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Full text of "International record of medicine"

Digitized by the Internet Archive 

in 2010 with funding from 

University of Toronto 



http://www.archive.org/details/internationalrec105wash 



NEW YORK MEDICAL JOURNAL 

INCORPORATING THE 

PHILADELPHIA MEDICAL JOURNAL 

AND THE 

MEDICAL NEWS 
A WEEKLY REVIEW OF MEDICINE 



EDITORS 

CHARLES E. de M. SAJOUS, M. D., LL. D., Sc. D. 

SMITH ELY JELLIFFE, A. M., M. D., Ph. D. 



ASSISTANT EDITORS 

Paul Ely McChesney, A. B., M. D. 

Charles F. Bolduan, M. D. Louis T. de M. Sajous, B. 5 , M. D. 

Caky Eggleston, M. D. William F. C. Steinbugler, M. D. 

Albert Robin, M. D. A. Strickler, M. D. 

H. Augustus Wilsok, M. D. W. H. Donnelly, M. D. 

Benjamin T. Tilton, M. D. Rufus B. Scarlett. M. D. 

Matthias Laxckton Foster, M. D. Guthrie McConnell, M. D. 



VOLUME CV. 

JANUARY TO JUNE, 1917, INCLUSIVE. 



NEW YORK 

A. R. ELLIOTT PUBLISHING CO. 

1917 




/7 



COPYRIGHT, 191 7, BY A. R. ELLIOTT PUBLISHING CO. 



LIST OF CONTRIBUTORS TO VOLUME CV. 

Those whose names are marked with an asterisk have contributed editorial articles. 



Abr.\movitz, Max, M. D., Philadelphia. 

Abt. Is.\ac a., M. D.. Chicago, 111. 

Adams, Edw.vrd, M. D. 

Alexander, Robert M., M. D., Reading, 
Pa. 

Allen, VV. H., M. D., Captain, Medical 
Corps, U. S. Army. 

Anders, James M., M. D., LL. D., Phila- 
delpliia. 

Apfel, H.\RRy, M. D. 

*.\rro\vsmith, Hubert, M. D., Brooklyn. 

AsHFORD, Mahlon, M. D., Captain, Med- 
ical Corps, U. S. Army. 

AsNis, Eugene J., M. D., Philadelphia. 

B.\BC0CK, W. W.WNE, M. D., Philadel- 
phia. 

Baker. Rollin O., M. D., Montour Falls, 
N. Y. 

Baker, S. Josephine, M. D. 

Ballencer, Edgar G., M. D., F. A. C. S., 
Atlanta, Ga. 

B.\NDLER, Samuel Wylus, A. B., M. D. 

B.\rker, Creigbton, M. D. 

Barnett, Charles H. J., M. D., Phila- 
delphia. 
• B.\STED0. Walter A.. M. D. 

Bates, William H., M. D. 

Bean, J. Robbin, M. D. Birmingham, 
Ala. 

Be.\tes, Henry, Jr., M. D., Philadelphia. 

Benedict, A. L., M. D., F. A. C. P., 
Buffalo. 

Birge. E. G., M. D., Jacksonville, Fla. 

♦Bishop. Louis Faugeres, A. M., M. D. 

Bl.\hd, M. E., M. D., F. A. C. S., Cleve- 
land. 

Bland, P. Brooke, M. D.. Philadelphia. 

Block, Siegfried, M. D.. Brooklj-n. 

Blumenfeld, Samltx, M. D. 

Book, Franklin W., M. D., Rochester, 
N. Y. 

BoGGS, Russell H., M. D., Pittsburgh. 

♦Bolduan, Charles F., M. D. 

Boston, L. N.\poleon, A. M., M. D., 
Philadelphia. 

Bram, Israel, M. D., Philadelphia. 

Brandeis. Juli.\n Walter, M. D. 

Bretzfelder, Karl B., D. O., M. D., 
New Haven, Conn. 

Brill, Nathan E., M. D. 

♦Brink, Louise, A. B. 

Brinkley, Arthur S., M. D., Richmond, 
Va. 

Brodhead, George L., M. D. 

Brown, Samlt;l A., M. D. 

Buerger, Leo, M. D. 

Bugbee, Henry G., M. D., F. A. C. S. 

Carter, William Wesley, A. M., M. D., 

F. a. C. S. 
♦C.-iRY, E. G., M. D. 
Cas.\le, John B.. Newark, N. J. 
Cal-ble, Willi.\m C, M. D., Brookl}!!. 
Chapin, Henry Dwight. M. D. 
Cherry, Thomas H., M. D., F. A. C. S. 
Chetwood, Charles H., M. D. 
Claiborne, J. Herbert, M. D. 
Clark, William L.. M. D., Philadelphia. 
♦Clouting, Charles A., M. D. 
CoATEs, George Morrison, M. D., F. A. 

C. S., Philadelphia. 
Cole, Lewis Gregory, M. D. 
conklin, col-rsen baxter, b. s., m. d., 

Washington, D. C. 



CoRNw.\LL, Edward E., M. D., F. A. 

C. P., BrookljTi. 
CouGHLiN, Robert E., M. D., Brookhti. 
Culver, Cyrus W., M. D., Lowville, 

N. Y. 
♦CuMSTON, Charles Greene, M. D., 

Geneva, Switzerland. 
CusAK, Thomas S., M. D., BrookljTi. 

Daland, Judson, M. D., Philadelphia. 

D.wiDSON, Bernard, M. D., Brookljii. 

DE Kr,\ft, Frederick, M. D. 

Densten, J. C, Ph. D., M. D., Scran- 
ton, Pa. 

Desha, L. Junius, M. D., Memphis, 
Tenn. 

Detwiler, Augustus K., M. D., Omaha, 
Neb. 

Disbrow. Frank lR\nNG, M. D., New 
Rochelle, N. Y. 

♦Donnelly, William H., B. A., M. D., 
Brooklyn. 

Dublin, Louis I., Ph. D. 

DuNC.\N, Charles H., M. D. 

Dyer, Isadore, M. D., New Orleans, La. 

Edelman, M. H., M. D. 

♦Eggleston, Cary, M. D. 

Einhorn, Max, M. D. 

Elder, Omar F.. M. D., Atlanta, Ga. 

Embree, Vern W., M. D., Sioux City, 
Iowa. 

Emerson, William R. P., M. D., Boston. 

Epstein, J., M. D. 

Erdmann, John F., M. D. 

Ersner, Matthew S., M. D., Phila- 
delphia. 

Ferguson, William, M. D., C. M. 
Fisher, Lewis, M. D., Philadelphia. 
Fisk, Arthur L., M. D. 
♦Foster. Matthias ■ Lanckton, M. D., 

New Rochelle, N. Y. 
Frankel, Bernard, M. D. 
Frauenthal, Henry W., A. C, M. D., 

F. A. C. S. 
♦Freudenthal, Wolff, M. D. 
♦Friedman, Henry M., M. D. 
Frischman, Louis, M. D., Yonkers, 

N. Y. 

Gallant, A. Ernest, M. D. 
Gellhorn, George, M. D., St. Louis, Mo. 
Geyser, Albert C, M. D. 
Gibson, Jefferson D., M. D., Denver, 

Colo. 
Goldbercer, I. H., M. D. 
Goldenthal, Carol, M. D. 
Gordon, Alfred, M. D., Philadelphia. 

