
the stomach, including only the outer coats. He
takes the sutures through all the layers of the ab-
dominal wall, and secures them externally over a
glass rod. At the end of four weeks he removes the
sutures, when the stomach is tightly adherent to the
anterior abdominal wall.
Dmreti Op*r*bm — "Gubnfxyf'
It is, however, to Duret, of Lille, that we owe the
first suggestion for the performance of the opera-
tion of "gastropexy." His patient, a married woman,
had suffered very severely for three years from a
gastric prolapse. Surgical opinions and consulta-
tions had availed nothing. Duret performed a median
laparotomy. The peritoneum in the upper part of
the wound was not incised. He exposed the
stomach and fixed it by means of a silk suture to
the undivided but exposed peritoneum. This opera-
tion is approved by many excellent surgeons, but it
is condemned by others, including Mayo Robson,
on the ground that gastric adhesions to the abdominal
wall are capable of producing serious and danger-
ous symptoms.
CoUjt Method
Coffey* "slings the stomach in a hammock" by
suturing the omentum along the greater curvature to
the abdominal wall above the umbilicus.
♦Philadelphia Medical Journal. Oct 11, 1902.
Beyeett Operdtien
The most satisfactory operation and that endorsed
unanimously by the profession, originated with
Beyea,** of Philadelphia. Beyea shortens the sus-
pensory ligaments of the stomach by passing a
series of sutures through the gastro-hepatic omen-
tum, which he applies in three rows. The great
advantages of the operation are to be found in
the retention of the normal mobility of the stomach
and the absence of any abnormal attachment to the
abdominal wall.
On the subject of gastroptosis the following is
Moynihan's opinion: "There are, doubtless, cases
in which an operation of this kind (Beyea's) is
necessary. Such cases, however, are few. The treat-
ment by external mechanical supports should always
be given a long trial before surgical measures are
advocated, and consideration must always be given
to the fact that the patients are often of a profound
neurotic type."
Hepatoptosis or downward displacement of the
liver (not due to fluid accumulations above it or to
lateral deviation of the spine), is often confused
with a colonic tumor, a movable right kidney, or
with tumor of the pylorus, gall bladder or pancreas.
In 1866, the condition was first accurately described
by Cantani, and within more recent years, Einhorn,
of New York, has shown the great frequency of the
occurrence of this displacement. As a rule it is a
part of the symptom-complex of Glenard's disease.
The organ may descend into the lower abdomen;
Demarquay has found it upside down. Griffith found
it rotated on its transverse axis, and others report
it firmly and immovably fixed by unbreakable adhe-
sions. According to Bevan, of Chicago, the condi-
tion is not infrequently congenital.
What Are the Mechmmcs Iwoelped?
Two varieties are recognized by systematic
writers: The partial, in which there is a downward
prolongation of a portion of the liver; this re-
sults in a condition known as "ReideFs lobe." The
complete variety, in which there is a prolapse of
the whole organ. The question naturally arises, what
are the mechanics involved in the downward dis-
placement of so large and well-fortified a gland f
Strange as it may appear, Faure has shown that
the vena cava is the most substantial mechanical sup-
port of the liver, comparable to the relationship borne
between the great vessels and the heart. The liver
is naturally strengthened by the support lent to
it by its ligaments proper. Another factor in main-
taining the liver in its normal position is intra-
abdominal pressure, plus the pressure exerted from
below by the stomach and bowels. Sappey and
Landau attribute much of the liver's stability of
position to the question of a constant intra-abdominal
pressure; Faure considers the matter as negligible.
**Amer. Jour. Med. Sci., June, 1899
Phila., December 1922]
Visceral Prolapse Surgically Considered— Hammer
861
As just stated, the vena cava is the mainstay of
the liver's support; therefore, in its descent, it is
natural and correct to infer that as this great blood
channel is in relation with the posterior surface of
the liver, that surface moves the least; per contra,
the anterior surface moves the most, hence the
movement is of a nodding or of a bowing character.
As the right lobe is larger and heavier, its descent
is greater than the small left lobe.
Immediately to the right of the gall bladder is a
downward projection from the right lobe of the
liver, designated "Reidel's lobe." This tongue-like
offshoot is almost always associated with gall-stones,
and its existence is thus caused, according to Reidel,
by the distension of the gall bladder, pulling down
that portion of the liver in its immediate vicinity.
That this is the true explanation would seem to be
evident, for Reidel and many other surgeons have
repeatedly shown that when the operation of chole-
cystostomy is performed in such instances, the projec-
tion gradually disappears and the conformation of
the liver slowly returns to the normal. As a rule,
a well-fitting abdominal belt is all that is to be
recommended. Byron Robinson's inflatable rubber
pad is approved by some of the best-known surgeons
in this country and abroad. But when these means
fail or are inapplicable, or where Reidel's lobe cannot
be mechanically dealt with or is extremely painful,
various operative measures have been brought for-
ward. These include removal of Reidel's lobe,
suture to the abdominal wall and cholecystectomy.
The operation of fixing the whole liver was sug-
gested by Kisbert in 1884, and the first total hepato-
pexy was performed by Gerard-Merchant in 1891. In
this . operation a portion of the liver substance is
picked up by a series of sutures of stout silk, and be-
cause of the friability of the liver substance, a special
needle devised by Kousnetzoff should be employed.
Each suture is fixed to the anterior abdominal wall
or to the costal margin. In addition, all parts of
the liver are to be subjected to vigorous gauze fric-
tion, in order to facilitate formations of adhesions.
Mojmkmj{$ PUm
All sorts of modifications have been practiced with
varying results, but the following plan devised by
Moynihan has very many adherents:
"The best plan," says Moynihan, "would seem to
me to be this: To make an incision obliquely about
one inch below the margin of the costal cartilages; to
replace the liver; to secure the anterior edge securely
with several sutures to the costal margin; to pack in
between the liver and the diaphragm and also pos-
sibly beneath the right lobe of the liver many strips
of gauze, which should be left in place a week; to
keep the patient absolutely at rest in bed (with the
foot of the bed elevated a few inches) for at least
one month."
Clark'*
John G. Clark, of Pniladelphia,* notes certain
surgical phases of enteroptosis ; cases of congenital
habitus, the acquired variety, and those following
post-operative adhesions, such as in cases of hernia
and after the removal of large tumors, and he
arrives at the following conclusions:
That all non-surgical means should be exhausted
before resorting to operation. All cases of con-
genital habitus are contraindication? to surgery. The
degree of prolapse is best studied by the X-rays.
When the colon is markedly prolapsed with stasis
and partial obstruction, partial colectomy is indi-
cated. When the sigmoid is the seat of prolapse,
suspension or sigmoidectomy is the operation to
be preferred. An abdominal belt must always be
worn.
A floating kidney bears an important relationship
to splanchnoptosis. Ransahoff says: "Quite often
a movable kidney is only a part of a general visceral
enteroptosis. In a large number of cases of the lat-
ter, observed for a long period by me, the kidney
was the first organ involved. In a secondary way
by traction on the duodenum and colon, the loosening
of the intra-abdominal viscera was seen to follow
in a secondary manner."
The preponderance of floating kidney on the right
side has been attributed to the naturally lower posi-
tion and the proximity of the right lobe of the liver.
Landau holds that the unsupported condition and
the greater length of the right kidney as compared
with the left, is responsible for the preponderance
of right kidney displacements.
When the displaced kidney is part of a general
prolapse, an abdominal supporting bandage sur-
rounding the abdomen from pelvis to abdomen should
be employed as a substitute for the lost intra-ab-
dominal pressure; this should be reinforced by a
pelvis band with lateral steel uprights reaching half
way to the axilla on each side. While the, operation
of nephrorraphy or nephropexy is demanded in in-
termittent hydronephrosis, hematuria, severe pain,
and beginning gastroptosis ; in general enteroptosis,
as pointed out many years ago by Ransohoff (and
whose view in these instances are in general accord
with the profession) ; " . . .the fixation of the
kidney alone is followed by not more than temporary
benefit. Although, as a rule, in cases presenting a
preponderance of nervous symptoms , kidney fixation
is not of permanent benefit, the writer has seen a
number of instances in which permanent good results
were obtained."
WmUrmg tyf ««a
Another organ which may be shifted from its nor-
mal position, either primarily or as a component fac-
tor, in Gle*nard's disease is the spleen. This organ,
* Surgery, Gynecology and Obstetrics, 1908, p. 3S9.
862
Visceral Prolapse Surgically Considered — Hammer
[The American Physician
which normally has a very slight range of move-
ment, may be found in any part of the abdomen.
When freely mobile its excursions in the abdominal
cavity are of wide extent, so much so that it has
been found in a sac of an inguinal hernia. From its
entry into the pelvis it has and is often mistaken
for an ovarian or a uterine tumor. The movable
spleen is always larger than normal and Bland- Sut-
ton remarks that, although it may be freely moved
in the abdomen by the surgeon's hands, and as the
patient turns from side to side it always falls to
the most dependent part, it seems to float upward on
the intestines, "like, a boat on the crest of a billow."
A wandering spleen may affect the pancreas,
especially its tail, and Rokitansky reports a case
where the tail of the pancreas was so pulled upon
that it measured ten inches in length and formed
part of the twisted pedicle, being wound three times
around the splenic artery. In reporting a case of
splanchnoptosis, Kouwer mentioned a spleen in the
pelvis that caused complete prolapse of the uterus,
bladder and vagina.
As a general rule, a wandering spleen is so badly
damaged, either by pre-existing disease or from
rotation on its pedicle developing through its mi-
gration, that splenectomy, rather than splenopexy, is
the demanded operation.
As was previously mentioned, operative proced-
ures are, as a rule, contra-indicated in neurotic in-
dividuals with a symptomatology of Glenard's dis-
ease. Mechanical devices should be given a thorough
trial. Operation should only be done when impera-
tively demanded.
Surgery and Tuberculous Peritonitis
Cancer in the Cervical Stump
Robert T. Frank (Surgery, Gynecology and Obstetrics,
Sept., 1922^) says complete hysterectomy for fibroids of
the uterus is not recommended as a routine measure, be-
cause of its increased mortality over supravaginal ampu-
tation.
Increased care in examining the cervix, before all opera-
tions for uterine conditions are undertaken, is enjoined
and it is suggested that the patients after operation be
warned to note and report bleeding or abnormal dis-
charge.
Studies in Asymptomatic Neurosyphilis
Albert Keidel (/. A. M. A., Sept. 9, 1922) says since
neural invasion occurs in probably all cases of early
syphilis, and the incidence of late symptomatic and asymp-
tomatic neurosyphilis is limited, it is probable, if not cer-
tain, that immune reactions protect the neuraxis. The
character of the early tissue reaction to syphilitic infec-
tion, the intensity, continuity and duration of the thera-
peutic attack, and the occurrence of pregnancy in women,
markedly modify the incidence of neurosyphilis, both
clinical and asymptomatic. An analogy exists between
these factors in human syphilis and the laws of progres-
sion and inverse proportions in animal syphilis.
To the Editor of The American Physician :
Sir: — Looking over some back numbers of The
American Physician I find the excellent contribution
on the subject of Tuberculous Peritonitis on page 35
of the January, 1922, number.
There is one point, however, to which I would take
decided exception. Dr. Forbes states that it was
formerly the custom to perform a laparotomy in
these cases, but of more recent years physicians had
felt that it has not been proven that the success
following this treatment was not due to it, but rather
to the general treatment which had been carried out.
In my own experience improvement has sometimes
been so prompt after a laparotomy that patients
have seemed to gain weight and to improve in general
well-being in less than a week after the peritoneal
cavity was opened. The philosophy of the subject
appears to be concentrated about the idea that open-
ing the peritoneal cavity calls out an immediate hyper-
leucocytosis of high degree. The phagocytes then
promptly attack tubercle bacilli, not in a month or
in a week, but in a day. It is not necessary that
laparotomy should be a formidable affair. It may
not interfere with a single meal on the part of the
patient if one cares to open the peritoneum through
a small incision under local anesthesia.
I am quite in accord with the view of Dr. Forbes
that general treatment of the right sort is of im-
portance not only in cases of tuberculous peritonitis,
Lut in any other sort of tuberculosis.
There should be almost no deaths from this dis-
ease if patients are in the right hands in the pro-
fession and if they are in a position to carry out
plans of the right doctors.
Robert T. Morris, M.D., F.A.C.S.
114 East Fiftv-fourth Street, New York Citv.
Fat Necrosis of Female Breast
Lee and Adair (Surgery, Gynecology and Obstetrics,
April, 1922) report after a study of three cases in addi-
tion to those previously presented state that the present
study furnishes important additional evidence that trau-
matic fat necrosis of the female breast is a disease not
infrequently encountered, and one which must always
be carefully differentiated from carcinoma.
They express the hope that this report may stimulate
surgeons and pathologists to a more careful scrutiny
of the gross and microscopical pathology of all tumors
of the breast in the belief that a thorough search for
evidence will reveal many cases of this disease hitherto
unrecognized, and suggest the possibility that some cases
which in the past may have been diagnosed by the gross
picture alone as carcinoma of the breast may not have
been cancerous in their nature at all, but perhaps true
examples of traumatic fat necrosis.
Doctor Mackenzie Forbes9 Post-Gradnate Diagnostic dinks
A Serin of Thirty Clinic* Emphasizing Diagnosis thai Should he Most Helpful to the General Practitioner
By A. Mackenzie Forbes, M.D., 615 Untamftty St., iloatr— J, Canada
Thirtieth Clinic
Surgeons, Hospitals and Teachers
MANY STRONGLY ob-
ject to the time-hon-
ored practice of writing an
epilogue. They think that a
book should tell its own
story.
Surgery is one of the
divine arts, but this does not mean that all who prac-
tice it are imbued with that breadth of character, that
liberality which calls us to the Divine.
Breadth of character comes from a diversity of
interest. It tends not dnly to add charm to a man's
personality, but it tends to give him sympathy and
consideration for others.
If one examines the roster of operators in any of
our North American hospitals one wonders what time
the surgeon has for study, for breadth of outlook and
for catholicity. In surgery we want architects, not
carpenters. But how many of our surgeons are
architects f
Surgical diagnosis means more as a test of intel-
lectuality than operative technique. The difference is
that difference between the architect and the car-
penter. Yet how much time do our surgeons spend
on diagnosis, at the bedside of the patient or in our
out-patient departments as compared with the time
they spend at the more showy, more theatrical, more
self -advertising work of the operating theatre f The
glamour of the operating theatre hv * over-shadowed
the out-patient department and the \tards from both
of which the greater part of the surgeon's training
should come.
An American railway magnate, before leaving for
a holiday, expressed the desire that his friend, a noted
surgeon, should accompany him. The latter pleaded
that his engagements must debar him from the
proffered pleasure. "Come," said the magnate, "any
carpenter can take your place." There is many a true
word said in jest.
I do not wish to decry the efforts of operating
This last paper is a fitting climax to the
notable series of clinics by Dr. Forbes,
which has stimulated so much interest among
progressive physicians. We believe' you will
find it an inspiration, as we did, — Editors.
surgeons. I do not wish any
one to infer or suggest that
technique is of no impor-
tance. I plead only for
catholicity. The physicians
are the most catholic mem-
bers of our profession. Yet
I remember once having been chided by a surgeon
for having called a physician in consultation in the
case of a patient suffering from an abdominal lesion
of an inflammatory nature. He said, "What can a
physician know compared with my knowledge who
daily opens the abdomen f" It was a question be-
tween appendicitis and pus in the gall bladder. When
the abdomen was opened he who had declared in no
uncertain terms for the latter was nearly drowned
by an out-pouring of pus which surrounded the dis-
eased appendix.
The physician has evidently a broader or better
education than the surgeon. This is shown by a dis-
regard of surgical training shown by surgeons in their
choice of assistants. They choose those who have
been trained as physicians.
A great American surgeon once said that the best
text-book of surgery was Osier's Practice of Medi-
cine. How true!
Diagnosis is a science, operative technique is an
art. Real knowledge comes from the former. Dex-
terity comes from the latter.
The greatest surgeon whom Britain has produced
was an indifferent operator. I think that I may say
with fairness that he who is responsible for our
knowledge of aseptic surgery has done more for the-
world than any surgeon in history.
"Surgeons," said Dean Shepherd, of McGill's Medi-
cal Faculty, many years ago, "should be men of
originality, judgment and a sense of humor." Does
this hold good today with men whose lives are spent
in the operating theatre f
Surely, said my critic, there must be some reason
864
Surgeons, Hospitals and Teachers — Forbes
[The
why so many general surgeons devote their lives to
the theatre, when study, diagnosis and the develop-
ment of character are so important.
Yes, there are two reasons: the first is that the
operating theatre of the teaching hospital is a place
of action and seems to more thoroughly satisfy the
surgeon's ambition than any other part of his work;
the second reason is that a surgeon who is responsible
for one hundred or more patients suffering from acute
conditions can have but little time for any work but
that of the operating theatre.
In our personal opinion the care of twenty-five
patients suffering from acute affections is a great
enough tax for any surgeon.
A critic may ask, What argument has been produced
in the past to justify the allotment of even one
hundred beds to one surgeon f Is not the answer to
this question that so great a number of beds have
often been allotted in the past to provide sufficient
clinical material for the purpose of teaching students?
The contention of the critic is well taken, but is it
taken without considering the facilities for teaching
in the out-patient department of our great hospitals
in which the greater part of teaching should take
place? 1 1
Should not every surgeon personally control an out-
patient department as well as the beds necessary to
accommodate the patients received in that depart-
ment? Diagnosis and emergent treatment should be
taught in the out-door. The student should follow
his teacher, the surgeon, into the wards, there to see
further development. Would this not mean the end
of the oligarchy of surgery? Would this not mean
that our surgeons would be evolved by hard work and
ability rather than by good fortune? Would this not
mean a new breed of surgeons — a class whose life
would be spent in thought, mental development and
teaching?
Tki Gretdtit Qmtiity im Smrgftu it Jmigmnt
Judgment which dictates when to do and when not
to do is of far greater importance than technique.
The practice of routine operations, day aftei day,
day after day, can hardly be conducive to the de-
velopment of this brilliant quality. Indeed, if
technique is desired, the dissecting rooms of the
department of anatomy or the operating rooms of
the department of experimental surgery should be the
best primary school, especially if the surgeon be a
man of originality and genius and has the moral
courage to depart occasionally from the routine and
the prescribed curriculum of teaching in the former
department. The dissecting room in many British
medical schools was, in the past, and may be still,
the high road to surgery, if the candidate possesses
the proper mental qualifications. The Germans ex-
alted pathology and the Americans followed. Thus,
many of our universities and hospitals became water-
logged with made-in-Germany principles. No young
man can be a candidate for high position unless he
well knows the relative usefulness of carbol-fuchsin
and methylene blue. We do not wish to depredate
a knowledge of pathology; on the contrary, we extol
it as we extol all learning, but we do not think that
the present system of training develops originality.
May we ask — are not surgeons today nearly all made
on one pattern and that often a very narrow pat-
tern? Are not some of them so intellectually cir-
cumscribed that they cannot conceive of their being
any other pattern than that in which they themselves
are moulded?
Are candidates for surgical positions chosen be-
cause of their possessing the mental qualities which
will advance the science which is their profession and
exalt the institutions to which they are to be attached
or are they chosen for their orthodoxy? This ortho-
doxy means, has meant, lack of progress, but it also
has meant peace for the intellectual sluggard who
desires no change but the change brought about by
himself.
General surgery embraces all surgery, but the
growth of surgery has been so rapid of recent years
that only a very few surgeons have been sufficiently
gifted to deal efficiently with all types of eases.
