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al |_-.:. :.-.-:: / / books . qooqle . com/| 



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ihl^WilrOTTrirt 



Boston 
Medical Library 



8 The Fenway 



2= 







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The American Physician 



[Phila., January. 1922 



Haa decide 


tsides showing 


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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. 
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Grow 

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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." 



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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. 



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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 

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For 

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per Introductory Offer 
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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 
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producing complete antisepsis 

But 

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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. 

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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. 

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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,., — ..,_.,,__ _ ~« w ajdiy 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 



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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 




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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 



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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. 



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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? 



Copyright 1022 by the Joimt Coffee Trade Publicity Committee of the United State*. 



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The American Physician 



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. 



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The Am 



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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: "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- 

i 118 - 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 specialists , 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 "Great 9 * 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 Forbes 9 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., Mo ntr — 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 Consi deration 

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 






inttfdtp tn o e nL 

defMfteMkt ii cood u c ted 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 Lusk 1 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. 

"~ T Lusk, 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«W H»M » W niHll ffll« 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 Albm mu m r ia 

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 proper ti es, 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. 

Chicago, 136 N. La Salle St. Kansas City, Mo„ 711 K. C Life Bid*. 

Denver, 621 Central Sav. Bank Bid*. Portland, Ore., 607 Pittock Block. 

Dallas, 1606% Commerce St. 



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 physicians 9 

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^ 

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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 



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,.-> 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. 



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Pond's Extract 



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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 

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Did any other orthopaedic institution ever make you a like offer? 
Do you know of any other orthopedic institution that trill make you a 
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If you have a case of spinal weakness or deformity now — no matter 
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Every Philo Burl Appliance it made to special measurement. It liftith* weight 
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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 
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use attached coupon. 



Creo-Tussin 



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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«. 
Fricm: TaMcts, 4t la • bn, S2.M; umk 2t la • fez, SS.M. 

EXTENSIVE LITERATURE ON REQUEST. 

CAVENDISH CHEMICAL CORPORATION 

Sole Agents. 



Pearl Street 



Established 1905 



New York 



You can buy with Confidence— See "Service Guarantee to Readers" on page 82 




An Honest Market Place ** 



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 
COr puscles 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, Detroit 1 

MAIL THIS COUPON TODAY 

j y g mt 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? 

Totn y pF,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 WAS HABLE 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 stu bborn 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 t rial 
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 i t h.™e™daWV»hrph t t D ft ' 117 liM*aa*t thatontwrffi? For a centtlT Y 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 Holi 1 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" ?]? ?*• *? 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 'rMcw P '»«.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 C im uia trUm Whm Tm Cm Bail WW C w Hur t 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 .u e 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 *™^ table Ji "*» 



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 



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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 
H s 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 
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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 am P u ^°* 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 . | /20 00. 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 

aloin, gr. 1/10; podophyllum gr. 1/20. (List No. 420) 

Net price, 100 $1.21 Contains quinine valerate, aconitine 

Net price, 800 !!!•!!!..!!!!.! $8.93 an< * hyoscyamine sulphate. In winter 

and all the year an effective recourse. 

ALL sx9 TL1 Net price, 100 04c 

Abbott a Thaloten Net price, soo $4.46 

A palatable laxative tablet contain- AnticOttatipation (Abbott) 

ing phenolphthalein, sulphur, senna. (List No. 233) 

Pleases the most finicky. Segmented Originated by us. A formula many 

for divided doses to children of all t^e. imitated, so satisfactory is it in 

•8°*« chronic cases. 

Net price, 800 $1.99 Net price, 800 83c 

Net price, 1000 $3.78 Net price, 1000 90c 

Special bulk prices quoted on any of the items listed 
above. All orders filled promptly. 

THE ABBOTT LABORATORIES 

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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 
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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 

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ASEPTIKONS (sup V p A o% N t A o L r,es) 

producing complete antisepsis 

But 

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Indicated in cervicitis, leucorrhea, 
specific and non-specific vulvo-vaginitis, in all cases 
where complete vaginal antisepsis is desired. 

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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. 



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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 



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\~OfltCfllS rx>nlin V tdfr> nn p ge92 

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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The A . _.. „.._ _. r 

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 

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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. 

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ERREll C0MI * ,iY 
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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. 

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Oral Solution: Vials of 12 Cc 



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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- 
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[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 



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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. 



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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 



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In those cases that have a 
tendency to a high blood 
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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 V 9 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 el im in ate 
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 Am d o my 

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. 

Dm g m ttM 

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. 

Q m t tlnn 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 I Thl 

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 Moi i cd tmm 

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, req ui te s 
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. Comte 1 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 



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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) 



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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. Jour H 
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 
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 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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Denver, 621 Central Sav. Bank Bid*. Portland, Ore., 607 Pittock Block. 

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Mentioning The American Physician Insures Prompt, Careful Service 



142 



Book Reviews 



IPhila., February, 1922 



Roemtgem Imterpr et a ti om 

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. — ' 



The Amman Physician] 



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Mentioning Tht American Physician Insures Prompt, Careful Service 



144 



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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During pregnancy and confinement, Hemorrhoids occur with great frequency, 
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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. 