GOTTHEIL, WlLLI.\M S., M. D. 

Grad, Herman, M. D., F. A. C. S. 
Graf, Charles B., M. D. 
Graham, Douglas, M. D., Boston, Mass. 
Graham, Henry F., M. D., F. A. C. S., 

Brookl>-n. 
Gr.\nger, Fr.«lnk B., M. D., Boston. 
Greenberg, Geza, M. D. 
Greene, Charles Lyman, M. D., St. 

Paul, Minn. 
Greene, James Sonnett, M. D. 
Gregory, Menas S., M. D. 
Grimberg, L., M. D. 
♦Gwathmey, James Tayloe, M. D. 



Hall, Horace C, M. D., Laredo, Texas. 

Harris, Thomas J., M. D. 

Haynes, H. A., M. D., Lapeer, Mich. 

Haynes, Irving S., Sc. D., M. D., F. A. 
C S 

Hays, Harold, M. D., F. A. C. S. 

Heacox, Frank L., M. D., Auburn, 
N. Y. 

Healy, William P., M. D., F. A. C.-S. 

Hibbs, Russell .\.. M. D. 

HiRSH, A. B., M. D., Philadelphia. 

Hirst, Barton Cooke, M. D., Phila- 
delphia. 

HOGUET, J. P., M. D. 

Holcomb, R C., Surgeon, United States 
Navy. 

Hollender, A. R., M. D., Chicago. 

Hopkins, A. H., M. D., Philadelphia. 

Hubert, Louis, M. D. 

Hudson, W. G., M. D., Wilmington, Del. 

Hyde, Clarence L., M. D., Perrysburg, 
N. Y. 

Ives, Robert Franklin, M. D. 
♦IviMEY, R. Muriel, A. B. 

Jackson, J. Allen, M. D., Philadelphia. 
Jackson, William R., M. D., F. A. 

C. S., Mobile, Ala. 
Jacobson, Arthur C, M. D. 
♦Jelliffe, Smith Ely, A. M., M. D., 

Ph. D. 
Jenkins, T. W., M. D., Albany. N. Y. 
Jones, Isaac H., M. D., Philadelphia. 

Kaempfer, Louis G., B. S., M. D. 

Kahn, Max, M. D., Pittsburgh. 

Kahn, Morris H., M. D. 

Kaplan, D. M., M. D. 

Kaufman, Joseph, M. D. 

Kearney, J. A., M. D. 

♦Keves, Edward L., Jr., M. D. 

♦King, Howard D., M. D., New Orleans, 
La. 

Klein, Alexander, M. D., Philadelphia. 

Kleinberg, Samuel, M. D. 

Knopf, S. Adolphus, M. D. 

Knox, Howard A., M. D., Skillman, 
N. J. 

KoHN, Louis Winfield, M. D., Phila- 
delphia. 

Konkle, W. B., M. D., Montoursville, 
Pa. 

Kramer, Jacob, M. D. 

Landsman, Arthur A., M. D. 
♦Lavinder, Charles H., M. D. 
Le Breton, Prescott, M. D., F. A. C. S., 

Buffalo. 
Leszynsky, William M., M. D. 
Levy, Louis Henry, M. D., M. S., New 

Haven, Conn. 
Lewin, S. a., M. D., Brooklyn. 
Lewis, D. M., M. D., New Haven, Conn. 
Lewson, Maximilian, M. D. 
LiEB, C. W., A. M., M. D., Watkins, 

N. Y. 

LiLIENTHAL, HoWARD, M. D., F. A. C. S. 

♦LiND, John E., M. D., Washington, 

D. C. 

Lo Grasso, Horace, M. D., Perrysburg, 

N. Y. 
Lower, William E., M. D., F. A. C. S., 

Cleveland, Ohio. 



INDEX TO VOLUME CV. 



♦McChesney, Paul Ely, A. B., M. D. 
♦McCoNNELL, Guthrie, M. D., Water- 
loo, Iowa. 
McCoRD, Carey Pratt, M. D., Detroit. 
McGuRN, W. J., M. D., Boston. 
McMeehan, F. H., M. D., Avon Lake, 

Ohio. 
McNair, Robert H., M. D., Springfield, 

Mass. 
*Macatee, H. C, M. D., Washington, 

D. C. 
Makepeace, Frank C, M. D. 
Makuen, G. Hudson, M. D., Philadel- 
phia. 
Marcus, Joseph H., M. D. 
Martin, William, M. D., Atlantic City, 

N.J. 
Massey, G. Betton, M. D., Philadelphia. 
Massey, H. Arthur, M. t)., Chicago. 
Maybaum, J. L., M. D. 
*Mayo, Caswell Armstrong, Ph. M. 
Mayo, Charles H., M. D., Rochester, 

Minn. 
Meagher, John F. W., M. D., Brooklyn. 
M"^ ELSON, Joseph A., M. D., Wash- 
■oton, D. C. 

vRritt, Arthur H., D. D. S. 
>'ER, Alfred, M. D. 
i...LLER, Frederick G., M. D. 
Miller, James Alexander, A. M., M. D. 
Mills, Charles K., M. D., LL. D., 

Philadelphia. 
Millstone, Henry J., M. D., South 

Chicago. 
Moore, J. Walker, M. D., Louisville, 

Ky. 
Morris, Robert T., M. D. 
MoRRissEY, M. J., M. D., Hartford, 

Conn. 
Munson, J. F., M. D., Sonyea, N. Y. 
Murphy, Frank G., M. D., Mason City, 

Iowa. 
Myles, Robert C, M. D. 

Naccarati, Sante, M. D. 
Neuhof, Selian, M. D. 
Neuwelt, Louis. M. D. 
Newcomb, W. H., M. D. 
NoDiNE, Alonzo Milton, D. D. S. 

O'Day, J. Christopher, M. D., Port- 
land, Ore. 
o'donnell, e. e., m. d. 
Ogilvy, Charles, M. D. 
Oliensis, a. E., M. D., Philadelphia. 
Oliver, James, M. D., F. R. S., London. 
Otani, Morisuke, M. D., Tokyo, Japan. 

Pancoast, H. K., M. D., Philadelphia. 
Park, William Halleck, M. D. 
Parke, William E., M. D., Philadelphia. 
Parmenter, Frederick J., M. D., F. A. 

C. S., Buffalo. 
Pearson, C. B., M. D., Arlington, Md. 
Pemsler, a. B., M. D. 
*Phelps, Edith B. 
Pieter, H., M. D., San Francisco de 

Macoris, West Indies. 
PiTFiELD, Robert L., M. D., Philadelphia. 
Pittenger, Paul S., Ph. G., Ph C 

Phar. D., Philadelphia. 



PoDviN, Edward C, M. D. 

Potter, Nathaniel Bowditch, M. D. 

Pratt, j. A., M. D., F. A. C. S., Aurora, 

111. 
Price, George E., M. D., Philadelphia. 

QuIMBY, A. JUDSON, M. D. 

QuiMBY, Will A., M. D. 

Randolph, B. M., M. D., Washington, 
D. C. 

Rankin, William, M. D., Keokuk, 
Iowa. 

Ransdell, Robert C, M. D., Passed As- 
sistant Surgeon, U. S. Navy. 

Rathbun, Nathaniel P., M. b., F. A. 
C. S., Brooklyn. 

*Reed, Alfred C., M. D., San Francisco, 
Cal. 