The peculiar mentality of some surgeons is well
shown in their attitude towards the surgical specialist
They seem to fear him as a competitor. The gyne-
cologist, although usually a better abdominal surgeon
than the general surgeon, must not be allowed to
remove an appendix, the genito-urinary surgeon may
be allowed to make the diagnosis for the general
surgeon, who often wonders why he, the genito-
urinary surgeon, should be allowed to go further.
Surely, the general surgeon should not object to a
special study being made of any subject or branch of
surgery, if such study either tends to advance the
general knowledge of the subject or the knowledge
of the individual student.
It has been said that a surgeon cannot be great
unless he is a teacher. This is questionable, but it is
generally conceded that hospitals which do the best
work are those in which teaching is done.
In these undemocratic days one cannot be an
operating surgeon unless he is associated with a
hospital, because this association alone gives him the
moral right to operate. One would, indeed, be cul-
pable who opened the cranium for a tumor of the
brain in the patient's private house. For this reason
the hospitals are able to control surgical practice.
Indeed, the surgeon soon becomes their slave, thus
the boards of management of these hospitals which,
of course, are usually composed of business men, do
not hesitate to hold the whip over the surgical pro-
fession. Naturally these committee-men, ignorant of
things surgical and often unconsciously prejudiced,
believe that good surgeons can be picked up any-
Phila., December 1922]
Surgeons, Hospitals and Teachers — Forbes
865
where. It is not long since it was inferred in a
large hospital that it would be very much easier to
get a new surgeon than a new plumber.
If this be the sentiment, how can we expect our
surgeons to be big and broad-minded? Yes, "sur-
geons" can be picked up almost anywhere, just as
tradesmen can be picked up anywhere. But architects
are born and not made, and if we accept the postu-
lates already laid down that a surgeon must be a man
of originality and judgment, that he must be a broad-
minded and big man, certainly our committees of
management will have great difficulty in finding a
successor to the surgeon who is sacrificed for the
plumber.
Every one knows that members of the committee
of management of a hospital sacrifice a great deal of
time to, and are intensely interested in, the manage-
ment of their hospitals. For this all will unite in
their praise, but does it not seem absurd that as
highly technical an institution as a hospital should be
operated exclusively by a committee of men who know
little about hospitals, hospital life or the work which
should be done in a hospital f Business men will
always be invaluable on the financial and general
executive committees of hospitals and public institu-
tions, and especially will they be valuable on those
sections or departments which have to do with the
purchasing of the ordinary necessities.
The only safeguard which a hospital can have
against the lack of technical knowledge on the part
of its committee of management is that at least one-
quarter or one-third of such committee shall be com-
posed of members of the medical profession who are
actually working in the institution and who know
intimately the needs and requirements of the patients
being treated in its wards.
The Executive Committee of a hospital ordinarily
appoint an administrative officer to represent them
and to carry out the actual management of the insti-
tution. The late Mr. J. Ross Robertson, who did so
much for the Children's Hospital in Toronto, used
to declare that the best manager for a hospital was
one who had been trained to manage a hotel.
Of recent years it has been the practice in many
hospitals to appoint a medical man who, having given
up the practice of medicine, has specialized in the
business administration of a hospital. This has many
things to be said in its favor, but there is one very
great danger. A medical man who ceases to prac-
tice medicine, ceases to be a medical man. The dan-
ger lies in the committee of laymen forgetting that
their administrative officer has become a professional
administrator in lines of business administration and
now his judgment of things medical and of medical
men is worth no more than that of a layman. Unless
the executive committee of a hospital fully realize
this important consideration they are liable to be
led into making vital mistakes in the policy of
their hospital and in their dealings with the medical
attendants of their hospital.
Hospitals Art Becoming Commercudiied
Our hospitals are becoming commercialized. They
are losing their old personal and humanitarian touch.
Business efficiency, amalgamations and combines have
so intoxicated our lay friends that they aim at run-
ning our hospitals after the pattern of the Untied
States Steel Corporation or the Canada Cement Com-
pany.
We must not accept as gospel truth the doctrine
that combinations, unions, and mergers make only
for efficiency, economy of administration and every-
thing that is good. Yet, it will be hard to divorce this
from the minds of our business men who have be-
come so accustomed to thinking in terms of mergers
that they are now even carrying this principle into
their religious, social and philanthropic life. Indeed,
we shall be fortunate if we escape dictation as to
where we shall worship, where we shall lie when sick
and afflicted or where we shall die.
The personal touch, that touch which is so important
when dealing with the sick, is not considered. The
sentiment expressed in the words of Hamon, the
great sociologist, is unknown to many business men
of today. "Man is an animal living with a life of
its own and not a machine driven by a will external
to itself." Theoretically, union is strength, but prac-
tically the union which makes machines of men kills
competition and initiative; it is not only oligarchic
and non-democratic, but also soul-destroying. Re-
member the words of Schiller:
"Organization has condemned to crawl like
a snail him. who should have soared like an
eagle. Organization has hot yet produced a
single great man. It is liberty that gives
birth to colossi and extraordinary beitta*."
The rules and regulations of a hospital must be
more elastic than the rules and regulations of a busi-
ness corporation. The first function of a hospital
should be the care of the sick, the second the teach-
ing of the student, the third business efficiency. If
we reverse the order of these, we debase the hospital
to the level of the soulless machine. If we reverse
the order of these, our medical men will become simply
parts of this soulless machine. They will be con-
demned to crawl like snails, they who should have
soared like eagles. Let us remember that a hospita*
is for the care of the sick, that this cannot be prop-
erly carried out unless liberty of thought and action
is part and parcel of the life of those who are re-
sponsible for the care of the sick.
It is true that we have many splendid hospitals
in which the rich can be cared for at a fair cost, and
in which the poor are generously cared for at the
expense of a patriotic and open-handed public, but
866
Surgeons, Hospitals and Teachers — Forbes
[The American Physician
the great majority of the middle class cannot afford
to pay the "fair cost" charged to the rich, and to
beg they are ashamed. Hospitals should be supported
by the state, although they should be managed by
individuals. It is wrong to expect the widow to
spend her mite in the voluntary support of these.
In a democratic society it is absurd to expect our
physicians and surgeons to sacrifice their lives in
unremunerative service in their wards. The govern-
ing class have been so remiss that the widow and
others charitably disposed have had to provide hos-
pital accommodation for the laborers employed in
our large corporations. Many corporations have
made no real provision for their casualties, and the
governments have neither insured these nor insisted
that provision should be made by which they are
insured at the expense of the corporation employing
them, that they may not become the recipient of
the largesse of the non-manufacturing public.
Ttacktrt
It is a great mistake to think that a surgeon or
physician cannot rise to high estate unless he be
associated with a teaching school. We often hear
those who are interested in teaching telling our phy-
sicians and surgeons that they owe their success
to their association as teachers with their university.
While I am quite willing to agree that some surgeons
and physicians may get certain legitimate advertis-
ing by teaching, and especially theatre teaching,
again, while all must realize that, in order to teach
the physician or surgeon must continue to study th>
subjects which he is called upon to teach, I canno*
accept the doctrine that association with a teaching
institution is essential to the professional man's suc-
cess. Let us think of the case of Sir James Mac-
kenzie, a man whose work on cardiac conditions revo
lutionized our knowledge of that subject. Was hv»
not a general practitioner without special connection
with hospital or university f
Let the universities realize that their hold over
their teachers lies neither in the self-interest of the
teacher nor in his financial remuneration, but rather
in the fact that all medical men are brought up in
a school in which there is a certain mental associa-
tion between the teaching and the practice of their
art.
Has it not been said that clinical teachers in medi-
cal colleges are sometimes appointed either because
of their ability as investigators in pathology and
the sciences, their ability as operators or their abil-
ity to advertise the college employing themf Is it
possible that some of them are chosen without re-
gard to their qualifications as teachers f
Neither the initiative of the investigator, the me-
chanical skill of the operator nor the ability to please
will make a teacher. More is required. Teachers
are born and not made. This is said with no de-
sire to depreciate a knowledge of pedagogy, because
we believe in training. Yet, judgment and an in-
herited ability to impart knowledge are the two
great essentials for teaching. It is fortunate for
medical colleges that since the time of Aesculapius
medical practitioners have esteemed the imparting
of knowledge to others as part of their life's work.
University authorities who are impressed with the
misapprehension that teachers in the faculty of medi-
cine receive more than they give are operating on
a principle which is erroneous and cannot be defended.
Hippocrates stated that "Experience is fallacious
and judgment difficult" For this reason the thoughts
expressed in this essay on "Surgeons, Hospitals and
Teachers" may, in some cases, be based on false
premises. There are many big, broad-minded men
who are surgeons. Many surgeons have earned the
attribute of "God's noblemen." There are many hos-
pitals which have not lost the personal touch. There
are many seats of learning which preserve their
ancient virtues. But surgeons, hospitals and teachers
will agree that neither universities, colleges nor hospi-
tals are made by the walls which surround them, nor
are surgeons or teachers made by the intellectual
garments which they wear.
Roentgen-Ray Diagnosis
Franklin W. White says the roentgen-ray method is .
a very delicate one in the diagnosis of chronic changes
in the appendix and clearly shows fixation, kinking,
changes in shape, obliteration, slow emptying of the fecal
material, etc.; in short, it gives many facts about the
appendix, but it does not tell us what to do. Many times
when the report comes from the roentgenologist "chronic
appendicitis," our impulse is to do immediate appendec-
tomy. This is not a wise attitude. Frequently chronic
changes are found, such as poor mobility, small fecal
masses, peculiar shapes, chronic obliteration and mod-
erate delay in emptying, which apparently do the patient
no harm, and often we do not benefit him at all by taking
the appendix out as result of such an examination. I
have been following up quite a series of patients for
four or five years, in whom the roentgen-ray has shown
definite chronic changes in the appendix, and have found
quite a large number in whom these changes apparently
made no difference to the patient at all. He kept his
appendix and was happy.
Hopes of Long Life Blasted
"Secret of long life is work," says an Illinois cen-
tenarian, and thus blasts many a hope.
fhila., December 19221
Successful Treatment of Chronic Diseases — Geyser
867
The Successful Treatment
of
Chronic Diseases
THE PHYSIOLOGICAL RESPONSE OF UVINC CELLS TO AN AGENT MUST
BE OUR GUIDE
By Albert C. Geyser, M.D.,
140 W. 75th St., N. Y. C., and Huntington, L. I.
DURING the last few years physical therapy has
mad* tremendous strides. In the various reha-
bilitation camps many things have been accomplished
that were previously considered impossible. This is
all the more remarkable because all of these cases were
in what we are pleased to consider the "chronic stage"
of disease.
In order to appreciate more fully the underlying
principle involved, it will be necessary to have a thor-
ough understanding of the meaning of the term
"chronic stage."
What is disease t When an individual is in a normal
state of health, .he is not aware that he is the possessor
of any organs; he k at ease with himself. On the
other hand, the moment he becomes aware of the fact
that he has an arm, leg, stomach, liver or any other
organ 6r appendage to hie body, from that moment
on he is at dis-ease with himself. In other words, as
soon as any part of human anatomy functions con-
trary to the laws of physiology, there can no longer
be that mutual co-operation and restraint essential
for body harmony. If body harmony is interfered
with, there is bound to be dis-ease. Disease may be
brought about by physical, chemical or bacterial
agents. When one of these forces affects the body,
the door is opened for all the others. When a person
has met with some injury, there is a locus minoris
.esistantia, a favorable opportunity for bacterial in-
vasion; this in turn causes harmful chemical sub-
stances to enter the blood stream; all of these acting
in concert produce mental depression. The patient
is thoroughly at dis-ease with himself and all of his
surroundings.
All of these enumerated conditions apply more
especially to the acute disease processes.
What U the Ckrtdc Stage?
The individual, injured or attacked by disease,
makes every possible effort for a recovery. Sir Astley
Cooper once said: "Some patients get well with
treatment, some without it, but most of them in spite
pf it." This attempt ajt recovery involve* increased
physiological function. If the injury is of such a
nature that, with all of the available physiology, com-
plete recovery cannot take place, then the patient
suffers in a dual capacity ; the one is the result of the
uncured original injury, the other, the effect of either
hyper or hypo physiologic function. These two con-
ditions we have designated the "chronic stage"
Let us take a hypothetical case. A patient received
a compound fracture of the leg. Infection took place.
As a result of the coccus hemaleticus, local abscess
formed in various parts of the body, the joints became
swollen and painful, chills and fever alternated with
each other. With treatment or without treatment this
patient gradually recovered from the acute attack.
Various tendons and fascia? were bound down by
adhesions causing impairment or loss of function;
the red and white blood corpuscles were used up in
the attempt at repair and the hemogenetic powers of
the individual were inadequate to bring the blood
count up to the normal again ; secondary anemia was
the result. Of course, it was not at all necessary that
our hypothetical case should have met with so serious
an accident as a compound fracture, all that was
needed was an injury to the gum margin causing
pyorrhea. It does not matter where the local infec-
tion is located, nor how it was originally brought
about. Once the machinery is set in motion, there
may be anything from a complete recovery to the
most chronic stage of invalidism. It must also be
apparent that the chronic patient suffers more from
his own perverted physiology than from the original
disease as will be shown in the following cases. The
patient suffered an attack of poliomyelitis. Com-
plete recovery took place from the original infection,
but there remained a paralysis of some one or more
of the extremities. The immediate cause of the paraly-
ysis is a fibrosis in the anterior horn of the spinal
cord. The fibrosis was caused by an inflammatory
process in the cord. Had the inflammation continued
or had it been adequate at the time, it would have
removed this fibrosis by absorption and there would
not have been the chronic stage of poliomyelitis. In
a case of locomotor ataxia the original specific infec-
tion may long since have disappeared from the body,
but the results of the inadequate physiological func-
868
Successful Treatment of Chronic Diseases — Geyser
[The
tion left its traces in the posterior columns of the
cord. Even though the original specific germ is still
in evidence, there is no anti-luetic treatment that will
have the slightest effect upon this chronic stage of
syphilitic ataxia. Another patient suffered from cere-
bral apoplexy. As a result of an undiscovered arterio-
sclerosis, with its consequent high blood pressure,
rupture of a cerebral vessel occurred. The clot
pressed upon the motor cortical area causing a unilat-
eral paralysis. To remove the cause of the hardened
blood vessels may be good therapy, but it will not
clear up the paralysis. Another patient complained
of a tender and much enlarged knee joint. He was
a young man and admitted a Neisser coccus infection,
a urethritis veneria some months previous. Upon
microscopic examination no trace of the germ could
be found, but the chronic stage of the previous ureth-
ritis was much in evidence. The infective agent was
not in the urethra any more, but it was in the joint.
The urethral inflammation was adequate, but the joint
inflammation was inadequate. Enough has been said
to direct your attention to the fact that, as a rule, in
the "chronic" stage of a disease the original cause
may long since have departed, but that the symptoms
of which the patient complains are due principally
to a perverted physiology. This perversion may take
on the form of hyperfunction as chorea, paralysis
agitans, epilepsy, certain psychoses, etc., or it may
appear as a hypofunction, constipation, paralysis,
secondary anemias, glandular enlargements, general
apathy, etc. In either case perverted physiological
function is the basis of the chronic stage of most of
diseases.
Treatment
Whatever the method of treatment is, it must be in
harmony with physiology. Without fear of contra-
diction, I make the sweeping statement that any thera-
peutic measure not in harmony with physiology is of
questionable value, no matter what the apparent clin-
ical results may be.
What is physiological therapy f
It is much easier to state what is not physiological
therapy than what w.
Of one thing you may rest assured, "It is not the
agent, but the physiological reaction of living cells
to an agent that must be our guide in applied thera-
peutics." Much though we may question or even con-
demn Christian Science, faith cures, osteopathy, chiro-
practic and other cults, let me say to you, that while
I am not in sympathy with such cults on general prin-
ciples, every one or all of these measures, if employed
in such a manner as to evoke the proper physiological
response, become physiological agents. There are
many of my school who decry homeopathy. The
main fault that I find with homeopathy is that Hahne-
mann was born 100 years too soon — he was ahead of
his time. He was looking and striving for agents
that would produce proper physiological responses.
Since every chronic stage implies more than one
and as a rule several different physiologically per-
verted functions, it is evident that our first rule should
be to treat the patient and not the disease, A second
rule is to make a clinical diagnosis first, confirmed
by the laboratory later. If your clinical diagnosis
was correct the laboratory confirmed it. In New
York City we have typhoid Mary; I believe here in
Chicago her counterpart has been found. These per-
sons are healthy carriers of typhoid germs — they
themselves are immune to the disease. If either of
these should be taken sick, your clinical diagnosis
might have been a broken bone or even a case of par-
turition, but the laboratory diagnosis, based upon an
examination of the dejectu or the blood, but not upon
the patient, would have made it typhoid fever.
Having based your diagnosis upon the perverted
physiology, you may not have been able to label the
chronic disease, you may not have found an express-
ive nomenclature, but you will have known what
ailed the patient.
Every chronic patient requires specific and gen-
eral therapy. Since the scope of my paper does not
permit me to consider specific therapy, I will omit
that entirely. According to the laws of physiology
all metabolism is carried on in the capillaries. Nerve
shock or toxic agents in the blood stream cause spasm
of the capillaries. If the spasm is continued long
enough, from the want of nutrition, the spasm changes
to dilation, capillary paralysis, which produces stasis.
Either one or the other condition is bound to be pres-
ent in every chronic state. I need not waste your
time in picturing the consequences. There are many
agents that will overcome either of these conditions.
The question is, are they physiological agents f Capil-
lary spasm is quickly overcome by nitro-glycerine,
capillary stasis frequently yields to strychnine. The
first one causes paralysis in a spastic vessel, the sec-
ond causes spasm in a paralyzed vessel — enough said.
Hot and cold baths produce physiological responses.
The best and most convenient agent is diathermia
from a high-frequency apparatus. Diathermia, as
the name implies, heats the part through and through.
Heat is a normal physiological property of the hu-
man body. Heat dilates the spastic capillaries, allows
hot blood to course through them, thereby bringing
the nutriment of the blood stream where it is most
needed. In capillary stasis, the vis a tergo (power
from behind) causes the stationary blood and lymph
to be propelled onwards; as soon as new hot blood
reaches the paralyzed capillaries they contract to
normal because it is physiological for them to do
so. In every chronic stage either one or both condi-
tions are present; diathermia is the indicated physic-
logical agent. Through its effect new tissue is pro-
duced, old is absorbed, both of these conditions are
PhOa., December 1922]
Successful Treatment of Chronic Diseases — Geyser
869
necessary in every chronic disease.
The next important consideration is the condition
of the blood, for, after all, but little is gained by a
dilatation of the capillaries if the wandering cells are
insufficient to perform their physiological function.
How to increase the wandering cells T
It requires no proof on my part to say that col-
loidal iron is the best agent to stimulate the in-
creased production of the red blood cells. It has
been conclusively proven that iron as prepared in a
colloidal state can be introduced directly into the
blood stream by the intravenous method in enor-
mously larger quantities than is usually supposed. I
have seen the red cell count increased by 1,000,000
after the fourth injection. It is not enough to simply
increase the red cell count. Of even more importance
is a leucocytosis. A single intravenous injection of
sodium iodide, 30 grams, will show a reaction within
one hour. The leucocytes are the scavengers. It is
as important to remove the old as it is to renew worn-
out tissue. Both of these drugs when used intra-
venously produce physiological responses. They are
indicated in every chronic disease. So far we have
used diathermia to dilate the capillaries and to over-
come stasis, we have increased the erythrocites with
colloidal iron, we have stimulated leucocytosis with
sodium iodide. At this stage the condition of our
chronic patient may be compared with that of a horse
that is properly stabled and well fed. Something
else is now required, we must create the perform-
ance of physiological function. I do not suppose
that there are manv doctors here who still drive a
horse, but those of you who have ever driven one
know only too well what would happen if the horse
was well stabled and well fed, but not well exercised.