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The American Physician] 



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145 



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Mentioning The American Physician Insures Prompt, Careful Service 



146 



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- 
ment plan. Turn to page — , see the offer, and send in 
the coupon. 

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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the excessive acid in the stomach and pre- 
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lining the formation of additional acid. It 
reacts gradually, is superior to Bismuth and 
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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 and after 
operations. 




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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- 
soluble-B Vitamine. 



There ia atill do other product of thia i 
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Suppreeaed Growth Low Vitality 

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•Harria Tableta have ihown their clinical value in thouaanda 
Subnormal Hunger 



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W file for charb and clinical luggationt 



Mentioning The American Physician Insurer Prompt, Careful Service 



148 



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- 
duce satisfactory intestinal lubrication. Sample and 
brochure will be sent to American Physician readers. 
Address: The Allied Drug and Chemical Corporation, 
2413 Third Ave., New York City. 



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- 
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macteric symptoms, amenorrhea, neurasthe- 
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149 



NATIONAL BIOLOGICS 

Diphtheria Antitoxin (National) is of the highest quality, 
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An efficient prophylactic and an effective treatment in sinus infec- 
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THE BEST TREATMENT OF High BloOCL PreSSUTC 

should be studied and understood by every doctor 

Hypertension is always a danger signal 

Pulvoids Natrium Compound 

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is a scientific and clinically tested combination of safe, non-toxic, non-irritating agents, whose 
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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- 
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Dosage: One pulvoid ti.d. increased when necessary to twelve daily, until pressure 
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Booklet on High Blood Pressure. How to take, 

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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 

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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, M Fbr 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 AdcBctf o— D octor 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 



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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/Sr SS 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 p rove< i formulae. Now "they are offering their 

L. C. SMITH No. 5 w88$.'$Bl&m T nty pr< ?T V- 1 TT °f 2? p f cen L T , 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»iaSr I iaiurtb, 1 t»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», e iwn 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* m a chin e 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 , lpr e« 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* ^hi 1 "*"^ 1 " f og ^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 .:£?',ai r '"s;5" 1 ,'; h rr„rs J :" Ev ^ k ™' h v™- ^i ly - »>»«»<< ■»««.",•■' .■» 

the trpewrtter will be ahlpped promptlr. There i» nored tape. munologists make inoculations in respiratory infections 

■Tmpi? P uMe™tood' c th , 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 kc Pp 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 A nt j.p y .o Dental Cream, will be scot to 

*"* America.^ Physician Readers. Turn to page 94 and 

8tr *** *anra§i !erK | j n 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 sinu si tis. 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 



DO CTOR ; 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 th e 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 w ith 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/WaUES t hc 

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! 
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Pneumo-Pkthysine 

The best remedy (Pneomo-Phthysiue) 
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If FNEUMO-PHTH VSINK has failed 
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IF YOU HAVE ANY UNSATISFACTORY 
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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 
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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 
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AN IDEAL ARSENICAL 

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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. 

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]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. 

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LOESER'S INTRAVENOUS SOLUTIONS 



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evolutionary step toward rational 
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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 
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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. 



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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. 



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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 



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purpose — to give the aenerai practiliener the efficiently frielioll 

to promote and protect the opportunities and interests of thei 
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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?' 



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j alt communications 'and mo*, all funds payable to— 

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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» 
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NEURASTHENIA 

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rasthenia. 

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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 egg f 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 Editors 1 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 found 1 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 investigation 1 
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 

1 Fedele, 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 "inflammation 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?" 



Tre atment 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 Ah d s mtn 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 t Tl »« 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 

Menti on in g 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 Com pany, 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 ana 1 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 years 9 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_„___ 

\*TGO m 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 
wrt i l «£!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 „„ t he respiratory tract 
th* D « re wmp™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— hi Pi 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 ™ P iinde™too d'''th 0r,— "° ™"*'" , ™* — 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 (C 1 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 Vr fined 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 Oragg UtM 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 
CASE S, 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 Marke t -Puce 

4 Cmmmimt FW. Wktrt Ym. C D«l Wat C— tdeaec a-aia- 
faniocwr- naiaiercial. •riaditc, amnt- l&M I" at —J i Jafe 
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) 



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• r-ludl rated. Price 



"WHBT CULTURE, BACILLEH 
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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* 



S m m pit* and Littrmtmrm 

DIARSENOL COMPANY, Inc. 

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]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 

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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 
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PuBtrHO-SBHOBACTHfilN T YFB O^EBOB 1 CTEH! W MlUD 



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H. K. HULFOBD COMPANY. Philadelphia, U. S. A. 



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TW Aatricn Phrridu] 



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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] 



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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.> 



AseptikonS 

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 . ... 

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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 . 


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$1.00 
























Domestic postage— U* 5™and po 
























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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. $. Kahn t 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. 



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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. 



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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. 
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 : 



Imp r ok mb &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- lfl mkU 

"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 

<r We 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- 
vironment st 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 Forbes 9 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. JL P 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 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 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 4 l /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 7 l / 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 
2 l / 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 pr im a r y 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