Reilly, Thomas Francis, M. S., M. D., 
M. A. C. P. 

Reuben, Mark S., M. D. 

Rhein, John H. W., M. D., Philadelphia. 

RiCKARDS, Caroline F. J., M. D. 

Ricksher, Charles, M. D., Kankakee, 
111. 

Riddell, William Renwick, LL. D., 
Toronto, Canada. 

Robbinovitz. Samuel, M. D., Brooklyn. 

Roberts, Dudley, M. D., Brooklyn. 

*RoBERTSON, William Egbert, M. D., 
Philadelphia. 

*RoBiN, Albert, M. D., Wilmington, Del. 

Robinson, Beverley, M. D. 

*RoGERs, James F., M. D., New Haven, 
Conn. 

RosENBERGER, Randle C, M. D., Phila- 
delphia. 

*Rovinsky, Alexander, M. D. 

Rubenstone, a. I., M. D., Philadelphia. 

RuDis-JiciNSKY, J., M. D., Chicago. 

Sailer, Joseph, M. D., Philadelphia. 
*Sajous, Charles E, de M., M. D., 

LL. D., Sc. D., Philadelphia. 
♦Sajous. Louis T. de M., B. S., M. D., 

Philadelphia. 
Sanders. Harold A., B. S., M. D., 

BrookljTi. 
♦Scarlett, Rufus B., M. D., Trenton, 

N.J. 
Schapira, S. William, M. D. 
ScHOLTz, Moses, M. D., Cincinnati, Ohio. 
Schulman, Ma.ximilian. M. D. 
*ScoTT, R. J. E., M. S., B. C. L., M. D. 
Sharfin, Z., M. D. 
Sherman, Allton L., M. D., Orange, 

N. J. 
Sherman, G. H., M. D., Detroit, Mich. 
SiLVERBERG, Melville, M. D., San Fran- 
cisco, Cal. 
Simon, Saling, A. B., M. D., Denver. 
Smith, Harmon, M. D. 
Smith, J. Morrissette, M. D. 
Snow, William Benham, M. D. 
SoBOTKY, Irving, M. D., Boston. 
SoLETSKY, Max, M. D. 
SoLOVAY, Jacob, Chicago. 
Sparrow, Charles A., M. D., Worcester, 

Mass. 



Stearns, Benjamin W., M. D., Una- 

dilla, N. Y. 
Steers, William H., M. D., Lieutenant 

Colonel. Medical Department, New 

York National Guard. 
*Steinbucler, William F. C, M. D. 
Steiner, Sydney, M. D. 
Steinfield, Edward, M. D., Philadelphia. 
Stern, Ma.ximilian, M. D. 
Stern, Samuel, M. D., Atlantic City, 

N. J. 
Stewart, Douglas H., M. D. 
Stewart, F. E., Ph. G., M. D., Phar. D., 

Philadelphia. 
Strachstein, a., M. D. 
*Strickler, a., M. D., Philadelphia. 

*Talbot, Winthrop, a. B., M. D. 

Talmey, B. S., M. D. 

Talmey, Max, M. D. 

Taylor, Joseph C, M. D. 

*Taylor, J. Madison, A. M., M. D., 

LL. D., Philadelphia. 
Thom, Burton Peter, M. D. 
Thomas, B. A., M. D., Philadelphia. 
*Tilton, Benjamin T., M. D. 
Thompson, Loyd, Ph. B., M. D., Hot 

Springs, Ark. 
Todd, John B., M. D., Syracuse, N. Y. 
Tompkins, Frank E., M. D. 
TousEY, Sinclair, A. M., M. D. 
Tracy, James L., M. D., Toledo, Ohio. 
Tracy, Martha, M. D., Philadelphia. 

Upshur, J. N., M. D., Richmond, Va. 

Vansant, Eugene L., M. D., Phila- 
delphia. 
*Vedin, Augusta, M. D. 

Walscheid, Arthur J., M. D. 

Wechsler, I. S., M. D. 

Weidler, Walter Baer, M. D. 

Weidman, Frederick D., Philadelphia. 

Weinstein, Harris, M. D. 

♦■Whitford, William, Chicago. 

Wiener. Solomon, M. D., F. A. C. S. 

Wile, Ira S., M. D. 

Williams, Frank J., M. D., Albany, a 
N. Y. • 

*WiLLiAMS, H. M., M. D., Glen Ridge, 
N.J. 

*WiLS0N, H. Augustus, M. D., Phila- 
delphia. 

Wise, Fred, M. D. 

Wittenberg, Joseph, M. D., Brookl}Ti. 

WoHL, Michael G., M. D., Omaha, Neb. 

Wolbarst, Abr. L., M. D. 

Wolf, Charles, M. D. 

Wood, F. M., M. D., Chicago. 

Wright, Harold W., M. I3., San Fran- 
cisco, Cal. 

Wright, Jonathan, M. D., Pleasant- 
ville. New York. 

Young, Hugh Hampton, M. D., Balti- 
more. 

Zentmayer, William, M. D., Phila- 
delphia. 



New York Medical Journal 

INCORPORATING THE 

Philadelphia Medical Journal the Medical News 

A Weekly Review of Medicine, Established 1 843. 



Vol CV, No. 1. 



NEW YORK, SATURDAY JANUARY 6, 1917. 



Whole No. 1988. 



Original Communications 



BRONCHIAL ASTHMA. 

By Wolff Freudenthal, M. D., 

New York. 

I. HISTORICAL DATA. 

It was in that wonderful little town of Saekkin- 
gen, on the border line of Switzerland and Ger- 
many, where, many years ago, I saw my first case 
of asthma. Ever)' morning on my visit to the wards 
the Sister in the small hospital narrated the same 
story of the previous night's dreadful sufferings of 
a >oung man which my predecessor had been un- 
able 10 alleviate, anJ asked whether I could not give 
some relief. But whatever was tried therapeutically 
proved absolutely of no avail. That case made such 
an impression on me that ever since 1 have been 
on the watch for something that would help these 
[)Oor suli'erers. It would seem that only in the last 
few years have we begun to work in the right direc- 
tion. But before entering into the details, it may be 
of interest to follow up the conception of asthma 
as outlined by the different authorities in various 
centuries. This is by no means unprofitable or tire- 
some, for it gives us an insight into the thoughts of 
great men, who were keen observers, but lacked the 
facilities of modern research and modern instru- 
mentation. 

Undoubtedly asthma is as old as any civilization 
of which we have knowledge. In studying the lit- 
erature of asthma, from the earliest observation up 
to the present time, much is found that is ob- 
scure, a great deal that the writers themselves were 
not clear about, and a mass of theoretical deduc 
tions which were unproved and empirical. On the 
other hand, we encounter even among the earlier 
writers men who had a clear view of the disease, 
often mixed, however, with certain prevailing ideas 
or medical superstitions. We find asthma men- 
tioned in the Bible and in Homer. Hippocrates de- 
scribes it as a disorder incident to children. With 
him originated the idea that it is occasioned by cold 
and moisture, and he hints at its being confounded 
with epilepsy. ' 

The first good description of asthma was left to 
the world in the writings of Aretseus of Cappado- 
cia — works which are described as perfect master- 
pieces and exact descriptions true to nature. Are- 
tceus was the only one among the ancients who rec- 
ognized asthma as a disease in itself, and described 

Copyright, 19 f 7, by A. R. 



its characteristics. According to Aretaeus its seat 
is in the lungs, but he also knew that the auxihary 
muscles of respiration are called into action as wfell 
as the diaphragm. The cause of the disease ik ,.i 
cold or a great deal of humidity in the air (oVs-orr^iiM 
TU!j ;7>£y',aa'"s')> f^ictors which even nowadays ar'f''' 
made responsible for many an ailment — mostly, of''" 
course, without any scientific basis. Aretteus de- 
scribes two forms of asthma : First, one in which 
there is a difficulty of breathing, as in' nmning, 
climbing, wrestling, and every kind of hard labor. 
In order to breathe easier the nose becomes pointed 
(itirfC^tV/) 1 The description of an attack is very 
accurate. 