How can a rheumatic, gouty, anemic, despondent
or neuralgic patient take proper exercise?
The performance of all physiological function de-
pends upon tissue contractions and relaxations.
There certainly is no doubt about that. Neither
massage nor passive motion cause muscular contrac-
tion. Besides the patient's own effort there is only one
agent which can produce the desired effect and that
is a faradic current. The galvanic current is contra-
indicated because it causes electrolvsis which is un-
physiological. It can only cause muscular contractions
during the make and break of the current. A muscle
is never in a state of contraction during the time
while the galvanic current is flowing. The faradic
current, by means of its vibrator spring, is opened
and closed any desired number of times per second.
Muscular contractions and relaxations require time
for their performance; when the rate of interruption
is higher than 30 per second, there is not enough time
for complete relaxation and the muscle assumes a
state of tetanus. This tetanic condition becomes more
and more manifest as the oscillations increase in fre-
quency until they reach about 3000 per second and
is stationary or at its maximum up to about 5000 per
second.
If the rate of vibrations is still further increased,
the muscle gradually returns to a flaccid condition
because it can no longer respond; it no longer appre-
ciates the individual stimuli, consequently there is no
physiological response. Such observations compel us
to accept the vibratory theory of all living cells.
Biologically all cells are fundamentally alike; they
may differ in construction, size or function, but their
vibration is their manifestation of life; their rest is
death. It was for this reason that diathermia was
used to relax spasm in the capillaries. The alterna-
tions of the diathermia current are 1,000,000 per sec-
ond; they cannot evoke muscular contraction, their
energy is all converted into tissue heat.
The faradic current can be easily so attuned as to
give any number of vibrations per second ranging
from 30 to 3000. The faradic current must be con-
structed to meet physiological requirements, the cur-
rent must start at zero, gradually increase in strength,
then gradually decrease again to zero. This current
must not reverse itself, it must not be a true sinu-
soidal; it must flow in the same direction throughout
all of its curves.
Why h the SimwsoM Umpkysiologic?
While sensory nerves carry impulses from the
periphery to the center, motor impulses can only
travel from the center to the periphery. In general
practice we are apt to lose sight of the fact that all
tissue, in fact, every cell, can only perform thai par*
ticular function for which it was intended — it cannot
perform any other and remain within the domain of
physiology. Since it is our desire to aid in the resto-
ration of physiological function, it is certain that in
order to produce muscular contractions and relaxa-
tions, the artificial impulses produced by the faradic
current must travel in the same direction, over the
same route, as the normal impulses produced either
in the brain or spinal cord. In other words, the posi-
tive electrode must be placed over the spinal origin
of the nerve, while the negative pole rests over the
muscle, tissue or organ to be affected. The direction
of the current must never be reversed. The much-
vaunted sinusoidal current is entirely out of place
under these circumstances.
Conclusions
1. It is assumed that a correct diagnosis has been
made of the primary cause, that this cause has been
removed or compensated for; that the special treat-
ment as demanded by each special case has been used
prior to or in conjunction with general therapy.
2. A clinical diagnosis must be made first, later
this may be confirmed by the laboratory.
3. The average chronic patient does not suffer «*o
870
Gonococcemia mud Metastatic Gonorrhea — Goldstein
[The
much from his original disease as he does from per-
verted or arrested physiological function.
4. Our effort must be directed toward restoring to
normal as near as possible the individual's physiology.
5. To do this requires the selection of agents capa-
ble of calling for the physiological responses.
6. These are primarily diathermia for its capillary
effect, cocodillate of iron to overcome the anemia,
sodium iodide to increase the leucocytes, these drags
to be given intravenously, a faradic current applied
in a physiological manner for the purpose of tissue
contraction and relaxation.
7. Treat the patient, but do not treat the disease,
8. Remember: It is not the agent, but the physiolog-
ical response of living cells to an agent that must be
our guide in therapeutics.
Gonococcemia and Metastatic Gonorrhea
Stressing Gonorrheal Arthritis
THE SECOND SECTION OP THIS PRACTICAL PAPER PUBLISHED IN THREE SECTIONS. THIS
SECTION COVERS PARTICULARLY DIAGNOSIS AND PROGNOSIS. THE FIRST SECTION
GIVING SYMPTOMATOLOGY AND PATHOLOGY APPEARED IN THE NOVEMBER ISSUE
By Hyman I. Goldstein, M.D.,
1425 Broadway, Camden, N. J.
Assistant Visiting Physician and Chief of the Medical
Clinic, Northwestern General Hospital, Philadel-
phia; Assistant in Medicine, Graduate Medical
School, University of Pennsylvania, Phila-
delphia; Assistant Visiting Physician,
Philadelphia General Hospital.
Diagnosis must be made from acute rheumatism,
gout ("rheumatic"), tuberculous arthritis, acute luetic
synovitis, from acute arthritis of infants and Still's
disease, acute epiphysitis in children, and various
forms of septic and syphilitic ostitis, hypertrophic
and atrophic arthritis. In children, acute epiphy-
sitis may be confounded with gonorrheal arthritis,
as may also various forms of septic and syphilitic
ostitis.
The gonorrheal process is more gradual and milder
than acute articular rheumatism, resolution is slower,
is not common in women, and, as a rule, is less febrile
than acute articular rheumatism. Cardiac complica-
tions are exceptional as compared to rheumatism.
The joints affected are not so numerous and not
typically jumping in character as in rheumatism. The
disease frequently arises after painful instrumenta-
tion in cases of gleet and stricture. So-called articular
rheumatism, occurring in pregnancy and the puer-
perium, is often metastatic gonorrheal arthritis, be-
cause pregnancy, labor and the puerperium favor the
development of metastatic gonorrheal infection in
women. In women, the wrist joint is most frequently
affected, and in men, the knee joint (Nasse). There
is less prostration and sweat, and less tendency to
migrate from joint to joint, and the less frequent
occurrence of endocarditis than in acute rheumatism,
are important aids in the diagnosis. Blood cultures
may show gonococci. The complement fixation test
for gonorrhea would be positive and the gonococci
could be found in smears. The history of a urethral
discharge, being recently cleared up, would lead to a
correct diagnosis of metastatic gonorrheal arthritis.
Leucocytosis may be absent in gonorrheal conditions.
Gonorrheal rheumatism shows a tendency to go on to
recovery and may clear up in four to six weeks
with any treatment. The salicylates do no good in
gonorrheal arthritis, whereas if the case were a true
articular rheumatism, improvement would take place
under large doses of the salicylates. It has been
suggested that vaccines be used in diagnosing obscure
cases of arthritis of suspected gonorrheal origin.
In children, joint tuberculosis can be differentiated
by the usually slow advent of the condition, absence
of great tenderness, swelling or redness — but rather
a doughiness is present.. There is early rigidity of
muscles and fixation of the joint in tuberculosis. The
presence of vulvo-vaginitis or ophthalmia neona-
torum or a urethritis and the discovery of the gono-
coccus in the effusion, would settle the diagnosis. In
children, in gonorrheal osteo-arthritis, bone rarefac-
tion can be shown by the X-ray very early, even in
the first few days If there is no rarefaction, the dis-
ease has probably settled within the capsule.
Park and Krumwiede conclude that the non-speeffic
response to vaccines is of importance in gonorrheal
infections, and that a reaction following gonococcus
vaccine is of therapeutic value. Also, that a positive
focal reaction is not only of value as a guide to
dosage, but is of diagnostic importance; the absence
of reaction is not.
Aspiration of fluid may give information of the
Phila., December 1922]
Gonococcemia mud Metastatic Gonorrhea — Goldstein
871
greatest therapeutic and diagnostic value. Gonococci
may be obtained from the aspirated fluid. Cabot urges
that all monarticular infections of any seriousness or
obstinacy should be tapped.
The age of the patient is important. Most of our
patients are young men between eighteen and twenty-
five.
Hypertrophic Arthritis
Hypertrophic arthritis does not attack the hip, knee,
ankle, sacro-iliac joints, etc., in a man of twenty or
twenty-five. In the hip joint, hypertrophic arthritis
constitutes malum coxae senilis, leaving young men
unscathed. Arthritis deformans may, in some cases,
cause some errors in diagnosis — at the time of acute
exacerbations, or in cases of a recent or chronic
urethritis and leucorrhea.
Atrophic arthritis might involve these large joints
in a young man, but always involves other joints as
well, especially those of the hand, and it is very
prone to be symmetrically distributed — e. g., both ring
fingers, both feet, both wrists, both hips, etc. How-
ever, if a young man has subacute or chronic pain
in both feet without evidence of flat feet, gout nmv
be suspected. Of course, a gouty person may have
gonorrhea. It is also true that a patient having a
four plus Wassermann may also have an arthritis
due to a previous gonorrheal infection; in such an
instance the gonorrheal fixation test would also be
positive.
Irons (Archives Internal Medicine, Vol. I, No. 4,
p. 433) states that the injection of one-half billion
killed gonococci into the tissues of a person free from
gonococcal infection was found to cause practically
no constitutional disturbances in eight cases. In in-
fected cases, however, results were quite different.
Within twenty-four hours, and corresponding to the
negative phase, there was increased articular pain,
rise in temperature, and general malaise. It was
therefore suggested, because of the pronounced reac-
tion, that the injection of killed gonococci be employed
as a diagnostic agent in cases of doubtful gonococcic
infection.
In gout the patient is probably a middle-aged man,
living well rather than wisely, getting a sudden at-
tack of pain, especially in the great toe, ankle, knee
or wrist. The swelling of the toe is the most charac-
teristic; the metacarpophalangeal joint is tensely
swollen, livid and glossy, and he may have gouty
tophi around the small joints and in helix of ear;
there is no recent history of gonorrheal urethritis.
Infectious arthritis must be ruled out in a septic
arthritis. The history of the case, the presence of a
focus of infection, caries, osteomyelitis, or some re-
cent acute infectious disease like typhoid fever, pneu-
monia, or scarlet fever, will help to clear up the
diagnosis. Meningococcic and pneumococcic arthritis
must also be excluded.
Sex — Joimt Predilection
Women are singularly exempt from gonorrheal
arthritis; the female sex escapes almost entirely
(adults).
Many cases are diagnosed as chronic rheumatism,
neuralgia, neuritis, etc., attributed to focal infections
of the teeth, sinuses, tonsils, yet are due to gonorrheal
infection, recent or remote. In the differential diag-'
nosis, one must remember, too, that a gonorrheal in-
fection may occur in a rheumatic patient; a person
having gonorrhea may also develop an acute (artic-
ular) rheumatic fever (polyarticular rheumatism).
However, in cases where only a limited number of
joints are involved, without migration and associated
with a urethral discharge containing the small, round
or oval gonococci of Neisser and Bumm in the pus
cells easily stained with the alkaline solution of
methylene-blue, and their failure to stain by Gram's
method — with or without endocardial involvement and
the possible implication of the sternoclavicular or
tempero-maxillary or vertebral articulations, make
the differential diagnosis between gonorrheal and
articular rheumatism an easy matter.
Finally, gonorrheal rheumatism does not, as a rule,
give rise to very acute constitutional disturbance —
this is usually a transient one only. It is more or
less fixed, and has little tendency to change its local-
ity; the tendency to become multilocated is not
marked, and there is only a slight tendency to cardiac
complications. Of course, there rarely may be a
pericarditis, myocarditis, and endocarditis, or even
a pancarditis. Be that as it may, "gonorrheal rheu-
matism" is a bad term and should be abandoned.
According to Northrup, Finger, Benecke, the knee,
ankle, wrist, elbow, shoulder, hip, small joints of
hands, small joints of foot, heel and toes, tempero-
maxillary, and sterno-clavicular articulations were
affected in the above order of frequency; out of six
hundred and fifty-five articulations involved, the knee
was involved two hundred and fifty-eight times, the
ankle one hundred and twenty-five and the wrist
seventy-six times.
BmcUriology and Immunity
Gonococci can be grown best on Vedder's medium
(ordinary beef infusion agar — 1.5% agar, to which
1% cornstarch is added), or Wright-Steinschneider's
medium, consisting of urine, human or bovine blood
serum and nutrient agar-agar, or Lipschutz's medium,
made with nutrient agar-agar or ordinary bouillon
and pulverized egg-albumen called "egg-albumen
agar" or "egg-albumen-bouillon" medium, on which
micrococcus gonorrhoeae grows very satisfactorily. The
micrococcus gonorrhoeae is differentiated from the more
common pyogenic organisms by certain peculiarities —
1, in gonorrheal pus, it is nearly always within the
protoplasmic bodies of pus cells; 2, it stains readily
with the ordinary staining reagents, but loses its
872
Gonococcemia mud Metastatic Gonorrhea — Goldstein
[Tfct American Pfcyacitt
color when treated by Gram's method; 3, it is not
pathogenic for animals — such as are ordinarily used
in the laboratory, and is without pathogenic prop-
erties for horses, dogs, and monkeys, etc.; 4, it is
practically always seen in the form of diplococci,
the pair of individual cells having the appearance
of two hemispheres with the diameters opposed, and
separated from one another by a narrow, colorless
slit; 5, it does not develop upon any of the ordinary
nutrient media and is isolated in culture through the
employment of special methods, all including some
nutrient substance supplied by blood or blood serum ;
6, Wherry and Oliver (Forcheimer's — Ernest E.
Irons), Journal of Infectious Diseases, 1916, XIX,
288, say it is a micro-aerophile or partial tension
organism (grows best when placed under conditions
of partial oxygen tension).
Specific Tkermpy
Dr. B. C. Corbus, of Chicago (/. A, M. A.,
5-9-1914), reported a series of twenty-four cases
treated with antigonococcus serum. He recommends
36-45 c.c. as the dose; he gave his patients the serum
intramuscularly, but believes that intravenous admin-
istration would be followed by more rapid recovery
with a possibility of using less serum.
Block (Cor.-BL /. schweitz. Aerzte, 1914, XLIV,
No. 44) saw improvement in gonococcal arthritis fol-
lowing the injection of typhoid vaccine, as well as
following gonococcal vaccine, and suggests that the
improvement may be due to non-specific effects of
the reaction on gonococcus infection.
A man can usually not be reinfected by a woman
upon whom he has conferred the disease. The gono-
coccus only confers a relative immunity to the per-
son who harbors it. Relapses of a given attack are
less severe than the initial attack. No immunity,
or a very slight one, exists after a cured attack.
Subsequent attacks are milder, though they may be
even more complicated, than the initial attack.
In the severe cases, there is more apt to be a
pararticular infiltration and serious joint disability.
Cases may be mild and result in no disability what-
soever. There is a tendency to form adhesions, con-
traction of joint appendages, and surrounding mus-
cles. An osteo-arthritis may occur. At the beginning,
there is a focus with an area of rarefaction around
it, or a diffuse infiltration of the articular end of the
bone. The infection may spread rapidly to the joint
surface itself, and thus destroy the cartilage and
invade the interior of the joint, the joint involvement
being secondary in osteo-arthritis. These cases may
go on to resolution, without loss of joint motion.
Osteophytes and spicules and other thickenings of
the periosteum, as a result of proliferation, may take
place and thus limit motion. Complete bony anky-
losis may result in cases where the cartilages are com-
pletely destroyed. Bone rarefaction appears, as a
rule, within the first few days of an osteo-arthritis,
and never appears in arthritis at any stage — the
X-rays, therefore, are very useful. With an absence
of rarefaction and presence of arthritis alone demon-
strated, one can be reasonably certain that there will
not be any bony destruction or bony ankylosis. Where
rarefaction is present, the prognosis is not good —
bone destruction and some permanent disability is
sure to result, because of a primary bone focus of
infection. In the worst cases, arthritis alone may
at times end in fibrous ankylosis.
I wish to report a few cases of metastatic gonor-
rhea and emphasize a few points in the treatment
and diagnosis of this disease:
Case I— Young man. Negative family history. Had
second attack of gonorrhea for three weeks, when he
developed fever 100°-103°; chills; became nervous and
restless, and had severe pain in the hip and wrist
Previous medical history negative. Wassermann test
negative. Blood complement fixation test for gonorrhea
was positive. Urethral smears showed gonococci. Widal
and malarial smears were negative. Secondary anemia
present R. B. C. 4, 160,000, Hb 75%. This was a case
of gonococcemia with severe arthritic pains. Gono-
coccus vaccine and antigonococcic serum given subcu-
taneously and intravenously gave prompt relief.
After the antigonococcic serum and mixed gonococcus
vaccine were stopped, and while he was in the hospital,
he developed a marked inflammation of the knee, which
I believe might have been prevented by the continued
use of the vaccine and serum.
Case II— June 7, 1917. M.C. Little girl. 3 years old.
Father had an acute gonorrhea — mother gave positive
smears. Father's Wassermann was negative Shortly
after their return from a vacation period, the child devel-
oped a yellowish vaginal discharge and this was quickly
followed by enlargement and painful swelling of joints
of wrist and little (right) finger. There was a slight
rise in temperature. The condition existed for several
weeks when the child was first seen by me. I found
gonococci in the smears, and ordered argyrol in solution
and in 10.% ointment for the local condition. The
injection of polyvalent gonococcus vaccine (combined),
gave rapid relief — followed by a cure of the arthritis
and the vulvo-vaginitis.
Case III — Mr. B. Acute gonorrhea. Beginning of
third week, developed a marked swelling of wrist, and
ankle joints, later the elbow and knee became affected.
He tried to treat the urethritis himself, with various
remedies purchased at drug stores, and when he came
to me the urethral discharge was free and his wrist
and ankle joints were badly inflamed. After a long
stormy convalescence, he finally recovered. Treatment
consisted chiefly of the injection of argyrol solution for
the urethritis, prostatic massage and the use of huge
doses of vaccine. No serum was used in this case.
I now believe that had large doses of antigonococcic
serum also been given, he would have improved much
more rapidly, and it is possible that the later involvement
of knee and elbow joints would have been prevented
altogether.
PhUa.( December 1922]
Gonococcemia mud Metastatic Gonorrhea — Goldstein
873
Case IV— G. L. January, 1918. Age 43. Had gon-
orrhea twice. Pains in head and joints. Wasserman
negative. Prostate enlarged and tender. Complement
fixation for gonorrhea positive. Proctoscopic examina-
tion showed fissure in ano. Blood P.— S. 128, D. 76.
Heart and lungs, negative. Urine, negative. X-ray
head, negative. Prostatic massage and vaccine gave
him prompt relief and ultimate cure, after he had gone
about without a correct diagnosis and without obtaining
any relief for over two year9. In this case the examina-
tion of the prostate and the blood complement fixation
test for gonorrhea cleared up the diagnosis. His pros-
tatic condition was no doubt the focus of infection
causing his trouble.
The complement fixation test is most valuable in
systemic gonococcus infections ; the result is positive in
all such cases. If there is a history of gonococcic in-
fection no matter how remote, employ this test, when
the diagnosis is in doubt.
Case V— Mr. Valentine Y. Age 44. White Polish
man, well built and robust in appearance. Sick for the
past four or five weeks. Had a severe toothache four
or five weeks ago with an abscess swelling from a de-
cayed lower left molar. This tooth and a neighboring
tooth were extracted a few days ago. The tooth
abscess began eight or ten days ago. Says he never
had rheumatism and denies venereal disease. Married
24 years. Two children were born during the first two
years of married life. One died at nineteen months
and the second died a few minutes after birth. Wife
has not been pregnant since. Has been working in
leather factory, handled lime and raw hides.
Examination. Man very toxic Markedly dyspnoeic.
Appeared very dangerously ill from some septic con-
dition. Lungs moist, heart sounds feeble, endocarditis
and threatening pulmonary edema. Mouth in bad con-
dition. Right shoulder and left knee swollen and tender.
Says the left shoulder began to pain and swell eight days
ago, then the left knee began to swell and pain several
days later. Right parotitis present, says swelling began
three days ago. Has had chills, fever, sweats, every
day, several times a day for the past two weeks. No
urethral discharge evident. Prostatic examination prac-
tically negative except for some tenderness on pressure
No smear obtained for examination; Urine: albumin
present, sp.gr. 1.017. Total solids 37.6 gms. per liter.
Amorphous urates present. Many pus cells, huge num-
bers of granular casts, no sugar, no acetone, no indican,
acid reaction. Two Wassermann blood tests negative.
Complement for fixation of gonorrhea positive. Blood
cultures by two laboratories have so far shown no
growth. W. B. C. 38,600, Polymorphonuclears 85%,
S. M. 13%, L. M. 2%.
There was no evidence of external or internal anthrax,
neither pulmonary nor gastrointestinal anthrax. The
conditions found and contributing to the man's serious
illness and death were general septicemia (gonococcal),
endocarditis, septic arthritis, parotitis, pulmonary edema.
I first saw the man about 20 hours before his death.
He received combined gonococcal and streptococcal
vaccines and intravenous injections of serum. For the
pulmonary edema and the cardiac dilatation he received
atropine with adrenalin and digalen, digitan or digifoline.
He was also given alkaline water to drink.
Whether the condition of the mouth and teeth
had anything to do with the man's illness in this case
is difficult to say. He had a marked leucocytosis and
a positive complement fixation test for gonorrhoea,
with the condition of the heart, left knee and right
shoulder and the parotid gland as mentioned above,
without any history of previous attacks of rheuma-
tism, sore throat, or trouble with the mouth or joints,
leads one to believe that this was probably a case of
metastatic gonorrhoea and gonococcemia.
KarmtaaU Bltmmoirkagicm (Gonorrheal Keratosis)
Not many instances of this condition have been re-
ported during the past five or ten years. McDowell
(N. T. M. J., May 3, 1922) recently reported a well
defined case in a man who had had three attacks of
gonorrhea. He had pains in the right hip and ankle
joint. There were a number of elevated crusts, waxy
in appearance, on the right knee, thigh and hip and
left leg and back. McDonagh's colloidal therapy (in-
tramine) was used with good results.
Wadrack in 1917, was able to demonstrate a few
gonococci from lesions of his case.
tmrniU speaks of two forms — the localized, involv-
ing the feet and hands, and the generalized. Vidal
(1893), Turnbull and Sequeira (1910), Simpson
(1912), Haase, Wadrack, Buschke, Baermann, Roth,
Graham Little, Brown and Davidson (1918), and
others have reported cases of this condition.
According to Stelwagon and Gaskill (1921, Page
553, Ninth Ed.), Vidal was the first to describe this
rare condition.
Spontaneous involution of the eruption takes place
with the subsidence of the arthritic symptoms. Simp-
son found sulphur and resorcin in ointment beneficial.
Sequeira used gonococcal vaccine with favorable re-
sults.
In this condition the palmar and plantar epider-
mis may become quite thick, with irregular and uneven
horny looking, waxy or brownish crusts or projec-
tions. There may be some large waxy nodules, and
horny capped postules. The eruption may involve the
hands only, or both hands and feet. There is very
little if any hyperemia.
Costa and Coram (Jour, de Radiologic et d'Electro-
logie, Paris, Feb., 1921, p. 49), in their paper on
"Gonococcus Rheumatism/' state that in cases of
chronic gonococcus arthritis the roentgenograms show
that the tendency of the bone is to osteoporosis, just
as tuberculosis tends to necrosis.
CONCLUDING SECTION
The third and concluding section of Dr. Goldstein's
paper dealing with treatment and giving a very exten-
sive list of references will be published in the January
issue.
, I
The Best Health Servid(
Proper Recognition of the Fundament
The General Physician
The Service of the General Physician Cannot Be Adequately
Performed by Any Other Agency
"IT'S BETTER TO BUILD FRIENDSHIPS
THAN BATTLESHIPS," says Sir Harry Lauder.
For twenty-seven years we have been doing that,
you and this publication, and we are getting to feel
more and more brotherlv with the Medical Profession
as the years go by. And now the time has come
to renew our mutual pledges of friendship, as sub-
scribers and publishers must do if they really serve
each other, for 1923 is just around the corner. We
want to set forth our plans and specifications for
the 1923 American Physician and build — with your
help — a more enduring tower of friendship than was
ever built before in medical journalism. Medicine
in the abstract is well-represented in many medical
publications, but The American Physician repre-
sents the Medical Man in the concrete.
Mission W Service
The American Physician's mission of sendee is to
reassert the fundamental importance of the general
physician. We are in a time of medical change — old
landmarks are passing and a reorganized form of
medical service will, without question, be developed.
This publication believes the nucleus of any efficient
and lasting medical service must be the general
physician.
The PmbUc Is N« S*u£ed
The public is not getting the service from the
medical profession that satisfies it, regardless of
what the medical profession may think. That is why
certain pseudo-scientific cults like chiropractic make
headway. While recognizing the true value of sur-
gery, unnecessary "cutting" will be tolerated less and
less. The present fad — specialist group practice —
is not the answer. While there is a core of good
constructive thought in it, which will remain after
the glamour of a new fad has gone> there is very
great danger of the idea being overdone.
Passing the Patient At— mi
Any idea in group practice which competes with
the general physician, we feel, is wrongly based. The
great constructive place of the general physician can-
not be taken by a group of specialists passing a
patient around among them, each one interested in
his particular pet specialty and no one interested in
the organism as a whole — in the individual patient
and his well-being. The general physician is the
vital link between patient and specialist; he must
manage the case.
Bidding Technie Rather Thorn It* Human Application
DOCTOR, DID YOU EVER think over the pres-
ent situation in medicine and come to a realization
of the fact that medicine itself is not losing out, is
not degenerating, is not failing to meet the needs of
the times, and is not losing in popular esteem f It
is the present inadequate Human Side in the applica-
tion of medicine that is under fire, just as it is this
same human side that is the trouble in industrial,
racial, governmental and social relationships. The
head of the world has marched ahead of the heart,
the intellect has outstripped the understanding, and
we are studying problems instead of Men. Building
battleships has spoiled us for building homes, and
— even in medicine — we have been building technie
rather than human application of the same in friend-
ship and love of the race.
WE MAY BE A BIT OLD-FASHIONED, for we
The Human Side of the Application of Medical Science
Is Being Buried Under Mountains of Technie.
r the People Demands
ortance and Fundamental Position of
remember the Doctor as he used to be and as he may
be again — a balanced, dignified and lovable Man who
really knew his patients, not merely some one spe-
cialized phase of their disceased organisms and their
ratings in Bradstreet's.
THERE'S AN AWFUL LOT OF GOOD in the
things that have so upset us and the profession at
large: don't forget that fact for a minute. The
slipshod way of practicing medicine that the public
is tired of is destined to extinction, but the public
is also tired of having to be passed from specialist
to specialist, card-indexed, surveyed, and treated as
so much "material," when in need of medical service.
Xo wonder some very human but pseudo-scientific
cults are flourishing. There's too much instrumenta-
tion, too much operating, and too little general care
based on painstaking physical examinations and
sound sense, And the public knows it, despite its
admiration of what preventive medicine and research
have done and are doing. It feels it is being ex-
ploited by specialists, group clinics and faddists, and
that much of the contact of modern medicine with
sick people is wrongly based, is pretentiously com-
mercialized, in fact, if not in name, and the people
are getting ready to demand that the General Phy-
sicians take charge again and give sick and injured
humanity a square deal.
The Central Nndeus
THE GENERAL PHYSICIAN is the one who
knows the patient as a whole, who is cognizant of
all developed disease conditions and many threatened
ones, who knows the individual characteristics and
idiosyncrasies of his patient, and he it is who should
decide upon any surgical or special intervention and
manage the situation, from the hygiene that keeps
the organism properly functioning to the radical
intervention needed in emergency. Around him, as
a central nucleus, all medical service should be built,
from preventive medicine to the special technical
skill needed in regional surgery and special treat-
ment.
A Sommd BmsU for 1923
IN 1923 we are starting special efforts to regen-
erate and place on a sound basis the up-to-date form
of general practice the public is demanding. It is
high time to reassert the proper position and pres-
tige of the General Physician. We will not do this
simply by propaganda, and least of all by printing
ill-natured or carping articles. We side right in with
all of the proper aspirations and efforts of organized
medicine, which is, latterly, moving in the same
general direction we have long been advocating. We
will print original papers and editorial and other
comment of a nature to aid the General Physician
in taking the place the logic of events and the ten-
dencies of the times are fast preparing for him.
Doctor, remember the parable of the five wise and
the five foolish virgins; put plenty of oil in your
lamp and keep it trimmed and burning. Let us
help you to do these things.
The Following Are Some of the
Splendid Papers to be Published During 1923
Medicine
Non-Specific Ulcerations of the Genitalia, by N. E.
Aronstam, M.D.
Treatment of Aortic Diseases of Syphilitic Origin,*
by W. Busch, M.D., D.Nat.Sc, and E. Ahl-
swede, M. D., Germany.
Some Aftermaths of the Influenza Epidemic, by P.
F. Carlucci, M.D.
Rectal Findings in Mucous Colitis, by E. Jay dem-
ons, M.D.
(Papers for 1923 Continued
Some Experiences With Transduodenal Lavage, by
F. Ellsworth Clow, M.D.
Post-Operative Pneumonia — With Report of Cases,
by M. L. Dalton, M.D.
The Causes and Treatment of Constipation, by At-
water L. Douglas, M.D.
Syphilis of the Rectum, by Charles J. Drueck, M.D.
The Modern Treatment of Tetanus, by G. S. Foster,
M.D.
on Following Ttpo Pages)
The General Physician Is the Man to Manage the Case
Around him, as a central nucleus, all medical service should bejbuilt^
It Is High Time
The Proper Position
Splendid Papers to be Published During 1923
(Annual Announcements Continued from Preceding Page)
Goitre Classification and Treatment, by Drs. £. B.
and N. W. Gillette.
"Obesity/' by Hyman I; Goldstein, M.D.
Deviations in Blood Pressure, by D. S. Hanson, M.D.
Phlebitis — General Considerations, by Par ran Jarboe,
M.D.
The Trail of the Flu, by T. A. Jones, M.D.
Pyelitis, by I. Russell Kuhn, M.D.
The Role of the Heart as an Etiological Factor and
Therapeutic Agent in Pulmonary Tuberculosis,
by Henry I. Leviton, M.D.
Some Recent Advances in the Treatment of Inoper-
able Cancer, by Jacob J. Levy, M.D.
Care of the Heart in Middle-Aged Individuals, by
A. C. Morgan, M.D.
Clinical Results Following One Thousand Non-
Surgical Drainages of Pathologic Gall-Bladders,
by G. M. Niles, M.D.
The Treatment of Malaria on Plantations, by Albert
J. Ochsner, M.D.
Fecal Impaction, by C. M. Rickert, M.D.
High Blood Pressure; Significance of Its Changes
and Suggestions as to Management of the
Cases, by DeLancey Rochester, M.D.
Unusual Cardiac Cases from a Clinical Standpoint,
by Bruce Snow, M.D.
Disturbed Liver Functions in General Practice, by
B. W. Stearns, M.D.
The Body's Defenses or How Nature Prevents and
Cures Diseases, by J. W. Torbett, B.S., M.D.
The Relation of the Thymus Gland to Thyrotoxicosis,
by I. S. Trostler, M.D.
Etiology and Treatment of Erythema Nasalis or Red
Nose, by J. C. Warbick, M.D.
Circulatory Disorders from Disuse of Vigilance —
Disuse Cripplings as Affecting the Blood Dis-
tributing and Accessory Mechanisms, by J.
Madison Taylor, A.B., M.D.
Pediatrics
The Spasmophilic Child, by J. D. Leebron, M.D.
Epidemic Encephalitis in Children, by Josephine B.
Neal, M.D.
X-Ray Studies of Cardiac Diseases in Children, by
C. W. Perkins, M.D.
Therapeutics
A New Mercurial for the Treatment of Syphilis, by
A. B. Barker, M.D.
Treatment of Burns and Leg Ulcers by Heliotherapy,
by O. S. Brown, M.D.
Proper Selection of Drugs for Individual Cases, by
Elnora C. Folkmar, M.D.
Use of Psychology in Therapeutics, by A. W. Herr,
M.D.
Asthma; Its Prevention and Treatment, by Nathan
H. Hornstine, M.D.
Digitalis and Heart Disease, by C. F. Morsman, M.D.
Benefit Derived from Water Treatment in Consump-
tion, by Edward Podolsky.
Mexican Bitter Bush in Amebic Dysentery, by Albert
Schneider, M.D.
Auto-Therapy; Its Field and Technique, by T. M.
Stewart, M.D.
Ophthalmology, Laryngology, Rhinology
and Otology
The Clinical Picture of Interstitial Keratitis, by
Aaron Brav, M.D.
Submucous Resection of the Septum of the Nose,
by F. A. Grafe, M.D.
Tonsils — Indications for and Against Removing
Them, and Points of Importance to be Ob-
served during Tonsillectomy, by A. W. Kerr,
M.D.
Some Aspects of Nasal Sinus Disease, by William A.
Hitschler, M.D.
Defects of Teeth and Naso-pharynx: Their Relation
and Importance, by D wight M. Lewis, M.D.
Dermatology
The Circulation in Diseases of the Skin, by S. C
Parsons, M.D.
Skin Eruptions from Gastro-Intestinal Disturbances,
by A. Ravogli, M.D.
Diagnosis
The Graphic Chart in Heart Disease, by Louis
Faugeres Bishop, A.M., M.D., Sc-D., F.A.CP.
The General Practitioner and His Laboratory, by F.
Ellsworth Clow, M.D.
Diagnosis of Gall-Bladder Disease, by C. W. De-
lancey, M.D.
Appendicitis Simulating Disease in the Upper Right
Quadrant, by Samuel Floersheim, M.D.
Diagnostic Considerations in Surgical Affections of
the Stomach, by A. Wiese Hammer, M.D.,
- F.A.L.S.
The Early Diagnosis of Pulmonary Tuberculosis by
The General Practitioner, by Clair B. Kirk,
M.D.
Bedside Diagnosis of Abdominal Crises, by D. A.
Smith, M.D.
The Clinical Significance of the Wassermann Reac-
tion, by Burton Peter Thorn, M.D.
Economics
The General Physician and His Equipment for the
The Human Side of the Application of Medical Science
Is Being Buried Under Mountains of Technic.
lassert Emphatically
ttige of the General Physician
Care of His Patients, by W. Fletcher, M.D.
The Social Side of Medical Practice, by Jos. Leben-
stein, M.D.
An Outline of a Group Clinic, Its Equipment and
Its Work, by L. F. Long, M.D.
Public Health
The Prevention of Tuberculosis and Its Recurrence,
by Leon DeVills, M.D.
Tuberculosis Control, by W. R. Rand, M.D.
Studies of Social Hygiene and Diseases, by J. Shanks,
M.D.
Louisiana Physicians' Work in Developing the Idea
of Transmission of Disease by the Mosquito—
A Brief Historical Sketch, by George H. Tich-
enor, Jr., A.B., M.D.
Surgery
Local Anesthesia, by A. L. Blesh, M.D.
Series on "The Relationship of Internal Medicine and
Neurology to Accidental and Traumatic Sur-
gery," by G. F. Boehme, Jr., M.D.
Chronic Appendicitis, by J. U. Fauster, M.D.
Kidney Tumors, by Hyman I. Goldstein, M.D.
Paget's Disease of the Bones (Osteitis Deformans),
by Hyman I. Goldstein, M.D.
An Unusual Case of Bi-Lateral and Ureteral Calculi,
by C. M. Harpster, Ph.G., M.D., F.A.C.S.
Liver Abscess, by T. H. Kelley, M.D.
Visceral Syphilis with Surgical Manifestations, by
Charles F. Kuhn, M.D., F.A.C.S.
Delayed, Dilated and Infected Urachus, by H. S.
Lott, M.D.
Worthless Appendix Operations, by Robert T. Mor-
ris, M.D., F.A.C.S.
Intestinal Adhesions and Their Surgical Treatment,
by J. Shanks, M.D.
The After-Care of Industrial Injuries, by .Irving
David Steinhardt, M.D.
The Prepuce, a Useless Appendage; An Instrument
for Its Removal, by Chester Tilton Stone. M.D.
Diagnosis and Treatment of Spinal Abscesses, by
James K. Young, M.D.
Neurology
Some Neurological Problems, by G. F. Boehme, Jr.,
M.D.
Influence of Pain and Its Allies Upon the Cerebral
Cortex Cells, by G. S. Foster, M.D.
Neurologic Manifestations of Puberty, by Alfred
Gordon, M.D.
Dementia Praecox, Feeble-Mindedness and Retarda-
tion in Education, by Bayard Holmes, M.D.
Treatment of Mental and Physical Conditions in In-
fants and Children, by Leo Huth, M.D.
A Consideration of Neuritis and Myalgia, by £. J.
Lorenze. M.D.
The Rational Treatment of Facial Paralysis, by Wil-
liam Martin, M.D.
Pathological Psychology and Insanity, by Charles
E. Remy, M.D.
General
A Physical Evil of Greatest Magnitude Not Only
Ignored by the Medical Profession, but Cre-
ated and Augmented by Medical Practice, by
H. W. Champlin, M.D.
Results of a Research on Tobacco, by J. T. Denton,
M.D.
What Will tne Morrow Bring Forth? by J. H. Dowd,
M.D.
The Value of Studies in Nutrition for the Asthenic,
by E. E. Fisher, M.D.
Single Track Practice, by Frederick D. Keppel, M.D.
The Call of the Minister and Physician in the Con-
trol of Juvenile Delinquency, by Mayer Shoyer,
M.D.
Orthopedics
More Footlights -on the Feet, by C. V. Cross, M.D.
A Talk on Weak Feet, by Irving David Steinhardt,
M.D.
Obstetrics
A Report of a Case of Eclampsia, by Alfred Brown,
M.D.
Obstetrics is Surgery, by H. S. Lott, M.D.
The Duration of Obstetric Attention, by J. S. Rauden-
bush, M.D.
Electro-Therapeutics
Therapeutic Effect of the Radiant Wave— a Special
Type of Monopolar High Frequency Current,
by Elnora C. Folkmar, M.D.
Physiological Therapy in the Chronic Stage, by Al-
bert C. Geyser, M.D.
Radio-Therapy in Gynecological Conditions, by J. J.
Lrvv, M.D.
Focal Infection with Special Reference to the Inter-
pretation of the Dental Roentgenogram, bv
W. A. I uilc, M.D. y
Tonsil Fulguration Better than Tonsil Operation, bv
T. M. Stewart, M.D.
X-Ray Treatment of Uterine Hemorrhage and
Fibromyomata, by I. S. Trostler, M.D.