Second, a form called by him "pneumodes or 
dyspiiodes." The differential diagnosis between the 
two varieties consists in the duration (the latter be- 
ing more prolonged), in the age of the patient, the 
free intervals, etc. The chest is round, barrel 
shaped, but otherwise normal. These symptoms, as 
Eergson remarks, remind us of the barrel shaped 
conformation of the chest due to the catarrhe sec 
of Laennec. 

A third form of asthma is mentioned by Aretseus 
but not recognized as such, i. e., "orthopnoe." It 
seems to us that he mentions this form only to place 
himself in opposition to Celsus, who, as is well 
known, had made three divisions, viz., dys^jnoe. 
asthma, and orthopnoe. 

A very clear description of asthma was given 
later by the philosopher Seneca. He suggested call- 
ing the disease .fH.f/'n'Hnn instead of '""'^pa, and sus- 
piriosi or anhelosi (anhelatio) instead of <i.6':>iaT:/.iii. 

The man who later, we may say, dominated the 
whole medical world by his genius was Galen. In 
reference to asthma the main merit of his contribu- 
tion lies in his physiological demonstrations. By 
severing the medulla spinalis he showed his pupils 
how to produce asthtna artificially. Galen mentions 
two causes of this disorder, each distinguished by 
a material producing irritation, thick and pituitous 
humors, and a crude tubercle in the lung. His doc- 
trines on this subject were copied by w-riters during 
the fifteenth, sixteenth, and seventeenth centuries, 
in spite of the. fact that this great man had not 
added anything of importance to the knowledge of 
the true nature of asthma. 

Galen's influence was noticed also in the Arabic 
school. A product of Arabic medicine to be 

EH;ott Publishing Company, 



l-KliUDENTHAL: BRONCHIAL ASTHMA. 



(New York 
Meikcal Journa 



nienlioncd is that cxlradrdiiuu)- genius, Moses hen 
Maimon, Mainumi, or Maiinonides. lie was not 
only a great philosopher, but also a great physician. 
But it is to be regretted that we do not possess any 
exact knowledge of his influence on medicine in 
general. As to the subject of asthma, it is stated 
that there is an unprinted manuscript at Madrid, 
Spain, Tractatus contra passioncm astliinatis, but 
no further details of it could be obtained. But 
since Maimuni was by no means a blind follower of 
Galen and his other predecessors, it may be worth 
while for some -one to undertake the study of this 
manuscript (and parenthetically I would say of 
many other Arabic manuscripts which are known 
to the world only by their Latin "perversions," as 
Pagel calls them). 

It seems that in the seventeenth century the idea 
of asthma as an idiopathic disease was entirely over- 
looked. Neque enim asthma, anhelatio ipsa mor- 
bus est, sed morhi symptoma. These words — re- 
peated so very often in our times — gave evidence 
that the physicians in those days considered astlima 
only as a symptom, nothing being heard of a nerv- 
ous or spasmodic asthma. The first one to give an 
exact description of the latter, i. e., spasmodic asth- 
ma, was the English neurologist Thomas Willisius 
(1682). 

History then takes a wide leap, since nothing of 
any consequence is mentioned up to the middle of 
the eighteenth century, when J. Floyer's book be- 
came known to the medical world. Floyer was an 
Englishman, but his publications were translated 
into French, and hence, as his name might suggest, 
he was taken for a Frenchman. He considers 
asthma to be dependent on a primary disease, which 
must be removed before it will subside. He also 
speaks of a continuous asthma and a periodic one. 
The latter "depends on the constriction of the 
bronchi and bladders of the lungs by windy spirits." 

The great discoveries and ideas in medicine 
make themselves felt from now on in the 
domain of asthma. And among them have 
to be mentioned Harvey's discovery of the 
circulation of the blood, Auenhuugger's ausculta- 
tion and percussion, the humoral patholog}-, 
etc. Thus John Millar says in 1769 that Harvey's 
discovery was of the greatest use in "explaining 
animal economy and pointing out a rational theory 
and practice of physic." How confused the con- 
ceptions of asthma were at that time is plainly seen 
by his remarks: "Most authors who have written 
on this subject (asthma) treat under the denomi- 
nation of the peripneumony, vomica Pulmonum, 
flatus, hypochondriac and hysterick diseases, and 
indeed of almost every other disorder accompanied 
with difficult respiration, excepting the least com- 
plicated state of that which they undertake to de- 
scribe." His sentiments will be appreciated if the 
title of his book is mentioned, which reads, Obser- 
vations on the Asthma and on the Hooping Cough, 
London, 1769. It is also of interest to learn what 
he himself thinks of the disease. He divides it into 
an acute and a chronic variety, the first one of which 
he saw mostly in children who had been lately 
weaned ! It afifects the lower class of the people. 



and those who had a voracious appetite. If the pa- 
tient was neglected he gradually went into the sec- 
ond stage. We see here some truth mixed with a 
good deal of imagination. 

Quite a different writer was Robert JJree, whose 
work, A Practical Inquiry into disordered Respira- 
tion; distinguishing the species of conznilsive Asth- 
ma, etc., appeared at Birmingham, in 1800, and later 
on in London, in 1807. 

Bree was a man of great knowledge, who had 
tried conscientiously to give full evidence in support 
of his theories ; and he does that because he is aware 
that asthma had been more subjected to the "caprice 
of hypothesis and prevailing theories than any 
others whose appearances could be as distinctly 
traced to a material exciting cause." The primary 
cause of asthma, he believed, was an exudation in 
the bronchial tubes. This caused a contraction of 
the lungs (muscles of respiration, or, as we now 
know, the circulatory bronchial muscles) in order 
to expel the mucus therein. The irritating causes 
are found in the lungs, but they may also exist in 
some of the abdominal viscera. Later on, he even 
mentions a form of the disease which he calls asth- 
ma plethoricum, which arises from a "suppres- 
sion of usual evacuations of blood, or from a spon- 
taneous plethora." That he is the forerunner of 
.\dams and other modern English writers is evi- 
denced by his remark that the attack is preceded 
very generally by dyspepsia and the circumstances 
incident to a relaxed habit. This is nothing else 
than the dyspeptic asthma which Adams and others 
nowadays proclaim as the only cause of the disease. 

That Bree recognizes a humoral asthma as well, 
and mentions among the remote factors the influ- 
ence of air, dust, metallic fumes, tobacco, hys- 
terics, changes of the moon, etc., shows only that' 
in spite of much wisdom he did not rid himself of 
the wrong conceptions of the medicine of those 
days. But to his credit it must be added that he 
also speaks of a species of asthma sine causa mani- 
festa vel alio morbo comitante, or, in other words, 
of an idiopathic disease. His therapy consisted in 
cathartics, emetics, diaphoretics, bleedings, diuret- 
ics, blisters, inhalations, baths, etc., but he adds that 
no agent has been discovered which can remove 
asthma entirely. 

Let us mention one more writer before we ap- 
proach the era of auscultation and percussion, i. e., 
WiUiams. In 1841, Doctor Williams, in Tweedie's 
Dissertations of Diseases of the Organs of Respira- 
tion, describes two forms of asthma — a spasmodic 
and an atonic or paralytic form. He found "that 
defect of these properties (excessive contractibility 
of the bronchial tubes) would disorder the process 
of breathing, and is led to believe that there may 
perhaps be a nervous asthma or dyspnea "from 
weakness or paralysis of the circular fibres, or of 
the nerves which regulate their contractions." 

For some time afterward another form of asth- 
ina was discussed under the name of thymic asthma. 
The names of Doctor Kopp and Doctor Hirsch, of 
Germany, are connected herewith. They describe 
the now well known form of hypertrophy of the 
thj'mus, and the symptoms are clearly those of pres- 
sure on the trachea. There was no sign of asthma 



January 6, 1917-] 



FREVDESTHAL: BRONCHIAL ASTHMA. 



3 



ill the cases reported, but only dyspnea and the char- 
acteristic breathing of partial occlusion of the 
trachea. 

A great niiuiy other varieties of dyspnea arising 
from various organic diseases had been previously 
described, and this so called thymic asthma of Kopp 
and Hirsch is the last one of its kind. At that time 
the difference between dyspnea and asthma was 
gradually being cleared up, and this was mostly due 
10 the introduction of auscultation and percussion. 

But now another symptom was pushed more to 
the foreground, viz., disorders more or less properly 
called the nervous affections. Thus the great 
French physician, Laennec, writes of asthma under 
the heading of "nervous affections of the lungs." 

Even Laennec calls dyspnea, "when of sufficient 
severity," asthma, and this is nothing but a dr)' 
catarrh (his famous catarrhe sec) plus emphysema 
of the lungs. Yet it is easily seen that dyspnea is 
only a symptom of the disease, but to merit the name 
of asthma "it must be of sufficient severity and per- 
manence." Laennec frequently found no sign what- 
ever of vascular congestion, or of any other organic 
lesion ; hence his belief in its "nervous" character. 
He also considered it very probable that the dyspnea 
originated in an imperfect paralysis of the dia- 
phragm, a question much discussed many years 
afterward by Wintrich, and others to be named 
later on. 

Laennec divides the affection into asthma associ- 
ated with puerile respiration and spasmodic asthma. 
It is of interest to read the remarks appended by 
Andral and by the translator of the French edition, 
John Forbes. But as these belong mostly to the pathol- 
ogy, they will be mentioned at another time. We 
may add, however, that the supposition of puerile 
breathing does not account for contraction of the 
bronchi, and that this probably was attributed to a 
paralysis of the muscle fibres in a similar way to 
paralysis of the diaphragm. In reference to that 
point many believers in the humoral pathologj' fol- 
lowed Laennec. They believed in some specific hu- 
moral disturbance without which we cannot have 
asthma. Even Salter does not deny that in some 
cases the exciting cause of the attack is humoral 
(p. 8) ; but what he does deny is, that the humoral 
derangement has any greater prominence than that 
of an exciting cause. 

We now come to that interesting epoch in the his- 
torv- of asthma, which must be considered of much 
importance, i. e., the middle of the last century. In 
this period a great impetus to the study of the disease 
was given by tlic Prize Essay of J. Bergson {Das 
Krampfhafte Asthma dcr Encachsenen), which was 
completed on the day of the one hundredth anniver- 
sary of Goethe's birth, i. e.. August 28, 1849, but 
published at Nordhausen a year or two later ; and 
by another book written in i860, a work from which 
many authors have drawn their knowledge, one that 
even today is to be considered a classic — I mean 
that written by Henn,' Hyde Salter, of • London, 
whose name has been mentioned briefly before. 

Bergson in his essay states that the seat of spas- 
modic asthma is in the bronchi and alveoli of the 
lungs, and that the disease is characterized bv a 
spasm produced by some irritation of the vagus. He, 



loo, classifies asthma among the neuroses of the res- 
spiratory organs, and divides it into cerebral ami 
spinal asthma. The explanation of the former vari- 
ety (cerebral) is based mainly upon a few illus- 
trative cases which have nothing whatever in com- 
mon w'ith asthma, and it is surprising that even a 
man of such wide knowledge still mixed up cases 
of dyspnea with asthma. To give only one exam- 
ple : A drunken man fell into a coma ; breathing 
was most difficult and the patient was on the verge 
of suffocation when a tracheotomy restored him al- 
most inmiediately ! The laryngeal mirror had not 
been invented at that time, or else another diagnosis 
would probably have been made. Spinal asthma 
is subdivided by Bergson into, i, centric spinal 
asthma (here again all the cases included do not be- 
long to asthma), and, 2, excentric asthma. While 
in the first mentioned form the brain and medulla 
oblongata, the two principal regulators of the respi- 
ratory functions, are thought to be the seat of an 
affection causing asthma, in the following forms the 
nerve centres are considered perfectly free from any 
structural disorder, and the cause of the abnormal 
breathing is assumed to lie outside of these centres 
which are only conductors transmitting the irritation 
from without. Consequently this class is subdivided 
again into : 

a. Reflex asthma, aa: Orginating from the di- 
gestive tract ; bh, through irritation of the mucous 
membrane of the respiratory organs (inhaling of 
dust, pungent gases, certain odors, etc.) ; cc, through 
compression or irritation of the peripheral portions 
of the vagus (tumors, aneurysms, etc.) ; dd, through 
psychical disturbances. 

b. Ganglionic asthma: The diagnosis of this form 
is made by exclusion of the others. 

c. Motoric asthma, from affections of the vertebra 
or of the muscles of the chest. 

The principal fact brought out by Bergson is that 
there is no such thing as a pure asthma paralyticum, 
but that it is eo ipso a spasmodic disorder as soon as 
it makes its appearance. 

The work of Salter, which was written in i860, 
is so well known and so often quoted even nowa- 
days that we mention it only for the sake of histor- 
ical exactness. We would remind the reader that 
in that period htmioral pathology was in its last 
stages, the cellular pathology of Virchow not having 
spread all over the world as yet, and that aus- 
cultation and percussion were already part of the 
armamentarium of every practitioner. 

These two stages in medicine are plainly notice- 
able in Salter's deductions. While he concedes 
that the irritant in asthma is sometimes humoral, he 
at the same time examined the chest during the at- 
tack and at intervals, and found, i, that asthma is 
essentially a nervous disease ; 2, that its phenomena 
— the distressing sensation and the demand for ex- 
traordinary respiratory efforts — immediatelv depend 
upon a spastic contraction of the fibre cells of or- 
ganic or unstriped muscles ; 3, that these phenomena 
are those of excitomotor or reflex action ; 4, that in 
a large number of cases the pneumogastric nerve, 
both in its gastric and pulmonary portions, is the seat 
of the disease. 

With the exception of the theory of humoral irri- 



IRIU'DENTH.IL: BRONCHIAL ASTHMA. 



(New Yoek 
Mrdical Journal. 



lants, these are the proljlenis that are still under dis- 
cussion ; questions that have not yet disappeared 
from medical literature. 