Gynecology
Conservative Gynecology, by D. W. Basham, M.D.
Treatment of the Cervix Uteri, by Frank R. Fursey,
M.D., CM.
Medical Gynecology, by Charles Mazer, M.D.
The Repair of Perineum from a Gynecologist's
Standpoint, by H. E. Myers. M.D.
Leucorrhea and Its Treatment, hv Joseph Shanks,
M.D.
Office Gynecology, by Thos. J. Watkins, M.D.
The General Physician Is the Man to Manage the Case
Around him, as a central nucleus, all medical service should be built
878
Tuberculous Abscess of the Chest — Juergens
[The American Physician
Tuberculous Abscess of the Chest
Report of Ca.e
By Louis W. Juergens, M.D.
Milwaukee, Wis.
A YOUNG LADY of twenty, Miss S., consulted
me on March 12, 1910. She had begun to suffer
from an abscess in the chest wall about a year pre-
vious to my seeing her. The abscess was located on
a level with the third and fourth ribs a little to the
left of the sternum. Sometime later it had opened
spontaneously several inches lower down, directly
under the place of origin. Her general health was
considerably impaired. She had lost fifteen pounds
in weight and looked quite anemic
I advised the patient that her case would have
to be treated surgically. She readily consented to
this. The surgeon to whom I referred her corrobo-
rated my diagnosis of tuberculous abscess and decided
to operate. On March 15 the operation was per-
formed. A semi-lunar flap was cut and deflected to
the left side of the chest, fully exposing the entire
area involved by the abscess. The disease process
involved the sterno-costal cartilage and neighboring
structures. Every particle of the pathological tissue
was thoroughly removed as far as could be deter-
mined. The wound was closed with the exception of
the most dependent part, which was left open to pro-
vide for drainage.
The after-treatment consisted of cleansing the
wound daily and packing it with iodoform gauze and
balsam of peru covered by sterile gauze and absor-
bent cotton. The patient took a tonic of quinine,
iron and strychnine, breathed fresh air by day and
by night and ate good nourishing food. Sufficient
exercise and a daily bath were also advised. Despite
this truly tonic course of living, the suppuration
showed no signs of abating at the end of seven or
eight weeks. I reported this to the surgeon and a
curettment of the wound was suggested, but no date
fixed for this procedure.
The Copper Trujmtml
Considering the patient's delicate state of health
and listening to her entreaties to be spared this ordeal
of another anesthetic and the attendant loss of blood
without any positive promise of cure, I felt induced
to consider whether something else could be done to
help her. My attention had been called to the anti-
septic properties of oxychloride of copper, evidence
of which I had personally observed in my gyneco-
logical work. Considering it quite feasible to carry
out similar treatment in the case under discussion, I
once more conferred with my friend, the surgeon, sub-
mitting my plans to his judgment.
Having ever the patient's best interests at heart,
he encouraged me to give this method a trial. My
patient also readily consented. The treatment was
carried out in the following manner:
I took a copper wire, bent it upon itself and
inserted the ends in a needle holder for electrolytic
work. The loop was about three inches long and
bent in such a shape that it readily entered the
sinus full length. This holder and copper wire were
attached to the positive pole of a galvanic battery.
A large pad, about 8 inches in diameter, was fastened
to the negative pole, moistened with water and placed
under the patient's back, opposite the diseased area.
Before inserting the copper wire it was wrapped with
moistened absorbent cotton to prevent its sticking to
the walls of the sinus.
If the bare copper wire is used, the current must
be turned off at the end of the seance and then
reversed for a few minutes to free the electrode
With both electrodes in place the current was slowly
turned on, taking the feelings of the patient as a'
guide, to the strength of about 8 or 10 miUiamperes.
The treatment was given for ten minutes each day,
followed by the usual dressings.
The promptness with which the wound now healed
under the influence of this antiseptic was most grati-
fying. There has been no recurrence of the trouble
and the patient has remained in good health ever
since.
Brief Notes
"A prompt diagnosis is half the battle of disease."—
Osier.
Exfoliation and pitting of the nail cortex if of many
months' standing, and without involvement of the
matrix, is never mycotic in origin; old cases of onycho-
mycosis invariably show some involvement of the
matrix.
Treatment of syphilis in the second and third years,
particularly, should be of a supportive type as well
as specific. The essential feature is to increase tissue
resistance. With increased resistance specific therapy is
much more potent
Most sexual neurasthenics are nearer suicide than we
suspect Do not laugh at their fears and dismiss them
from your office. They need help. Give it to them.
These patients should be handled with patience and
given treatment of a definite character.
Remember that the bladder may be the site of a
syphilitic lesion. Especially in the case of a known
syphilitic this possibility should always be borne in
mind.
While surgery, the specialties, hospitals, people are to be served, the primary tm- ordinated in constructive co-operation with
institutional medicine, public health work, portance of the function of the General the essential service of the Family Physician,
industrial medicine, etc., have their definite Practioner must be recognised. Other divi- This is an integral purpose of The American
functions, if the best health interests of the sions of medical service must be properly co- Physician.
Should Mini
mimum
Standards Be Established
for Private Hospitals?
Should Not Private Institutions Be Placed Under the Same Inspection as Public Ones?
STANDARDIZATION of hospitals is agitated,
and with regard to public institutions it is easy
of attainment, for they seek public appropriations
and are inspected, but it is vastly more needed in
private hospitals, sanitariums, sanatoria, etc., for1
they run much as they please and are not inspected.
The writer is in position to know the inner work-
ings of a large number of both public and private
hospitals and institutions and gladly records the
fact that vast improvement has been made in the
institutions and their personnel within the recent
past, and improvement quite as marked in the bet-
ter grade of private establishments as in the public
ones has been especially noted.
Nevertheless there are private institutions that are
a disgrace to medicine, some of them housed nicely,
but terribly run down in personnel and manage-
ment. Formerly high-grade and well-conducted,
there are private hospitals living on their established
reputations, built up by former good management,
but are now in new hands that know nothing about
hospital management. Hospital management has to
be learned, just like any other profession.
Recently complaint was made about a small, private
hospital and it was investigated, with the result that
it was ascertained that the medical superintendent,
the matron and the chief nurse are all drug addicts.
No wonder things went wrong there. In another
small hospital the exceptionally large purchases of
liquor led to inquiry, and it was found that the staff
members were tipsy half the time — not really drunk,
but certainly not fit to operate. Of course, these are
extreme instances.
Colts in Private Hospitals
We have heard of two private hospitals where the
main reliance is in osteopathy and chiropractic,
while posing as general medical and surgical insti-
tutions. In another hospital the stress is laid on
a modified Christian science, and it is worked in
on every occasion. We have personally encountered
hospital nurses who are Christian scientists diligently
undermining medicine while working under physi-
cians. Doctor, do you want to send your patients
to places where they are under care of such cultistsT
Fortunately, this sort of thing has not gone far, but
the time to nip it is now.
Fat* Treatments
More or less fakery is worked in by one-sided or
commercialized physicians who want to exploit
some secret or semi-secret remedy to boost in an
advertising campaign later on. Some of these men
deceive hospital managements that are eminently well
meaning and who are humiliated when they find out
what has been going on under their noses and with-
out their knowing it until some physician writes in
a complaint. These men make a business of worm-
ing in to private hospitals, and then boring from
within after they are there. Of course, they don't
last long after discovery, but they care little, for
they have attained their real object, starting an-
other cancer cure, or consumption cure, or what
not, to exploit individually outside. Rarely is the
medical management directly responsible; they are
imposed upon.
Imt Kesaemy
Place private institutions under the same inspection
as are public ones, and this would not be hard to
do, for nearly all of the managers of private insti-
tutions are honorable people and would welcome
proper inspection; and they know it would pay
them in the long run. Minimum standards for pri-
vate institutions should be established, and those
below standard should be brought up to it or closed.
880
The Patient First
[The American Phyridn
The Patient First
The Clinical Golden Rule
ARE WE IN DANGER OF NEGLECTING THE HUMANITIES WHEN PATIENTS ARE HANDLED IN BULK?
THE PATIENT is under ether, and you are
tempted to pause and elucidate a point to your
colleagues standing by. The point may be very
interesting, but commenting on it prolongs the
operation three or four minutes. Doctor, don't do
it; make the patient first.
Your large class loves to view a spectacular opera-
tion in the main amphitheater, and your patient is
in Ward 6, over three hundred feet down a long
and cold corridor to be traversed twice. Doctor, don't
risk it; take her to the small operating room,
twenty feet away through a warm room. Make the
interest of the patient first.
You have tw.enty heart cases in the ward and you
are ever so enxious to try out quinidine and pub-
lish findings. Wait, Doctor, wait! Those who do
not progress under digitalis and careful case-man-
agement may be cases in which you are justified
in tentatively trying out a new and often dan-
gerous drug. The patient comes first.
You may be most anxious to try out a podalic
version in a tardy labor. Don't! Let the patient
do the laboring and you do the waiting. Perhaps
Nature will do a better job than you will, and cer-
tainly a safer one. You will know without speculat-
ing over it when a podalic version is necessary to
the interest of the patient. Why do it in your own
interest? Of all patients, the woman in labor comes
first.
You are not absolutely sure about that case in
whom you suspect appendicitis, and you don't like
the nearest surgeon consultant anyway, so you wait
for an increase in temperature and put off a con-
sultation. Don't do it, for it may be a fulminating
case and the patient die before the thermometer
shows much change. Remember, the interest of the
patient comes first — always first.
Tk* O&tr D*ct*r
Your patient is on the operating table, all trussed
up and covered with sheet and blanket and towels,
and you are sweating over the tedious details of a
nice plastic operation with lines of concealed sutures.
You forget all about the passage of time; and, in
fact, you forget about the patient in the worry over
a neat job. But the other physician, who is giving
the ether, is worried also; he is worried about the
patient, for the heart wobbles and respiration is
bad. From time to time he makes quiet comment
and you are annoyed. Look out, Doctor! The pa-
tient comes first; against his life an extra scar or
two counts for nothing.
Your assistant comments on the amount of hemor-
rhage, but you go on and cut two or three more
vessels, not waiting for previous ones to be caught
up and sutured. You are a speed operator, expect-
ing the assistant to mop up the blood while you speed
on on high gear. He knows better how much blood
has been lost than you do. Listen to him and put
brakes on your scalpel. The patient comes first, not
your record for fast operating.
Wckimg ft the Clime
The case is a most interesting one, just adapted
for demonstrating that new technic in your clinic
tomorrow. How proud you will be after the triumph-
ant operation! But Nurse 'phones you from the
hospital six hours before the clinic, as she is wor-
ried. You are also, but you put it aside and direct
the administration of stimulants, etc. When the
clinic hour comes the patient is dead. Comment
about the patient coming first is superfluous.
Then, too, there is the other side: haste. The
patient is in shock and you ought to wait Do yon
always do so T Remember, the interest of the patient
dictates delay and certain pre-operative measures.
Your convenience, or your clinic, are as nothing
beside these more important things.
Jfeftorf GMem JUi
Do unto your patient even as you would that
some other doctor should do unto you were you his
patient. Follow this rule and the patient will always
be first.
The instances cited are real ones, principally occur-
ring in institutional work. Since such work is be-
coming so general it is well for physicians so en-
gaged to take soundings from time to time and
to realize that the humanities are very apt to be
neglected when patients are handled in bulk.
December, 1922]
The American Physician Advertising Service
881
Sluggish Bowel Action in Childhood
is usually due to errors in feeding. Subjecting these fundamentals to the cus-
tomary careful correction,
INTEROL
may be administered coincidentally to relieve the immediate condition.
Dosage *» Children
Begin with- a half to
one teaspoonful, 3 times
a day before meals. In-
crease or decrease dose
until one good movement
is obtained daily. Then
gradually decrease to the
point where a small dose
at bedtime will maintain
this result.
This pure, tasteless and odorless mineral oil — notably free
from the greasiness common to such products — has proved
of exceptional value as a safe and dependable means of
moving the bowels of young children, and this without the
griping, straining and after-constipation by which the use
of castor oil and other drastic cathartics is so frequently
attended.
The constantly growing number of physicians who prefer
INTEROL to any other media in the routine management
of constipation in early life is its own best endorsement.
Sample and Interol brochure on request
Allied Drug and Chemical Corporation
2413 Third At«. New York City
Manufacturers of
OraseptinK — Internal and External Antiseptic, Wash, Spray and Douche.
Adacco Salt — Effervescent Saline Laxative and Uric Acid Solvent
Velocrn — "The Doctor's Hand-maid and Household EmoUent."
"He who puts up at the first Inn he
comes to, very often passes a bad night. "
Proverb of Italy —
The same holds true of the physician who does not carefully
discriminate in his choice of a drug, or combination of drugs,
for each individual case.
For the removal of effused fluid— dropsy — in loss of cardiac
compensation in valvular disease — in chronic Brights, in Post-
Scarlatinal Nephritis, or in ascites from Hepatic disease,
ANASARC1N TABLETS secure prompt and satisfactory
results, because ANASARCIN is a carefully worked out, scien-
tifically tested and proven combination of agents, which over-
come circulatory stasis, bring about resorption of effused fluid
and elimination of both urinary solids and fluids.
ANASARCIN TABLETS are designed to act specifically.
That they do so act can easily be established by
clinical test Convince yourself, Doctor
Sample, literature, case reports, etc., on request
The Anasarcin Chemical Company Winchester, Tenn.
Mentioning The American Physician Insures Prompt, Careful Service
882
The Sheppard-Towner Maternity Act
[The American
The fault is not wholly with the physician. Go
into the hospital wards unexpectedly, especially at
night, and note what is being done and what is being
neglected. Nurses, orderlies, clerks and even super-
intendents are very human, and one of the attributes
of humanity is to be inhumane in small things. We
see it every day, but it is deplorable when it occurs
in a hospital.
Doctor, you who may thoughtlessly bulk your
work, forgetting the individual patient in the maze
of detail that enmeshes you, you may have an awak-
ening some day. You may take sick far away from
home and among total strangers, and you are taken
to a hospital. May a kind Providence grant that
it be a small one, not one of the immense hospitals
run on the basis of factory efficiency! You will then
be in position to view a hospital from the stand-
point of a patient. Perhaps you may then have time
to think soberly over the Clinical Golden Rule,
The Patient First.
The Sheppard-T Comer Maternity Act
REFRAINING from caustic criticism or enthu-
siastic support of the much-discussed maternity
act, this journal has awaited eventualities. Undoubt-
edly there was much to criticise in the bill first
introduced into Congress; but these features were
eliminated before final passage. It must be conceded
that the fundamental purposes of the act are good.
All of the States of the Union except New York,
Maine, Massachusetts and Rhode Island have entered
into the joint federal and state agreement, these
states disagreeing more on legal grounds than upon
medical or sociologic ones. It will be observed that
the states objecting are in one section of the country
and are noted for conservatism, which is a good
thing to balance opinion in the country at large.
Thus far the medical profession has not met with
any disasters through the operation of this law.
Apparently the law has waked up states to their
obligations to mothers and children, and coming at
the time when women were given the suffrage it is
more than likely that scientific medical and welfare
supervision of motherhood and infancy will be pro-
moted, thus aiding the medical profession.
The United States Supreme Court having decided
that the Child Labor Law is unconstitutional, it may
be that the Maternity Act will also be regarded as
an intrusion on the prerogatives of the states; but
this is purely a legal matter to be determined by
the courts. Even so, states will now be compelled
to do something in the matter of child labor, which
will be a good thing in the long run.
As we view it, the main thing to avoid is bureau-
cracy.
Best Current Medical Thought
Evidences of Tonsillar Infection
Maxwell H. Kaiden (N. Y. Med. Jour., Aug. 2, 1922)
states that the following four points are of importance
as evidence of localization of primary focal infection in
the tonsils :
1. A history of repeated sore throats. Such history
can usually be obtained. By sore throat I do not neces-
sarily mean frank follicular tonsillitis. Experience has
shown that a patient may suffer from frequent follicular
tonsillitis and show no systemic disorders or sequelae
beyond the febrile disturbance at the time of the attack.
On the other hand, a patient may never have had any
attack of follicular tonsillitis, he may even never com-
plain of a sore throat, yet his tonsils may be the site
of a focal infection through which organisms and toxic
material may gradually or suddenly be absorbed or thrown
into the circulation, thus causing the various rheumatic
manifestations already referred to.
Such difference in action between acute follicular ton-
sillitis and a chronically inflamed tonsil may perhaps be
best compared to other organs where evident inflamma-
tion produces spectacular local symptoms, while the
slow insidious inflammation of the same organs may be
later responsible for farreaching serious systemic dis-
orders. Alveolar inflammation, for example, causes
no more than a local abscess, while an apical tooth
abscess although minute, difficult of recognition and
diagnosable by the aid of the X-ray alone, may be the
cause of socalled chronic rheumatism. Similarly acute
appendicitis may cause violent acute illness calling for
immediate and radical intervention, while chronic appen-
dicitis may produce chronic dyspepsias lasting for years.
Indeed, is it not possible that many etiologically puzzling
systemic diseases, such as myocarditis, arteriosclerosis,
chronic nephritis and diabetes have their origin in some
insidious chronic infection in the body not recognizable
by our present crude methods of diagnosis, but which
we hope later to be able to recognize and treat medi-
cally or surgically before systemic effects become mani-
fests. As far as the tonsils are concerned, fortunately,
they can be easily seen and examined, and if we can
establish the relationship between diseased tonsils and
rheumatic manifestations, it should call for early re-
moval of the tonsils, even before rheumatic symptoms
set in. This applies particularly when the onset of
cardiac disease is feared.
2. When the tonsils are diseased, the anterior pillars
present a characteristic red, "corned beef" appearance.
This is in marked contrast to the remainder of the
mucous membrane of the oropharynx. The character-
istic color may be confined to a narrow strip of the
free border of the pillar, or in some neglected cases,
the entire pharynx may present this appearance. A pillar
of this color always denotes a chronically diseased ton-
sil. This coloration of the anterior pillar is especially
noticeable in the chronically diseased tonsils of adults.
3. Simultaneous pressure on the anterior pillar and
on the tonsil with two tongue depressors, one held in
each hand, causes exudation of a cheesy whitish material.
4. Most cases of chronically inflamed tonsils, par-
ticularly in children, show enlarged tonsillar lymph
nodes at the angle of the jaw. During an acute ex-
acerbation these nodes may also become tender.
December. 1922] The American Physician Advertwng Service 883
Promoting a
Favorable State of Mind
On the borderland of illness or convales-
cence, patients frequently tend towards a
morbid state of mind.
The usual habits of active life perhaps
have been, or must be suspended. Daily
existence seems one negation after another.
And most irksome of all is the restricted diet.
In such cases, when even the limited
use of coffee or tea is contra-indicated, Instant
Postum may be a source of much comfort
and satisfaction, and therefore a vital factor
in promoting a brighter mental outlook.
Instant Postum is one of the most con-
venient of beverages for sick-room or hospital
use, since it is prepared instantly in the cup
by the addition of hot water, and may be
purchased from the nearest grocer at mod-
erate cost.
Samples of Instant Postum for individual
and clinical examination will be sent on re-
quest to any physician who will write for them.
Postum Cereal Company, Inc.,
Battle Creek, Michigan, U. S. A.
Mentioning The American Physician Insures Prompt, Careful Service
884
Best Current Medical Thought
[Philadelphia
Chronic Appendicitis
John A. Lichty (/. A. M. A., Sept 9, 1922) says the
diagnosis can be made with only a certain degree of
assurance, depending on whether a history of an acute
attack can be developed. Without such a history, phy-
sical signs and laboratory tests must be taken at a con-
siderable discount. In 400 chronic cases in which
operation was performed only 217 patients gave a satis-
factory history of having had acute attacks of abdominal
pain which could be interpreted as being of the appendix.
It will be found best, therefore, to make the diagnosis
by exclusion. In this way it may be possible to eliminate
certain diseases, such as chronic peptic ulcer, "latent
gallstone," cholecystitis, stone in the right ureter or in
the kidney, certain chronic pelvic diseases, the various
ptoses of the abdominal organs, and also certain so-
called endocrine disturbances, as well as the more com-
mon neuroses. To do this, a thorough routine physical
examination should be undertaken, which should be fol-
lowed by test meals, and examinations of the stools, of
the blood, including the Wassermann test, and of the
urine, including kidney efficiency tests. A roentgen-ray
examination of the entire intestinal tract may be of great
value, not so much in giving direct information of the
appendix as in determining the presence or absence of
disease elsewhere. His conclusions are :
1. The diagnosis of chronic appendicitis is often beset
with difficulties.
2. While surgery is the accepted treatment, the results
are frequently unsatisfactory.
3. The comparative satisfactory results following opera-
tion for acute appendicitis are convincing evidence of the
necessity for a more careful study of the more or less
acute conditions of the abdomen. Prevention of chronic
appendicitis is easier than cure.
4. Hospital statistics bearing upon the operative re-
sults of chronic appendicitis are unreliable, as the recov-
ery from the operation is considered as synonymous with
a cure.
5. In certain cases a course of medical treatment is
necessary before a cure is realized. In other cases, sur-
gery may be contraindicated even though medical treat-
ment affords only an approximate cure.
Physiological Adjuvant in Rest Cure of Tuberculosis
S. Adolphus Knopf (N. Y. Med. Jour., Aug 16, 1922),
in giving detailed information on how to teach the
tuberculous patient the diaphragmatic breathing, says:
To be sure that the patient understands exactly what
is meant by diaphragmatic breathing, it is well to teach
it in the following manner: Place the patient in a
sitting or half reclining position, with his feet extended
and slightly separated Then tell him to inhale as
slowly as the physician's hand with index finger pointing
moves upward along the limb, beginning at the toes on
the right foot, crosses the abdomen to the left, and then
stops a second to exhale while the hand moves slowly
in the downward direction to the left foot. The pny-
sician or nurse teaching this breathing should repeat
this procedure a few times until the patient fully grasps
what he is asked to do and does it correctly. To this
end it is well for the physician, while indicating the
direction and duration of the inhalation with one hand,
to place the other hand over the upper portion of the
lungs and thus observe whether they are at complete
or at least at relative rest. When the patient is lying
in the complete recumbent position, with head slightly
elevated, the diaphragmatic breathing will be materially
aided by placing a very small pillow or a folded bath
towel under the small of the back.
This diaphragmatic breathing not only gives rest to
the lesions in the upper lobes, but also causes a better
circulation in the lower extremities and abdominal vis-
cera especially aiding the hepatic function, all of which
is so essential for patients who are ordered complete
physical rest on a reclining chair or bed. As a rule,
the patient of average intelligence will soon learn this
method of breathing and will enjoy it because it gives
him physical comfort and something to occupy his mind
In fact, this slow type of breathing is conducive to quiet
and serenity; a psychic condition most desirable in the
rest cure of tuberculosis but as a rule absent in majority
of the patients.
The Percy Method of Treating Cancer of the Uterus
Applied to Treatment of Cancer of the Rectum
William H. Kiger, M.D., F.A.CS. (Amer. Procto-
logic Society, May 2, 1922), said that, since he adopted
the Percy cauterization method to the treatment of
cancer of the rectum three years ago, he had used it
in all his cases, a total of forty-fiye, without opera-
tive mortality; and that from these he had selected
three typical cases to report. It had been amply
demonstrated by his series of cases that incising the
sphincters with the cautery makes it possible to pre-
serve the greater part of them as useful structures,
and he does not expect to have to report later that
the anus was converted into a ring of scar tissue by
the treatment. His technic depends somewhat on the
location of the growth. If the tumor is not very
large or not more than half the circumference of the
bowel is involved, he incises both sphincters with the
cautery knife which. Percy uses in incision of the
breast. The knife should be heated to a bright cherry
red in order to cut through quickly, which prevents
too much destruction of the severed ends of the
muscles, and at the same time sears the surfaces
sufficiently to prevent transplantation of cancer cells
from the exposed mass in the rectum. This incision
definitely exposes the growth, and, if it is situated
near the sphincters, can be extended into the mass,
but need not go through it since the heat infiltration
is the important factor. His water cooled speculum
can be introduced so as to protect the uninvolved
srtuctures, and the cautery head laid on the growth
and left from forty to sixty minutes or until the mass
is thoroughly hot or pasteurized, care being taken to
avoid carbonization of any of the involved structures.
If the whole circumference of the bowel is involved,
the water cooled jacket or the small water cooled
vaginal speculum can be used to cover the heating
iron and protect the sphincters from prolonged action
of the heat. Either of these instruments may be
found useful in some situations or conditions where
his special water cooled rectal specula may not fully
meet the purpose. He has also had two extra sized
cartridge shaped heating heads made to more quickly
expose massive rectal cancers to a greater body of
heating surface, till by constant contact the parts
are thoroughly and completely heated through.
REVIEWS OF PRACTICAL BOOKS FOR THE GENERAL PHYSICIAN ONE LEAF OVER
December, 1922]
The American Physician Advertising Service
885
Kellogg's Bran is constantly increasing in
favor among physicians because it can be pre-
scribed with confidence both in mild and
chronic constipation cases.
Where constipation conditions prevail, as
you know, half-way measures cannot be
recommended. Bran must be ALL BRAN to
secure results. Foods with a small bran con-
tent only delay relief and restoration of
normal conditions.
. Kellogg's Bran has won merit, not only
for its really delightful nut-like flavor and
palatability, but because it is ALL BRAN!
Its natural bulk gives the required mechani-
cal action that affords the required relief.
Patients enjoy Kellogg's Bran because it
is cooked and krumbled. It is served as a
cereal, sprinkled over other hot or cold cereals
or used with great success in baking and
cooking. Two tablespoonf uls daily for mild
conditions; as much with each meal in chronic
cases. All grocers sell Kellogg's Bran.
Physicians are requested to mail the Kellogg
Toasted Corn Flake Co., Battle Creek, Mich.,
a request card for a full-sized sample pack-
age of Kellogg's Bran. It will be sent im-
mediately without obligation.
*SADY TO EAT
^J»^i?nAKEca
An Analysis of
KtUogg's BRAN
cooked and krumbled
Aside from its regula-
tory value, Kellogg's
Bran commands attention
as one of the most valu-
able foods known. Read
this analysis:
Moisture 2.50
MINERAL SALTS 8.4 1
Protein 15.8
Pat 2.8
Crude Fiber 8.9
Carbo-hydrates 61.6
Calories 1480.46
(per pound)
■y-
the original BRAN * cooked and krumbled
Mentioning The American Physician Insures Prompt, Careful Service
886
Book Reviews
[Philadelphia
"Book cReMews
Manual of Psychiatry
Edited by Aaron J. Rosanoff, M.D. John Wiley & Sons,
Publishers, New York City. 684 pages. Price, $4.00
net.
The present work is constructed on a special basis.
The chief portion of the book was written by a well-
known French psychiatrist, J. Rogues de Fursac. A
chapter on Psychology is presented by H. L. Holling-
worth. Mary C. Jarreth deals with application of soci-
ology and psychiatry. Dr. C. A. Neymann writes on
the characteristics of the cerebro-spinal fluid. The editor
himself endeavors to adapt the French views of psychia-
try to the needs of the English speaking readers. He
also added a few chapters on subjects of a special
interest to the American psychiatrists.
The construction of such a work and the compilation
of a great variety of subjects suitable to an American
reader and based originally on a foreign point of view
is quite odd and, as it has shown, very interesting. The
book has undergone five editions. The editor has also
found useful to describe psychoanalysis and especially
the intelligence scale for testing mental standards.
Every one of the writers of the book has acquitted him-
self in a creditable manner, and the entire work deserves
to be commended as a useful manual not only to the
specialist, but also to the general practitioner. — A. G.
Hughes' Practice of Medicine — Including a Section
on Mental Diseases and One on Diseases of the
Skin— Twelfth Edition
By R. J. E. Scott, M.A., B.C.D., M.D., New York.
Fellow of the New York Academy of Medicine;
Fellow of the American Medical Association;
formerly Attending Physician to the Demilt Dis-
pensary; formerly Attending Physician to the
Bellevue Dispensary; author of "The State Board
Examination Series"; editor of "Witthaus' Text-
book of Chemistry/' "Witthaus* Essentials of
Chemistry and Toxicology," "The Practitioner's
Medical Dictionary," Gould and Pyle's "Cyclo-
pedia of Medicine and Surgery," etc. With 63
illustrations. P. Blakiston's Son & Co., 1012
Walnut Street, Philadelphia. Price, $4.00.
This small manual needs no introduction. It has
survived eleven — and is entering upon its twelfth
edition. It is as handy a volume as it previously was.
Several new sections have been added, such as those
on Trench Fever, Notifiable Diseases, Poisoning by
Wood Alcohol, Acidosis, Functional Activity of the
Kidneys, Coleman's Diet for Gastric Ulcer, von
Jaksch's Anemia, Leukanemia, Disorders of the
Salivary Glands, Sinus Irregularity and Premature
Contractions of the Heart, and Classification and
(Continued one leaf over)
The Management of an Infant's Diet
cc-*T>T<
Mellin's Food contains 58.88 per cent of Maltose
MeUin's Food contains 20.69 per cent of Dextrin*
a proportion of
Maltose and Dextrins
best suited to the carbohydrate needs of the average baby.
Mellin'8 Food contains 10.35 per cent of Cereal Protein.
Mellin's Food contains 4.30 per cent of Salts which consist mainly
of Potassium Salts, Phosphatic Salts, and a small amount of Iron.
These facts should be considered in selecting a modifier of milk
for infant feeding and these facts point out some of the reasons for the
success of Mellin's Food which probably is unparalleled in any decade
since the beginning of the study of scientific infant feeding.
■tiiiiiiiiiiiiini
^csP4rygggg>>2<
Mellin's Food Company, Boston, Mass.
F2»S<
G^^f.
You can buy with Confidence — See "Service Guarantee to Readers" on page 906
December, 1922]
The American Physician Advertising Service
887
HUGHES' PRACTICE OF MEDICINE
12th
Edition Enlarged, Revised.
Illustrated. Octavo, xxiv
810 Pages. Cloth
$4.00
Revised by R. J. E. Scott, M.A., B.C.L., M.D., (New York)
Fellow of the N. Y. Academy of Medicine, etc.
A complete, modern practice of medicine with additional sections on Mental Diseases and
Diseases of the Skin. It is compact, concise and most serviceable. It fits easily in your travel-
ling case, instrument bag, pocket of the automobile, desk drawer, etc. It gives in quickly
available form, the synonyms, definitions, causes, pathological anatomy, symptoms; diagnosis,
prognosis, treatment, prescriptions, etc. In the preparation of this edition such changes and
additions have been made as the progressive development of medical science required. The
general arrangement of the first part of the book has been materially modified. The specific
infectious diseases are subdivided into four groups; diseases due to bacteria; due to protozoa;
due to metazoa ; diseases of unknown etiology. This accords with* modern views on pathology
and etiology. Several new sections have been added such as those on Trench Fever ; Notifiable
Diseases; Poisoning by Wood Alcohol; Acidosis; Functional Activity of the Kidneys; Cole-
man's Diet for Gastric Ulcer; von Jacksch's Anemia; Leukanemia; Disorders of the Salivary
Glands; Sinus Irregularity; Premature Contractions of the Heart; Classification and Treat-
ment of Mental Diseases; Numerous lesser additions and alterations, tests, etc., have been
made.
P. BLAKISTON'S SON & CO., Publishers
1012 Walnut Street Philadelphia
ON APPROVAL ORDER
Please send for 10 days' examination the new Hughes' Practice of Medicine. I will remit in 30 days
if I keep the book.
Name
Address
A P.
m
If a Cow Had a Conscience
she might balk at drowning the valuable 14% of milk solids in 86%
of water I
But the problem of supplying concentrated milk solids in unmodified,
easily digestible, immediately assimilable form has been practically and
satisfactorily solved by
DRYCO
a fine, flocculent white powder, produced by rapid drying (2 seconds)
of pure, carefully selected cow's milk.
DRYCO supplies casein in a colloidal form which does not form large,
tough curds during digestion. There is no caramelization of the sugar.
The fat is rendered more easily digestible. DRYCO is free from harm-
ful bacteria, uniform in composition, easily prepared.
Dryco is die Ideal Milk for Sick, Invalid, Convalescent and Infant Feeding
Send for a sample of DRYCO and literature "How to Use DRYCO.*' Part I1I-V of The
Doctor's Rubaiyat is being mailed. If not received notify us.
THE DRY MILK COMPANY
14 Park Row New York City
"An International Institution for the Study and Production of Pure Milk Products"
Mentioning The American Physician Insures Prompt, Careful Service
888
Book Rtvwwi
[PhiUdcIphia
Treatment of Mental Diseases. Numerous lesser
additions and alterations have been made, some new
tests have been inserted, and some obsolete matter
has been omitted."
Signs of Sanity
By Stewart Paton, M.D. Charles Scribners* Sons,
New York City. Price, $1.50.
The main object of this work is to show that the
final test of a sound mind is sane conduct, not merely
intelligent thinking; also that physical and mental
qualities enable a person to face critical situations in
life successfully, but not merely to sit down and think
about them.
Sanity is a successful attempt to adjust life to
reality. Productive work is the result of such an
attempt. The author having this principle in mind,
discusses soundness of mind from every possible
angle, also from the standpoint of inheritance. He
elaborates upon the facility with which a normal
mind adjusts itself to circumstances, and the diffi-
culties with which an abnormal mind meets complex
situations. After all, a struggle for happiness is a
struggle for mental adjustment, it is an effort to
strike a happy balance between the adjustment of
external and internal conditions. The author finally
adapts the above mentioned ideas to principles of
Mental Hygiene.
The book is written in an interesting manner and is
to be commended for its highly sound views. — A. G.
Nerve Exhaustion
By Maurice Craig, M.D., F.R.C.P., Lecturer in
Psychological Medicine, Guy's Hospital. Cloth,
148 pages. Lea & Febiger, 706 Sansom Street,
Philadelphia, Pa. Price, $2.25.
The author has undertaken to present his subject
from the standpoint of psychology, and his every
effort has been to avoid the ultra-psychological bear-
ing of the discussion, with its maze of technicalities
that so serve to confuse the reader that the average
physician tends to pass up the whole subject of
psychology. This no physician can afford to do,
which this book makes clear, more particularly as
regards the prevention of nerve exhaustion. The
book is sensible and useful, though there is some
occasion to call in question the wisdom of some of the
recommendations regarding drugs, more particularly
those of mixed composition and uncertain status
pharmacologically. — T. S. B.
The Healthy Child From Two to Seven
A Handbook for Parents, Nurses and Workers for
Child Welfare. Containing the Fundamental
Principles of Nutrition and Physical Care, includ-
ing Sections on Child Nature. Training and
Education, and Safeguarding the Nervous System
during the Pre-school Years. By Francis Hamil-
ton MacCarthy, M.D., Assistant Professor of
Diseases of Children, Boston University. The
Macmillan Company, New York, 1922. Price,
$1.50.
There is no doubt that "much of the illness and
suffering and deformity" of our children may and
can be prevented or corrected during the early years
of life. There is a great field for such work.
The book of Dr. MacCarthy is essentially "A
Handbook fon Parents, Nurses and Workers for Child
Welfare/' As such, it supplies a practical need.
(Helpful Points one leaf over)
Q0QOQ90QQ9Q0Q0®
qPU. Cascara Compound— Robins@
g^ MILD, 1 GR.— STRONG, 4 GRS. ^
^^T It is the failure of the secretory function of the bowel, together ^^
|M with a poor bile secretion, which, in nine cases out of ten, i*l|w
^^ responsible for constipation. 5^
^27 Most cathartics altogether overlook this factor and address V^
themselves solely to a stimulation of the musculature. Some even ^^k
inhibit intestinal secretion. The result is a rapid, unsatisfactory \Jp
bowel movement, followed by paralytic reaction.
e
f^k bowel movement, followed by paralytic reaction. /*%
W PU. CwcaraComp. (Robins) is a rational therapeutic formula, v£
m£M which promotes a natural flow of secretions, which is, in turn, the (AM
^■^ ohvsiolocric stimulant of Deristalai*. Thu* a normal evacuation i«^S^
^_ physiologic stimulant of peristalsis. Thus a normal evacuation is ^_
||1 produced, without subsequent inhibition. fd|
^^ Samples and descriptive literature on request 2^.
1W A. H. ROBINS COMPANY Richmond, VirginiaNM
00900Q90QQQGQQ®
You can buy with Confidence — See "Service Guarantee to Readers" on page 906
December, 1922] The Americn Physician Advertising Service {539
Pluriglandular Therapy in
DIABETES MELLITUS
T70R SOME YEARS we have been developing
F an effective polycrine formula for increas-
ing glycolysis and sugar tolerance in pancreatic
diabetes.
After much clinical and laboratory testing we now offer to the
medical profession
Lot No. 44
PAN-SECRETIN CO.
(Hammer)
An endocrine combination embodying —
( 1 ) A specially prepared extract of islets of Langerhans (pan-
creas tail) , rich in its incretory glycolytic product.
(2) An acid extract of the duodenal mucosa containing the
pancreatic activator, secretin, and
(3) A small dose of desiccated calves tonsil.
PAN-SECRETIN CO. (Hanower) is clinically useful in
many cases of diabetes mellitus, favoring the reduction
of the glycosuria, increasing the dietetic latitude and
modifying the deranged endocrine balance.
The dose at first is one Sanitablet t. i. d., later an additional dose
is taken at bedtime and still later the amount may be advantageously
increased to as much as 2, q. i. d.
Practical
Organotherapy
A 416-page, cloth
bound book of ref-
erence, should be in
your hands.
A copy will be
sent to any physician
of record for one dol-
lar postpaid! — and it
may be returned if
desired and both the
dollar and the post-
age will be re-
funded.
Prescribe this formula — over 200 jobbers
in the U. S. carry it. Literature to physicians
from any of our offices mentioned below.
THE HARROWER LABORATORY
Home Office: G LEND ALE, Calif.
New York City Chicago Baltimore
31 Park PI. 186 N. La Salle St. 816 Equitable Blag.
Dearer Kansas City Portland, Ore.
Cent. Sav. Bk. Bldg. 712 K. C Life Bldg. 707 Pittock Blk.
Dallas, Tex.
1805 Va Commerce St.
Mentioning The American Physician Insures Prompt, Careful Service
Hdpfd Poinfa
■nee that reflect* ■■
light and beat la
spot to burn or blister.
USED IN All. GOVERNMENT HOSPITALS
Sold by electric*! end *arfl«I enpplr dealers.
r Ther
^ „_t of:
NEURITIS. RHEUMA-
TISM, LUMBAGO,
BPRAINS. STIFF1 NECK,
BURNS, ULCERS. CAR-
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FECTED WOUNDS.
Reflector 12™ dlam.
Stand adjustable from
0 MT btgli. C'onanmcB 375 watta
» volts A. C. or D. C. Covers
iquare Inches 36" from reflector.