Certain theories aroused very strenuous opposi- 
tion. Thus Wintrich did not believe in a bronchial 
spasm. He had suggested, in 1854, a tonic spasm 
of the diaphragm (alone or in combination with 
bronchial spasm), a theory proclaimed before by 
Willis and later on by Neumann, but not in that pre- 
cise form. Wintrich's idea was then taken up by 
such men as Bamberger, Germain See, and others, 
but opposed by Biermer, who held that the low 
(deep) position of the diaphragm was due not to 
a spasm of that muscle, but to a spasm of the 
bronchial tubes, which thus caused an expansion of 
the lungs (Lungenbliihung) ; and soon the influence 
played by the vagus came more and more in evi- 
dence. But the opinions expressed by the many 
German writers on that subject varied greatly. Rie- 
gel, Lebert, Weber, and Stoerck, are some of the 
men who sided either with Wintrich or Biermer. 

A well known contribution is that of von Leyden, 
in 1871, who found small oblong octohedral crystals 
in the sputum of asthmatics, and attributed asthma 
to their presence. Charcot also saw them, and they 
were exhibited for many years as the Charcot-Ley- 
den crystals. Very soon, however, linger and 
others declared that these findings in the sputum 
were merely accidental, and later the theor\' was 
given up entirely. The theory brought forward by 
Curschmann, in 1883, had about the same fate, says 
Schmiegelow in his book on asthma. "Curschmann 
considers a great many forms of reflex asthma to 
be caused by a catarrhal affection in the finer 
bronchial tubes, which he named bronchiolitis ex- 
udativa. A characteristic of this disease is the pres- 
ence of peculiar spiral threads in the sputum. The 
threads are casts of the bronchioles, and are in di- 
rect relation to the asthma, which is caused by them 
through a secondary bronchial spasm. These spi- 
rals of Curschmann's are meanwhile no more patho- 
gnomonic than the cr\'stals of Charcot and Leyden. 
as they are also found in cases of fibrinous pneu- 
monia" (Schmiegelow). 

Salter's theor}' of a reflex action was the one that 
from now on came into prominence. Indeed, the 
reflex neuroses from the nose played a dominant 
part for more than twenty-five years, and were dis- 
cussed by physicians and laymen all over the world. 
The man responsible for this was Hack, of Frei- 
burg. It was known that cases of asthma had been 
cured by Voltolini, of Breslau, B. Fraenkel, and 
Haenisch, after the removal of nasal polypi, but it 
was left for Hack to arouse the medical world by 
his theory (1882) that the swollen cavernous mu- 
cous membrane at the foremost end of the inferior 
turbinated body of the nose was the cause of reflexes 
which disappeared as soon as this tissue was re- 
moved (cauterized). In this country Daly. Seiler, 
Bosworth, Roe. JarA-is. and J. N. Mackenzie, were 
among the earliest writers on this topic. 

Hack's forceful theory was attacked very soon 
afterward, i. e., at the Copenhagen Congress in 1884, 
by B. Fraenkel, who asserted that reflexes could be 
produced from every part of the nose, and "not only 
from the cavernous tissue of the inferior turbinate- 



and by Cjottstein, wiio maintained that asthma of 
nasal origin was a I'cry rare occurrence, in spite oi 
this. Hack's Schzvcllkdrpertheorie prevailed for 
many years, and nasal reflex neuroses were part of 
the permanent menu of every meeting and every 
congress. 

It is not possible to present here with the slightest 
degree of exactness a review of the enormous liter- 
ature on this topic. Most of it is forgotten and will 
probably remain so forever. To gain an idea of the 
marked changes in the views of laryngologists, it 
may be profitable to look over some of the laryngo- 
logical textbooks which the writer took up by 
chance. 

J. Solis Cohen, in his work. Diseases of the Throat 
and Nasal Passages, published in 1879, does not 
mention bronchial asthma at all. But a few years 
later, already under the influence of Hack's theory, 
viz., in 1884, Mackenzie discusses asthma in connec- 
tion with hypertrophic rhinitis, polypi, etc. The 
translator of Mackenzie's work, Felix Semon, even 
at that time deemed it proper to caution against be- 
ing overenthusiastic on that subject. Again, a few 
years later (1889), Bosworth devotes an entire 
chapter to the question of asthma. This may give 
an approximate idea of the growing importance of 
_ the diagnosis and treatment of this disease to the 
laryngologist. And so enthusiastic was Bosworth, 
for example, that he was led to remark (p. 243), "I 
have ticz'cr known a case of hay fever or asthma to 
occur in other than an obstructive lesion of the nose 
or upper air passages. . . ." 

Bosworth does not include nasopharyngeal catarrh 
among the causes of asthma. If present, he re- 
gards it "as a somewhat secondary cause," in that 
the vasomotor paresis which constitutes an asthmatic 
attack is more intimately associated with disturt^ 
ances of circulation in the turbinated bodies. At 
that time Hack's theor}' had reached its zenith, and 
most laryngologists were under its influence. We 
must not, therefore, be surprised at Bosworth's re- 
marks. 

Let us leave the subject of nasal reflexes, the im- 
portance of which I have lived to see exalted and 
later belittled. Trousseau described asthma as epi- 
lepsy of the lungs, a view held in a similar way by 
Todd (in 1850), and after him by Goldschmidt, of 
Munich. 

Ernest Kingscotc, of London, found (1899) that 
every one of his patients had a dilated heart, and 
believed that asthma was brought about by pressure 
of the dilated heart upon the vagus. This is more 
evident in the prone position during sleep. .Ml that 
is not in accord with the writer's experience, and is 
not convincing ; but later on Kingscote broadens his 
views. He says: "Whether it be from the (jrigin 
in the medulla, from Meckel's ganglion as in iiay 
fever, from a superior laryngeal, from ear mischief 
through Arnold's nen-e. through the phar)-ngeals, 
through the recurrent laryngeal, through pressure 
on the main trunk in the neck.^ through irritations 
of the heart, lungs, stomach, liver, spleen, or other 

'The case of Mr. Treves is cited, in which asthma wais produccil 
by pressure of cancerous glands in the neck. Salter cites "many 
cases on record," in which the asthma was due to organic disease 
of the pulmonary ner\-ous system itself, such as, for instance, a 
tumor or exostosis pressing upon one of the pneumogastric nerves- 



SNOW: TREATMENT OF HYPERTENSION. 



abdominal or pelvic viscera, or of the sympathetic 
system, it is difficult to evade vagal origin." 

Finally, it should be stated that attempts have 
been made to attribute the asthmatic paroxysms to 
toxemia (Adams). This toxemia alters the asth- 
matic so that his condition becomes like a powder 
magazine; nasal disease is apt to supply the sparks 
which cause the explosion and precipitate an attack. 
This is the opinion of Adams, who pays more atten- 
tion to the digestive tract than to anything else. 

And now we have reached our present era, which 
is characterized by two innovations : bronchoscopy 
and anaphylaxis. 

Although Novotny, of Cracow, had used the 
bronchoscope for endobronchial applications, the 
credit for having instituted its systematic use be- 
longs actually to Ephraim, of Breslau, who through 
his many reports induced others to try the method. 
In this country H. Horn, of San Francisco, has 
worked in this field, as well as G. F. Keiper, of 
Lafayette, Indiana, and myself. 