Finish, OIlTe and Nickel. Price com-
plete with stand $30.00 each.
, OMB BAND APPLICATOR
._m design as 0970 only 8" dlam.
'Consumes 200 watte, 120 volts A- C.
or D. C. Made of Aluminum, weight
18 os. Finish, Black and Nickel.
Price complete without stand 1 10 .00
only ;
; No.
0645, 18.00 eac
rrlte for Interesting and instructive literature
H. G. MeFADDIN at CO.
84 Warren Street, New York
(Makers of Lighting- Devices Since 18T4)
Scientific Investigations in Yeast Therapy
A double series of tests recently conducted to
determine the laxative effect of yeast, has revealed
the following facts: the addition of Fleischmann's
yeast to the diet in quantity of two to three cakes per
day produced a definite increase in the elimination of
waste by the bowel— an increase both in the bulk of
the feces and in their moisture content, and that the
laxative effect was more marked with the ordinarily
constipated subjects than with the normal ones —
indicating that yeast acts as a bowel regulator rather
than a cathartic.
Further research work is now under way. The
Fleischmann Company is sponsoring these important
investigations and is anxious to give the full results
to the medical profession, as soon as possible after
they are complete. A new authoritative book, written
by a physician for physicians, Yeast Therapy, will be
sent to you on request. Turn to page 839 and send m
the coupon.
Stimulant in aoDDuirau Ac&puauuu
The inadequacy of manual and mechanical methods
employed for re -establishing physiologically correct
respiratory equilibrium in cases of sudden enfeebled
or suspended animation, due to diseases, accident and
other causes, led to the discovery and manufacture of
the independently active Alpha-Lobeline, which di-
rectly and exclusively stimulates physiologic function
of the entire respiratory mechanism.
When life is at a low ebb, due directly or indirectly
to subnormal respiration, Alpha-Lobeline, through
quick and specific restorative action, becomes a life-
saving antidote of indescribable value in general and
emergency practice.
For interesting literature and further information,
address: Ernst Bischoflt Co., Inc., 85 West Broadway,
New York, N. Y.
A Complete Milk Food
Nestle's Milk Food is dried milk plus cereals, malt
and sugar. It is a complete food, presenting in
digestible form, everything that the infant needs to
assure normal growth.
When breast feeding is impossible, many physicians
have found Nestle's Milk Food a reliable substitute in
infant feeding. Complimentary packages will be sent
to American Physician readers. Address : Nestle s
Food Company, Nestle Building, New York.
Effective WmMtnmnta
At this season, when tt J*
influenza, pneumonia, br< »
the physician to have in i jfj
will best help him to con *
demulcent expectorants i •»
and Hyotole, made by S '■
if samples are desired, i f
mention your Fed. Lit •
records. None needed w *t
Gives Satisfactory Results
Pluto Water has been successfully employed and
endorsed by the medical profession as a uric add
solvent and eliminating agent in renal disorders. It
is prompt, safe and efficient; and is well retained by
the most delicate stomach. It is bottled at the
famous French Lick Springs, French Lick, Indiana,
where so many physicians have directed their
patients for rest and complete treatment.
(Continued one leaf over)
You can buy with Confidence — See "Service Guarantee to Readers" on page 906
December, 1922] The American Physician Advertising Service
Mentioning The American Physician Insures Prompt, Careful Service
892
Helpful Points
[Philadelphia
DRIED MILK
PLUS +
DURING the war, a
British Commission,
appointed to investigate
dried milk reported:
"When breast feeding is im-
possible, dried milk is a very
valuable food for infant
feeding. . . .
The physical and chemical
changes produced by the pro-
cess used in the preparation
so alter its character that it
is better borne in the infant's
stomach than ordinary cow's
milk whether raw, cooked or
sterilized. . . . The effect on
nutrition is marked."
NESTLE'S MILK FOOD
is dried milk plus cereals,
malt, and sugar. It is a com-
plete Food, presenting in
digestible form everything
that the infant needs to as-
sure normal growth.
Write Nestle's Food Com-
pany, Nestle Building, New
York, for complimentary
packages.
NESTLfiS
MILK
FOOD
For Babies and Invalids
Unusual Therapeutic Value
It is the particular combination with zinc chloride
that gives such therapeutic value to Lavoris. That
is why many physicians have found it the mouth
wash and antiseptic of choice and why they rely on
its antiseptic and healing properties. That Lavoris
is a product of merit and endorsed by discriminating
physicians is evidenced by the success with which it
has been used by the profession during fifteen years.
If you are not acquainted with Lavoris, a compli-
mentary supply will be sent to American Physician
readers. Address: Lavoris Chemical Company, Minne-
apolis, Minn.
A Great Many People Need It
Most physicians know that bran is effective in
both mild and chronic cases of constipation. But in
years past, it has not been easy to get a bran product
which was pure, all bran, and good enough that the
patient would readily take it.
If you have not tried Kellogg's Bran, which is cooked
and krumbled, you do not know how good bran can
be. It has a delicious nut-like flavor; you will find
your patients will take it readily and be glad to know
of a food which is at the same time delicious and a
corrective.
An important fact about a pure all-bran product
like Kellogg's Bran is the 8.41% mineral salts it con-
tains^— a vital element in the diet too often refined out
of food by modern processes.
A full size package of Kellogg's Bran will be sent
to American Physician readers. Just send a card
to the Kellogg Toasted Corn Flake Co., Battle Creek,
Mich.
For the Weil-Being of Your Patients
The idea back of the Sunsweet Prunes advertising
is to preach the gospel of healthr— exactly what phy-
sicians are doing. So it seems that we have a com-
munity of interest — The California Prune and Apricot
Growers Association and the medical profession.
There are well substantiated reasons why prunes
should be a part of the everyday diet of your patients:
they are rich in natural fruit sugars, they contain
salts and organic acids that improve the quality of
the blood and react favorably on the secretions; and
they provide a natural corrective — a laxative from
nature's own pharmacy. The value of Sunsweet
Prunes in your patient's diet is well and interestingly
told in their literature which gives reasons. This
together with their new recipe packet will be sent to
you gladly. Address, California Prune and Apricot
Growers Association, 1248 Market Street, San Jose,
Calif.
Cod Liver Oil "Vitamines"
It has been a hobby of a certain school to deride
the materia medica of the past generation, so much
so that therapeutic nihilism has been taught to grad-
uates of medicine for the last decade. There now
seems, however, to be a tendency for the pendulum
to swing in the other direction.
One well-known therapeutic agent, Cod Liver Oil
is again a candidate for favor on the ground that
this oil contains "vitamines," hence is useful in
diseases affecting nutrition. This is exactly why
our great-grandfathers prescribed it in cervical adeni-
tis and other forms of tubercular disease, and the
beneficial effect of cod liver oil in these and other
(Continued one leaf over)
You can buy with Confidence — See "Service Guarantee to Readers" on page 906
December. 1K2I The Amaican Pt&tkim Aivaljmg Service
Of the Highest Quality
lenamme-Neoarsphenamine
From the Dermatological Research Laboratories
These arsphenamines have the fullest confidence of the leading physicians
in America. More reliable drags have never been produced and are not to be had
from any source. They represent the highest degree of parity, and the greatest
measure of therapeutic efficiency yet attained in arsenicals of this class.
They are made in laboratories especially equipped for and devoted exclusively
to the manufacture of the arsphenamine preparations, by especially trained
chemists and their helpers, working under the able direction of Dr. George W.
Baiziss. Before being released to the medical profession, every lot is rigidly
tested upon animals to determine beyond a doubt that it conforms to government
standards, and after further tests approved by the U. S. Public Health Labora-
tories, Washington.
Orders will be filled promptly from The Dermatological Research Laboratories.
Philadelphia, or from local distributors in all large cities. Always specify
-D. B. L." brands.
THE ABBOTT LABORATORIES
EXECUTIVE OFFICES
Dept. 49, 4753-57 Ravenswood Ave., Chicago
•r, n _ • . • — .Production Laboratoria*
Br«nch«: The DermaJtolofrtcal Research ckica»
NEW YORK Laboratories North Chicago
san^cco ,720-1722 L-ri-rf St „ ."^KS.,^.
TORONTO iru -i . . ■ • _ ...
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
conditions are ascribed now largely to the vitamines
Chapoteaut, the great French dentist, some thirty
years ago, showed that cod liver oil, apart from its
nutritive qualities as a food, possessed a number
of alkaloids and amino acids, such as:
Morrhuine Cu H» Ni
Nicomorrhuine Cao Ha N4
Morrhuic Acid C> KuNOi s.s.o.
tinct specimens of these bodies were isolated by him
from an alcoholic extract of the oil which he called
morrhuoi Chapoteaut believed these to be ■ the
active medicinal principles of cod liver oil and the
clinical findings of French and other authorities, such
as Germain See, Dujardin Beaumetz, Sommerbrodt,
Penzoldt a.s.o. seem to confirm those claims, that
the therapeutic value of cod liver oil is dependent
chiefly upon the percentage of those alkaloid prin-
ciples or what would now more properly be denomi-
nated as vitamines, present in the oil.
Morrhuoi (extractum morrhuae alcoholicum)
Chapoteaut represents all the active principles of cod
liver oil, each little capsule holding the vitamines of
one teaspoonful of the best oil, freed from the nauseat-
ing fat, and this preparation is prescribed with suc-
cess by the members of the medical profession, edu-
cated on these lines.
When combined with creosote, morrhuoi gives bene-
ficial results in the catarrhal stage of tuberculosis and
in bronchial catarrh.
Whether the creosote merelv assists the action of
morrhuoi by favoring general nutrition is some-
what difficult to decide; there is, however, no ques-
Morrhuol creosote (Chapoteaut) comes in capsules
containing 3 minims of morrhuoi and 1 minim of a
creosote rich in guayacol, and the dose for adults
is from four to ten daily, gradually increased. These
products are wholesaled by E. Fougera & Co., 92
Beekman Street, New York.
A Superior Product
Mel 1 in's Food was introduced to the medical pro-
fession in 1866; it was the first Maltose and Dexlrins
product presented to physicians in serviceable form.
This means over fifty years' experience in the
selection of materials that enter into the manufacture
of Mellin's Food; and over fifty years' experience in
the manipulation of these materials to secure cer-
tain definite results, and over fifty years' experience
in the perfection of every detail that would have a
bearing upon the making of a superior product. And
every physician who has had experience with it can
undoubtedly testify that Mellin's Food is a superior
product.
Mellin's Food contains the following vital ele-
ments: Carbohydrates (maltose and dextrins); pro-
tein in a most available form; potassium bicarbonate,
together with the salts in wheat and barley — the in-
organic constituents.
The final test is the clinical evidence; the thousands
of healthy babies as a result of Mellin's Food feed-
ing are the best proof of the value of this product.
(Continued one leaf over)
The Obstetrical "Shoe Horn"
AnatoaicaUr Comet na
Retard* Stw and Shape
Where the foetal head en-
fagee agaimt the pa be* hi-
lt!* d of emerging directly
toward the birth canal tfaii
An Invitation
SINCE our inception thirty yean ago
we have never swerved from our purpose
to market at a moderate profit only the
beat surgical i
WE INVITE all physicians to inVMti-
gate our claim* that we can save you
money on absolutely first quality, com-
plete lines. We await your inquiries and
HUSTON BROTHERS
Atlas Anwteaa Bid*. CHICAGO
Compute Linn of Phyticiemt' S*fflitt
a buy with Confidence — See "Service Guarantee to Readers" on page 906
December, 1922]
The America Physician Advertising Service
895
"NERVES"
When you have a plain case of "nerves" with the patient irritable,
unhappy, over-excited, with nerves all on edge, prescribe
PENTABROMIDES
This is a combination of the five bromides in a palatable form; it is well borne
by the most irritable stomach and is less apt to produce gastric derangement and
bromism than the same quantity of any single bromide when given in larger doses
over a long period.
Pentabromides is of value wherever there is irritation of the nerves, as in hys-
teria, epilepsy, insomnia, or headache of nervous origin, uterine derangements,
dysmenorrhoea, menorrhagia, acute laryngitis, etc.; in fact, in all the conditions in
which the bromides are indicated, its advantages over the ordinary bromides being
that it is better borne by the system, is less apt to produce bromism and is much
more palatable.
Prescribe a* (( Pentabromides Mmrrell"
TM
M founded taaa
ERREU.CMM"
J mCf»CSIIMTI.ULSA
With Over a
Active Cases of Tuberculosis
HOME TREATMENT
IS ABSOLUTELY NECESSARY
Dr. Beverley Robinson has stated that we have no remedy
equal to creosote in the treatment of tuberculosis.
It diminishes the cough in frequency and severity.
The breathing becomes deeper and more satisfactory.
Night sweats diminish and soon disappear.
Nutrition is aided and weight is increased.
A fair trial of Mistura Creosote Comp. (Killgore's) will con-
vince you of its value.
Dose: — Teaspoonful in one-third of a glass of milk or water
after meals.
Samples sent to Physicians on request.
CHARLES KILLGORE
Manufacturing Chemist Established 1874
55 WEST THIRD ST., COR. WEST BROADWAY NEW YORK
Mentioning The American Physician Insures Prompt, Careful Service
896
Helpful Points
[Philadelphia
Where Liquid Petrolatum is Indicated
A noted authority, whose observations have covered
hundreds of cases, states that aside from routine meas-
ures, the regular use of liquid petrolatum is the most
effective means of combating incompetency of the ileoce-
cal valve. Medicinal laxatives increase the antiperistal-
sis by which the reflux from the colon into the small
intestine is increased. Liquid petrolatum increases the
motility of the small intestine, but does not increase
antiperistalsis.
The correct viscosity, high uniform quality and ab-
solute purity of Nujol make it the dependable aid of
physicians in the host of conditions where liquid petro-
latum is indicated.
Sample and authoritative literature dealing with the
general and special uses of Nujol will be sent gratis
on request Address: Nujol Laboratories, Standard
Oil Co. (New Jersey), Room 765, 44 Beaver Street,
New York.
For Conservation of Health
It is of real importance that children be properly shod
with resilient rubber heels. The light, springy step
and the avoidance of shock and jar mean much to the
growing child. Thus the child who wears O'Sullivan's
Heels as happier, the structures of the feet are
strengthened, the gait and carriage are improved and
there is a marked decrease of nervous irritation, with
its all too frequent depressing effect on the whole
body.
The sum total is more comfort, greater efficiency
and a real conservation of health. O'Sullivan's Heels
fill a definite place in the hygiene of childhood.
Relief of a Painful Condition
That painful condition, congestive dysmenorrhea,
can be relieved by proper medication. Gynecologists
have found Hayden's Viburnum Compound of in-
estimable value in the treatment of dysmenorrhea,
and many clinicians rely on this well-known product
for relief in these cases.
A card will bring literature and sample of H. V.
C. to American Physician readers, Address: New
York Pharmaceutical Co., Bedford Springs, Bedford,
Mass.
In Tonsillitis
Few remedies are so dependably useful in relieving
the acute discomfort and pain of tonsillitis as Pond's
Extract. Used as a gargle every hour — a tablespoon-
ful to a half glass of hot water — its effects are prompt
and gratifying.
Dryco Solves the Problem
The ideal agent for sick and convalescent feeding
is, according to all authorities, milk. But as such
it has several shortcom.ngs.
Dryco solves the problem of feeding, which is
as large a part of successful treatment of disease as
is the correct use of indicated medicine.
Dryco is dry milkt produced by the rapid process
— two seconds at 212° F. This prevents carameliza-
tion of the sugar, changes the casein into a col-
loidal form and breaks up the fat emulsion into an
easily digested, free, fatty acid. Dryco is palatable,
easily prepared, rapidly digested, completely assimi-
lated and bacteria-free.
(Continued one leaf over.)
HEMORRHOIDAL
Suppositories
Ask a fair number of fellow practitioners:
"What is your preferred prescription in Hem-
orrhoids? "
And note how many unhesitatingly reply:
"Anusol Suppositories/*
Ample Trial Quantity and Information on
Genuine Anusol Suppositories
from
SCHERING & GLATZ, Inc.
150 Maiden Lane NEW YORK
You can buy with Confidence — See "Service Guarantee to Readers'* on page 906
The Americn Physician Advertising Soviet
Correction of
lal Curvature
i new idea could ask for greater appreciation
ent than has been extended by the profession,
veil as the laity, to the Phiio Burt Company,
lufacturers of the Philo Burt Spinal Appliance.
first testa of this invention, made and reported
(teen years ago by several physicians and sur-
is, were followed by reports which gained the
ntion of practitioners everywhere, with the re-
that we have supplied more than 40,000 of
e appliances in cases covering every known
ii and condition of spinal trouble.
physieian can pursue very far a special study
pinal curvature and approved methods of treat-
t without quickly learning about the Philo Burt
i and being impressed with its demonstrated
value. Detailed information, with comprehen-
tnce of results obtained in many interesting
be sent upon request addressed to
THE PHILO BURT COMPANYns-24 o<u f,ii0w. bu». Jamestown, N. Y.
A Danger Signal
There remains no question as to the wisdom of employing suitable means to
reduce hypertension and counteract or prevent it.
It is safe to regard high blood pressure always as a danger signal. It is wise
always to treat it intelligently and safely by means of
PULVOIDS No. 373 NATRIUM CO.
which is essentially the famous formula of Sir Lauder Brunton, modified and
proven by Dr. M. C, Thrush.
PUL VOIDS NO. 373 NATRIUM CO. contain Sodium Nitrite, Potassium
Nitrate, Sodium Bicarbonate, Nitroglycerin and Crataegus Oxycantha. Sugar
coated white or green with a special coating to disintegrate in the intestinal
tract, thus avoiding gastric disturbance.
A safe, non-toxic, effective combination which is prompt in action and pro-
longed in effect.
A clinical test will demonstrate its superiority and service.
Bottles of 1000 Pulvoids $5.00, direct to Physicians and Hospitals only,
mailed free when cash accompanies order. Trade bottles of 1 00s, per
dozen $9.00.
Literature, case reports, etc., free on request
If von dWenie. uk for complete price list, including Endocrin Caniulea mad SalvaroU
(606 Suppoiitorie*)
THE DRUG PRODUCTS CO., Inc.
ISO MEADOW STREET LONG ISLAND CITY, N. Y.
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Points
[Philadtlpbu
The physician who uses Dryco in the feeding of
cases of pneumonia, typhoid or any acute disease,
in surgical cases, in chronic wasting diseases or
cachexia, during convalescence and for infants —
need never worry about the nutrition of his patient.
Literature, directions, etc., will be sent to Aemri-
can Physician readres on request. Address: The
Dry Milk Company, 14 Park Row, New York City.
Correction of Constipation and Autotoxemia
Besides lubricating the canal. Interol renders the feces
soft and plastic, thereby promoting their easy passage
and evacuation with gratifying freedom from discomfort
and distress. Interol is a pure mineral oil of the proper
density and viscosity to assure satisfactory lubrication of
the intestinal canal, and thus relieve and correct bowel
inactivity without the usual disagreeable effects of ca-
thartics as commonly employed. This pure, tasteless
and odorless mineral oil is notably free from the greasi-
;o such products. Interol will be found
correction of constipation with ilsattend-
...„ __. a conditions.
For sample and interesting brochure, address: Allied
Drug and Chemical Corporation, 2413 Third Avenue,
New York City.
Yon Can Depend on Them
Clinicians have found, over a number of yean,
that Huston products can be depended upon. And
that'a the only kind of goods the wise physician has
time for.