For more than six or seven years 1 have been en- 
gaged in bronchoscopic work, and have expressed 
my views repeatedly. I have been forced to ivy 
endobronchial therapy as an tiltimuin reftigiiiin. 
Many a patient presented himself with severe asth- 
ma of ten, or twenty years, and more, duration, who 
had undergone all sorts of surgical and dietetic 
treatment without obtaining permanent relief. Nay, 
patients on whom I myself had operated years ago 
for nasal polypi, spurs, etc., and who had been con- 
sidered cured, were found to be suffering as much 
as ever. If, I reasoned, we make applications to the 
diseased mucosa of the nose, the larynx, etc., why 
not to that of the bronchi ? 

The pathological endobronchial findings, as well 
as the treatment, will have to be discussed at an- 
other time. Here I would only repeat what consti- 
tutes my conception of the nature of the disease. 
In considering this question I came to the conclu- 
sion tliat bronchial asthma in the adult is a similar 
or perhaps even the same condition as the laryngis- 
mus stridulus of children. While the secretion pass- 
ing down from the nasopharynx into the larynx 
causes the trouble in children, the same secretion fails 
to irritate the more tolerant larynx of the adult, but, 
running down into the bronchi, becomes the source 
of asthma. The way in which that happens has 
been explained in my article in American Medicine, 
March, 191 5. In this connection it may be well to 
mention that Avicenna and the Arabian ])hysicians 
believed that the mucus flowing down from the head 
obstructed the air passages. Professor v. Roki- 
tansky, of Insbruck, the internist, considers this a 
naive conception. It seems to the writer that Avi- 
cenna and his followers were not far from right. 

Every patient suiifering from asthma has both 
varieties : a spasmodic and an atonic. It is 
spasmodic during the paroxysm, and atonic at the 
intervals. This is my own opinion, and accordingly 
local treatment has been advised by me. 

How far we shall succeed with these topical ap- 
plications, whether we shall reach the desired goal 
or not, cannot be predicted. Scientific progress in 
such an affection is slow, and judgment difficult : but 



1 am very optimistically inclined as to the future of 
this therapeutic measure. 

Aiiapliyla.vis: If a soluble protein is injected into 
an animal sensitized to it, a syndrome results which 
is called anaphylaxis. This syndrome consists of 
marked respiratory distress, analogous to an asth- 
matic paroxysm, cyanosis, vomiting, and asphyxia 
which may prove fatal (Kahn and Einsheimer). 
The investigations of S. J. Aleltzer tend to prove 
that "the asthmatic individual is sensitized to a cer- 
tain substance and that an asthmatic attack sets in 
every time this substance Iiappens to enter into the 
circulation." How to counteract this foreign pro- >• 
tcin is a question of high importance. Two laryngol- 
ogists have been interested in this study, viz., Alex- 
ander C. Howe, of Brooklyn, New York, and A. 
Goodale, of Boston. Both have done excellent 
work, and it is to be hoped that we shall hear more 
from them. 

Asthma is a very big field, and it may safely be 
said today that some cases will be cured by endo- 
bronchial treatment, others by anaphylaxis, and a 
liiird class, which may prove the overwhelming ma- 
jority, will probably be cured by a combination of 
both methods. 

From what we have learned from the medical his- 
tory of this disease it can be said that it is not only 
difficult to recognize its true nature, but also to ef- 
fect a cure. Or, as an old writer, Baglivius, puts 
it : quantum difficile est curare morbos pidmo- 
iiuin! quantum difficilius eosdem cognoscere, et 
dc lis certnm dare presagium! (Baglivi'i Opera, 
Lib. I, p. 34.) 



THE TREAI'MENT OF HYPERTENSION 
AND COMPLICATING CONDITIONS*. 

By William Benham Snow, M. D., 
New York. 

When we view the records of death and come in 
contact with the victims of hypertension in the ad- 
vanced and advancing stages of arteriosclerosis. 
wrecks often at the time in life when there should 
be many years of useful and happy existence before 
them, we are brought face to face with the impor- 
tance of discovering rational methods of treatment 
to prevent and relieve the condition. 

Unfortunately there is now very little in medical 
literature that offers much for the relief of these 
sufferers or to encourage the physician in their 
management. Few who are authorities in medicine 
have shown a disposition to investigate the physical 
methods of managing these unfortunates, but have 
been disposed to criticise or condemn these meth- 
ods. Others employing them without a correct 
knowledge of the technic required do not obtain fa- 
vorable results, and, naturally, condemn them. It is 
often argued that the hypertension is compensatory. 
They do not, view the condition as secondary only 
to a toxic cause, and as the actual cause of the re- 
sulting arteriosclerosis. It is the heart that com- 
pensates against the resistance and not the resist- 
ance that is compensatory; therefore, if the tension 

•Read at the Twenty-s''xth Annual Meeting of the American 
Electro-Therapeutic .\Ksociation, New York, Scptemher t3, 19x6. 



SXOW: TREATMENT OE HYPERTENSIOX . 



I New York 
Medical Journal. 



is relieved the labor of the heart is lessened and the 
arterial degeneration in a degree arrested ; for the 
arterial muscles kept tense degenerate. After a 
l)ersistence of hypertension a cardiac hypertrophy 
develops to meet the added resistance. This is 
physiological, not pathological. The important sub- 
ject for investigation, therefore, is not the dimen- 
sions of the cardia, but the hypertension and its 
cause. It has been a serious error of clinicians in 
the past to have laid stress upon the cardiac hyper- 
trophy and not to have considered well the cause of 
such hypertrophy. 

The sphygmomanometer, a relatively modern 
means of diagnosis, is a more reliable guide than 
percussion of the chest as indicating the presence 
of ventricular enlargement. In the early stages of 
hypertension the findings by that instrmnent are 
the key to arterial degeneration that must follow if 
the cause is not corrected. In the later stages it is 
the guide to treatment and to control, marking 
from day to day the improvement, persistence, or 
the stubborn, unyielding condition of the hyperten- 
sion. The physical condition of the heart is best 
studied by the pulse, blood pressure, and the findings 
of the electrocardiogram. Murmurs are of relative 
importance as indices of the heart's impediments 
and earmarks of present or previous toxemias. The 
management of cardiovascular conditions depends on 
the study and treatment of the hypertension and its 
causes. 

The causes are to be found in the habits of life 
of the subject and the workings of the organs upon 
which the body's resistance to toxic poisons and the 
chemical processes, depend. The presence of hyper- 
tension in child or adult is an index of faulty 
metabolism arising usually from errors of diet, 
other irregularities of habit, or less frequently from 
incidental infection. It is rare to find a case of 
marked hypertension without an associated symp- 
tom complex — a train of irregtilarities which has 
contributed to the development of the condition. 

The management of a case requires, first, a dif- 
ferential consideration of the associated conditions 
of functional or organic derangements present in 
order to establish the causal factors, which will 
determine the varied courses to be pursued in dif- 
ferent cases. 