For example, "Neverslip" — the round cord that will
always hold — will serve you well in the obstetrical
case where you have to be sure of your product. A
supply for thirty cases (only a nickel each) will be
(hipped to you prepaid for $1.50. ^^
Or the New Comfort U-Supporter you will find
a practice-builder, it gives such satisfaction to the
patients. It has been found excellent in enteroptosis,
gasteroptosis, floating kidney and post -operative con-
ditions. It is washable, durable and economical;
prices range from $6.00 for six-inch width, to $7.00
for eight-inch width-— and larger sizes proportionately
higher. From which a discount of 2'% is allowed to
physicians. Order today or write for descriptive
literature. Huston Brothers, Atlas American Build-
ing, Chicago, 111.
A Record to Be Proud Of
Colonel Herman A. Metz, president of the H. A.
Metz Laboratories, Inc., was nominated for Con-
gress on the Democratic ticket in the Seventeenth
Congreslonal District in the City of New York in
the primaries on September 20.
Colonel Metz was formerly a representative in
Congress from the Tenth Congressional District of
Brooklyn and made a very enviable record as a
member of the lower House.
Colonel Metz was the first Comptroller of the
Greater City of New York, and through his efforts
the city was placed on a firm financial foundation.
Diuretics
G. Strooman (Therap. Halbmonalsh, July, 1921)
cites a number of nephritic cases in which sudden
diminution ih the quantity of the urine occurred after
initial diuresis as the result of continued ingestion of
the xanthine bodies- The return of diuresis could
then only be brought about by stopping the admin-
istration of the theophyllin or lessening its dose, or
{Continued one leaf over)
Jr
%,
A Compound Conn mini ihe Bile Sain Sodium
Glycocholile. Sodium Tiurocholne with Caicara
Sajradi and Phenol phi hal ten
TAUROCOL COMPOUND TABLETS
THE PAUL PLESSNER CO.
Operative
Surgery
Special course in general
surgery, operative
technique and gynecologic
surgery given to physicians
of both sexes. Enrollment
limited to THREE.
Firtt asmutakip—No cadaver or dax-werk
For para culm'* addreaa,
DR. MAX THOREK
AMERICAN HOSPITAL
846-856 Irving Park Boulevard, CHICAGO
You can buy with Confidence— See "Service- Guarantee to Reader
December, 1922]
The American Physician Advertising Service
899
Sedatole
in coughs
an elegant ethical expectorant that actively
attacks and clinically conquers coughs.
If you do not now know Sedatole, you should —
so when you send in for your sample please
mention your Fed. Lie. No. just for our records.
Sedatole
Sharp & Dohme
Chemists since '60
at Baltimore
A Logical Sequence of Events:
4 FORMULA
THE Premises : Infection, Inflammation,
Swelling, Fever,
THE Argument:
The Conclusion: Result, Relief from
Pain, Reduction of Swelling and Fever. Resolution
of Inflammation.
Read the Formula
Pneumo-Phthysine Chemical Co.
Chicago
Mentioning The American Physician Insures Prompt, Careful Service
Helpfal Points
[Phfladelpliia
Sterile
ANTISSPTtC
IOCALANAESIHEIK
Ampules of Waits'* Antiseptic Local An-
aesthetic are sterilized after they are filled.
Each lot is then tested for sterility in our
bacteriological laboratory.
The ampules ere hermetically sealed —
won't deteriorate — will keep indefinitely.
Are ready to use. Also sold in bottles.
Send tor Free Sample
Let your own experi-
ence prove the mpe-
riority of Dr. R. B.
Wailc'i Local Anaa-
thetic. Send in tlic
coupon with your pro-
ftuiorial card or let-
terhead and we will
-d ,o, . „„..»».
free temple box for
your own tests.
ANTIDOLOB MFG. COMPANY
S3 MAIN ST. SPRING VI LLE, ERIE CO., N. T.
Cheek. Btsn and Ma.il This Coupon
ANT1DOLOR MFG. CO.,
32 Main St.,
Springville, Erie County. N. Y-. U. S. A.
Attached find my professional card or letterhead.
by the use of the weaker Diuretin.
come to prefer Diuretin to the xanthines especially
in cases of sclerotic kidney lesions. He employs this
remedy in a course of closely succeeding dosage, be-
ginning in the afternoon at perhaps 2 o'clock and
giving, at intervals of one to one and a half hour,
doses of O.S gins, up to eight times, rarely more.
Carl Pototsky (Therap. Halbmonatsh, April 1, 1921)
having found that theobromine preparations such as
Diuretin increase the secretion of salts in the urine
even in animals with sodium chloride deficiency, sug-
gests its use in epilepsy alongside of salt free diet and
bromides in order to hasten the appearance of bromide
Dispensing Physicians Can Buy Direct
Many physicians have found Merz Santol Comp.
Capsules unsurpassed for happy effect in urethritis,
cystitis, prostatic troubles, difficult micturition, etc
Dispensing physicians can now buy direct from the
company in various quantities. Prices and samples
will be sent gladly to American Physician readers,
on request. Address: The Merz Capsule Co., Detroit
Mich.
An Effective Antiseptic That is Non-Caustic
The medical profession has long wished an antiseptic
that would be thoroughly efficient, but at the same time
non-caustic Their wish can now be satisfied in Thera-
pogen — an efficient antiseptic that is not only non-corro-
sive, but also non-toxic. Moreover, instead of destroy-
ing tissue together with the bacteria, as do most effective
antiseptics, Therapogen actually stimulates granulation.
It does not irritate wounds, but is soothing. It may be
used on the most delicate membr&nces, even to the
mucous membranes of the throat, nose, vagina, etc
(Continued one leaf over)
MORPHINE
Drug Addictions
Treated by the "QgayU ^Method."
DR. QUAYLE SANITARIUM
Ch.. H Quark, M-D- Msdkal Dintm
Dept. 305 Madisoo, Ohio
i can buy with Confidence — See "Service Guarantee to Readers" on page 906
December, 1922] The American Phytician Advertising Service
Tf VERY DAY doctors are advising a rest, a trip to a sanitarium, a visit to
J-'a specialist, an operation — anything to get rid of their old, stubborn cases of
Prostatic Disease and Impotence
' thing. You are losing possibilities of dollars and prestige.
I ftlt.
iora, only to fall into the hinds of unscrupulous men who
YOU CAN GET RESULTS
hi many of these ease*. If you will try SVPPOS. PROSTANS thoroughly In one or two cases you will surely
eonilnce yourself snd will thereafter ktip th* bunnin yon'vt bttn (Hi-nine away.
If after s fair clinical ten you feel that the results do not more than meet all your expectations, we hereby
agree to refund your money upon request This offer places the burden of proof upon us at our own expense.
your patients to mall this before other matter, cause you to lay it aside, and aaye that much time for other
things— tomorrow.
Fill out the coupon now. Sincerely,
REGENT DRUG COMPANY
TUt Coupon Mien, Succtu and Mcney Savti ci Witt, Pill It out. Send Today.
RECENT DRUG COMPANY. Tha' Bmi*m of Proof test. Upon tJV
3152 Woodward Ave., Detroit, Mick.
I enclose $5.00, send me six boxea of Name
Suppoe. Proatans (worth $9.00) alao
the nhove book and "Successful Prosta-
tic Therapy" — free. Address
Mentioning The American Physician Insures Prompt, Careful Service
Helpful Poinli
A Stand-By in
Uterine Troubles
VIBURNO
(BEACH)
The beat evidence of this » the
repeat order* received from physi-
cian* and druggists.
Nervine-Tonic and Antjcongest-
ivc, with calmative and corrective
action on the bladder. Employed
with much satisfaction in ovarian
congestion and congestive dysmenor-
rhea; weak pregnancy and deficient
lactation [ menopause and its phe-
nomena, including hallucination*, hot
flushes, etc; nervous and menstrual
derangement* after "flu," and the
trouble* of adolescent girls. Sterility
often responds after 2 or 3 bottle* if
no lesion exists.
Unlike dniltr product*. VIBURNO
U rrr1-*-"- and planaant to tnkn.
Domi 1 twp. (ew&lntW) U.J.
More bmmu*.
Put np In 11 m bottl*.
Sample *W Formada on Rttpu*
THE VIBURNO COMPANY
116 Mnaana Um, New York
Sal Hepatica
THE
STANDARD SALINE
LAXATIVE
Bristol-Myers Co.
NEW YORK
It is ideal as a sterilizing solution for instruments,
dressings, gloves, hands, etc. Its odor is aromatic and
does not cling to the clothes like the cresots and other
tarry acids. It is freely soluable in water, alcohol, ether
and glycerin and readily mixes with oils in the_ com-
pounding of salves, etc It is a clear golden liquid. It
is a soluble thymol-terpene compound of definite anti-
septic properties and of wide possibilities.
Its use in general surgery, in open wounds, even in
the abdominal cavity, is an aid to healing. For its use
no complicated technic is required, as is the case with
Dakin solution. Simply apfly Therapogen— the desired
strength. It is valuable in obstetric work; in gynecology,
for inflammations, and before and after operations; m
gonorrheal and other forms of urethritis, vesiculitis,
etc.; in eye. ear, nose and throat diseases; in skm dis-
eases of parasitic or bacterial origin, particularly eczema,
ringworm, etc In fact, in every case where an efficient
antiseptic is indicated Therapogen is the choice, because
it not only does the work, but it does not destroy tissue,
but rather helps build it up.
The manufacturer's claims are borne out by the fact
that it is used in many of the large hospitals of the
country, such as the Preston Retreat, of Philadelphia.
It is not advertised to the general public, but is strictly
an ethical preparation.
A sample will be sent free to any member of "^P™-
fession upon request to the manufacturing chemist, Theo.
Meyer, 213 S. 10th St., Philadelphia.
Lyman O. Fiske. who for the past two years has
been connected with the Haiard Advertising Cor-
poration, severed his connections with that agency
and on June 1st, became associated with the Metro-
politan Advertising Company, 111 Broadway. New
York. Mr. Fiske has been active among chemical
dyestuff, and pharmaceutical fields. Hts experience
as business manager of the Dramatic Mirror for many
years particularly equips him for personal adver-
tising service to his clients.
Woodlaum
Maternity Home
A itrietly private and ethla' " "
fat unmarried firls end woi
nenCT and confinement, wi
^.nuran. and protection. **!«™
for the infant by adoption if denied. AH
publicity avoided Pncea reasonable- For
vJo^LAWN,COWKW>. Ttom C*, N, V.
e effective and reliable
the none end throat than
, Used u a douche or jargic— a tnble-
half cUw of *"' ' """" ' '
December, 1922] The Amenen Phytidan AJvcrtumg Service
USTERS DIABETIC FLOUR
Strictly Starch-free. Produces Bread,
Muffins.Pastry that makes the
distressing features
903
I
1 P" ^lessand
■ sWeaJfLess .
Litter* prepared casein Diabetic Hour — self rising. A month's supply of 30 boxes $4.65
LISTER BROS. Inc.. 405 Lexington Avenue, New York City
Fur Lined Overcoats
Black wool keraer cloth, lined and
collared with dirk brqwn marmot fur,
•fees 36 to 46: while toe? last theae
handsome garment] will be sold at
BMFFinrS COMPOUND MIXTURE
of Gualac, Stillingia, etc.
A Powerful Alterative — Composed of Coaiac,
Stilling*, Prickly Aah, Turkey Corn, Colchicum,
Black Cohoah, Saruparilla, Salicylate! of the Alka-
liea. Iodide of Potassa and other well known reme-
by all patients suffering; from Rheumatism, Gout,
Lumbago. Neuralgia. Sciatica, etc
Prescribe it for "That Stubborn Case"
upon receipt of 2S cents for
Griffith's Rheumatic Remedy CompaiT
Newburgb, New York
Binder and Abdominal Supporter
For Men, Women and Children
For Ptosis, Hernia, Obesity, Pregnancy,
Relaxed Saxro- Iliac Articulation*, High
and Low Operations, etc
Atkfor 36 pate DatrtpU* Fold*
Katherine L. Storm, M. D.
OrWufcw, fMtnlm. Smk Omm *W **«*.'
1701 Diamond St. Philadelphia, Pa.
New Remedies for Gonorrhea
come and go. but GONOSAN. a scientific combination of
the purest East Indian Sandalwood Oil and Kava-Kava
Resins, retains its predominant place with the medical
profession as the most efficient balsamic in the treatment
of inflammatory condition* of the genito- urinary tract.
Prescribe GONOSAN for acute and chronic caaes.
eof You
Sample, Are at Your Disposal
RIEDEL & CO.
104 South Fourth Street
Mentioning The American Physician Insures Prompt, Careful Service
HctpftA Pdnb
Results Are What Count
Worldwide clinical results extending over
thirty years past should be conclusive evi-
dence to the most skeptical, that a palatable
combination of the alkaloid -amino acid prin-
ciples of pure Cod Liver Oil with a Creo-
sote rich in guaiacol, such as represented in
Chaupote&ut's
MORRHUOL CREOSOTE
{Cap nit* ef S "tin, Merrhttol tm& 1 mi*. Cr»iot«)
is the only practical way to confirm the
favorable results obtained from the use of
these well known therapeutic agents in the
routine treatment of :
T. B. — Influemza. and Bronchial Catatrt)
In all cases where Creosote is contra-
indicated :
MORRHUOL PLAIN
(CapsuUi of i mi*. Morrkuet Ckafotmt)
exerts its alterative tonic and stimulant
action alone upon metabolism by virtue of
its constituents and will be found of great
service in: — Rickets, Scrofulosis and simi-
lar "deficiency diseases."
DR. PH. CHAPELLE
Pari*. New York
E. F«MPTB iCo., Ik. Lymana. Lla*lt»4,
U. 5. AgM, Mtw Ynrk Cmdlu A«ta, Mat.
In Urethritis
of gonorrheal or non-
infectious origin, the
best instillate is an anti-
septic that, while abso-
lutely effective, does not
irritate the delicate mu-
cous membrane,
THERAPOGEN
Soluble Thymol-Terfene
has been proved effective
and non-irritating by
clinical and laboratory
tests. It is non -caustic,
rosive. N o offensive
odor. For use wherever
a healing antiseptic is in-
dicated.
Wholaml* Dm* Ha cm* Sap
COUPON FOR SAMPLE
THEO. MEYER, 213 S. lOlh St.. Phil*.
•t THERAPOGEN
These Advertising Pages are
A Constructive Market
'• M-* *• sMf JsV - — *** <•— ■* ■■■ ***■ - sgfc
Our Advertising Standards
Advertisements must give honest service to em
readers and their patients is the baste principle for these
standards and for the conduct of The Americas
Physician's advertising pages.
Our attitude in applying these standards is not eat
of narrow technicality but of practical service.
Advertisements of the following classes are net
acceptable for the pages of Thk American Physician:
Fraudulent pharmaceuticals; those making dishonest
claims.
Pharmaceutical! charging excessive price; price Dot
warranted by content and by trade conditions.
Pharmaceuticals and other mixtures for internal nse
and containing narcotics or other habit -inducing drags
in quantities sufficient to promote their improper repeti-
tion on prescription (chloral-bearing proprietaries, etc).
Potent pharmaceuticals which justly merit profes-
sional disapproval because of their lay advertising or
manifestly unethical exploitation.
Financial advertisements that claim returns not com-
patible with conservative investment Only conserm-
tive investments are advertised.
Further
Advertising copy is subject to revision by the editorial
staff.
The American Physician agrees heartily with n»
principles of the Council on Pharmacy and Chemistry
of the American Medical Association and we exclude
from our advertising pages such pharmaceutical prod-
ucts as they have definitely shown to be unworthy of
professional confidence and the manufacturers of which
have not removed the cause of objection; but we do
not accept such findings as are based on academic data
without due recognition of general clinical experience.
Concerning formula:, The American Physioah »
urging pharmaceutical manufacturers to give full thera-
peutic data regarding formulae, stating quantitatively
active medicinal content, in order that physicians may
intelligently prescribe. We do not accept advertising of
secret pharmaceuticals.
But We do not Decline
Advertinng of original dross, c
toted in current ar""-- ■ *» •!•» Tt
Foi-mulirj (excep
againit thii elm of
Preparation! containinf
i Pharmacy and CfaeroiatiT. w
jt will alvayi consider proper
ledic*.
limited number of dross ii
You can buy with Confidence— See "Service Guarantee to Readers" on page 906
December, i»z] Tht American Phfddm AJfoHmg Service
Mentioning The American Physician Insures Prompt, Cartful Service
Helpful Points
Clinical Evidence
proves the most satisfying
results are obtained by pre-
scribing
Pluto Water
in cases of habitual consti-
pation, gout, rheumatism
and all cases when a uric
acid solvent is desired.
Many practitioners direct
convalescent patients to the
spring for rest and complete
treatment where can be
round two well-known
members of the American
Medical Association with
trained assistance.
French Lick Spring* Hotel Co.
Fnnck Lick, In*
Oar AJrcrtuiaf Sfamdardj
n prtctdntf pas'i
quitted phytic
Product! composed of minor
doMfe. proTidcd theae drug! have
tare And ire well defined in ma
rsjs,
: pbarmacolooc dan
, •cap* and toilet article* henutlr u&rtilhti
to both phriiciuu and laymen without falae or fraudulent wait-
■sent: honeitly idferriied mineral wateri and m
Service Guarantee to Readers
IF YOU HAVE ANY UNSATISFACTORY
DEAUNG WITH AN ADVERTISER IN THE
AMERICAN PHYSICIAN, WRITE US THE
PARTICULARS AT ONCE.
WE WILL IMMEDIATELY TAKE THE MAT-
TER UP WITH THE ADVERTISER AND SEE
THAT THE ADVERTISER EITHER MAKES
GOOD, OR HIS ADVERTISEMENT IS ELIMI-
NATED FROM THE AMERICAN PHYSICIAN'S
PAGES.
NGosalvarsan
(Neoariphcnamme-Mctx)
is unsurpassed in reliability,
trypanocidal efficiency and
ease of administration.
)p| Neosalvarsan is manu-
factured by the process
y used in preparing the orig-
inal Ehrlich product and
offers the physician the
ideal means for treating
the luetic
We have just prepared and are
mailing to physicians a review of the
common pathological condition* of
the female pelvic organs, which is
intended to be a ready reference by
which the busy practitioner can re-
fresh his memory. It is entitled:
A Brief Handbook
of
Gynecological Practice
Should you fail to receive, a copy
shortly we would be pleased to for-
ward one to you upon request
MARVEL COMPANY
25 Weal 45th Stmt
New York City
You can buy with confidence— See "Service Guarantee to Readert" top of this page.
December, 19221
The American Physician Advertising Service
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Dioxojfen
Antiseptic Efficiency
Without the "Unknown Quantity"
NEVER was the necessity for prompt and effective
antisepsis in the care of emergency or infected wounds,
to widely and thoroughly recognized as it is today. As a
logical consequence, never was there a time when the
value of Dioxogen as an all round antiseptic was more
evident.
This is easy to understand on the part of th* many medics] men who
slop to realize that the germicidal efficiency and tissue healing properties of
Dioxogen are due entirely !o me pura.actir* osygan il ii aUe to cany directly
to the wound or place required. Naturally they have come to prefer Dioxogen
to those poisonous and essentially
irritating germicides like iodine,
carbolic, bichlorides, and *o on, the
toxic dangers and possible injurious
effects from which are always an
"unknown quantity."
The use of Dioxogen in cleans-
ing infected wounds and injuries
assures maximum antiseptic effi-
ciency with gratifying freedom from
the "unknown quantity" of toxicity
and tissue irritation.
The Oakland Chemical Co.
Mentioning The American Physician Insure* Prompt, Careful Service
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