Regulation of diet is, as a rule, the most impor- 
tant factor to be considered. It has been found in 
our cases by careful investigation of the histories 
of a large number of patients that a diet with ex- 
cess in animal protein has contributed most fre- 
quently to hypertension, which should therefore be 
eliminated. This should not exclude, as is allowed 
by many clinicians, only red meats, but all animal 
foods, including fish and fowl. While the latter 
may be less rich in nitrogen, they are also subject, 
when taken in excess, to decomposition in the in- 
testinal tract, constituting a nidus upon which the 
toxin producing bacteria feed. The toxins so pro- 
duced are undoubtedly the sources of irritation in 
the circulating blood stream. Most clinicians now 
recognize the toxins present in the circulation, 
as the cause of hypertension, and relief obtained by 
their exclusion when the pressure has been once 
lowered verifies the theory. It is, therefore, in ad- 



vanced cases a prerequisite liial all animal food 
should be eliminated from the diet, and in all cases 
that it should be curtailed in quantity to the amount 
that can be both digested and assimilated, excess 
serving, as stated, as food for the disturbing bac- 
teria. The plea of some clinicians and particularly 
of patients, that they cannot exist without animal 
food as part of their diet is disproved in the expe- 
rience of those who have adopted that dietetic re- 
gime with their patients. It is more a question of 
distaste and individual insubordination than of fact. 
The dietary of each patient should be regulated to 
the individual idiosyncrasies, tastes, and physical de- 
mands. This will require careful investigation. It 
will be necessary in each also to study the condi- 
tions of the symptom complex. They may include 
one or many disturbing conditions — hypertension, 
chronic constipation, inactive liver, and in advanced 
cases varying degrees of arteriosclerosis with or 
without angina pectoris. There may be a compli- 
cating dilatation of the splanchnic area with the 
pathognomonic symptoms of higher pressure and 
pulse more marked when lying down than when 
sitting. 

Nephritis will mark the later stages of the con- 
dition, and in the aged, peripheral gangrene may 
occur as well as other conditions arising from de- 
fective metabolism. The management of a case 
must include the careful survey of all of the ele- 
ments in order that the conditions may be corrected, 
and the patient placed as far as possible upon a 
stable basis. There is no doubt, as demonstrated 
at the present time, that it is possible to prolong 
life for many years, even in the most advanced 
cases, if the patients implicitly follow a regulated 
plan of life, and no greater responsibility rests upon ^ 
the physician than to prolong life and prevent apo- 
plexy in these cases. 

Hypertension, as previously stated, is but a symp- 
tom commonly indicating the presence of irritant 
bodies in the circulation, acting either upon the 
adrenals or vasomotor mechanism or directly upon 
the arterial walls. The latter is the most probable 
and most generally accepted view at present. The 
removal of these sources of irritation, as previously 
suggested, rests largely in the habit of diet, regu- 
lating the quantity and quality of intake to the phys- 
ical demanrls of life or occupation. The sedentary 
subject requires a lower dietary than the laborer or 
the man who pursues an active physical life. It is 
relatively rare to find arteriosclerosis in the labor- 
ing man who may eat larger quantities of animal 
proteids to meet the body's physical demands. This 
is well exemplified in the longevity of the rural pop- 
ulation, whose lives are the most laborious and 
whose habits are simple. 

The hypertension, in addition to the regulation 
of the causes which have led to the* condition, can 
be best controlled by the employment of the high 
frequency current, by the autncondensation, or au- 
toconduction method. The French employ largely 
the autoconduction method, treating the patient 
within a large solenoid, but in this country the auto- 
condensation method is found the most practical, 
convenient, and efifective. 

The management of a given case will depend 



SNOIV: TREATMENT OF HVPERTENSIOy. 



considerably upon its present status or condition. 
In childhood a tension above eighty-tive mm. Hg. ai 
iwelve years of age is a condition of hypertension. 
Any degree of pressure at any age above 120 mm. 
Hg., with the full pulse or diastolic pressure, is too 
high, and indicates the presence of toxic processes. 
It is not uncommon to find men at forty-five and 
fift_\- years of age in health whose pressure is not 
over 110 mm. Hg. full pulse pressure; nor is it 
uncommon to find men at sixty or seventy years 
whose pressure is not over 140 mm. Hg. These 
will be found to have followed a moderate diet with 
exercise. An error made by many clinicians is to 
undertake to assume and state to their patients as a 
comforting assurance that difterent pressures arc 
normal for different ages. The average of pres- 
sures at a certain age may be and is above normal. 
Normal pressure, as the nomial of pulse or respira- 
tion, is the same at any age alter maturity, or it is 
not normal. In children the pressure rises grad- 
ually as they approach maturity. A pressure above 
the normal range is always indicative, as previously 
stated, of toxic processes, and calls for a correction 
of diet and other disturbing conditions. If the 
young adult is taught in early life to observe the 
proper rules of diet, and no intervening infection 
occurs to cause a systemic toxicity, pressures will 
remain practically normal throughout adult life. 

Tliere is no condition which the clinician should 
investigate more frequently in all ages, including 
childhood, than the arterial tension. He will be 
thus warned of the presence of toxemias to be cor- 
rected. Greater attention given to the regulation 
of habits, together with an education in essentials 
of diet, will contribute most to longevity as a proph- 
ylactic measure, particularly after maturity. 

Treatment by the high frequency current consists 
in the employment of the autocondensation method. 
It is our custom to treat the patient having hyper- 
tension daily until the pressure falls to normal or 
recurs to the same figure on the meter scale fol- 
lowing each daily treatment. This will be the com- 
pensation point for the case ; for it has been demon- 
strated clinically by this method of observation in 
the study of a large number of cases that cardiac 
sufficiency is in no sense impaired by this method 
of treatment, but that arterial relaxation can be 
carried only to a limited degree, varying with the 
advanced condition of the afTection. At this point 
a fixed tension will persist despite treatment, and 
beyond this it will be impossible to lower the pres- 
sure. We have termed this the compensation point. 
It seems to be as relative and positive as the pro- 
visional regulation of the other functions of the 
vasomotor mechanism, as the automatic control of 
the respiratory and cardiac functions. There is no 
danger, then, of reducing the blood pressure below 
the point at which the heart's compensation is fixed 
relative to the extent of resistance of hypertension 
or the sclerotic process. Finding this point, there- 
fore, the frequency of administration should be so 
regulated that administrations will be given with a 
freriuencv that maintains the pressure approxi- 
mating this lowered point. 

This, together with judicious attention tn diet and 
other conditions of the alimentan- tract, with dis- 



cngorgement or restoration of activity of the fimc- 
tion of the liver, will shortly control the condition 
by very infrequent administrations of the current 
except in advanced cases or in indifferent patients. 
It is our custom, however, to keep these patients un- 
der observation, requiring their attendance at least 
once monthly in the advanced cases, and less fre- 
quently in the early cases. This is done for safety, 
and is usually acceptable to those who care to con- 
trol the condition that their lives may be prolonged, 
in advanced cases of arteriosclerosis it may be nec- 
essary for the patients to continue to take treat- 
ment as often as two or three times weekly, rarely- 
oftener. 

Constipation naturally favors a greater degree of 
intestinal decomposition from retention of fecal 
matter in the colon. It is therefore imperative in 
all cases, even in the young, as a preventive measure 
to demand a daily evacuation of the colon content. 
Sedentary habits with physical inactivity £md care- 
lessness concerning diet and an established hour of 
evacuation, lead to this unfortunate habit. Its cor- 
rection, therefore, must depend upon the establish- 
ment of a diet which will aid in overcoming and 
controlling the condition. In chronic cases it will 
be necessary, first, to overcome atony of the bowel 
resulting from long habits of neglect. This may 
usually be accomplished by etnploying some agent 
which will restore the functional activity of the 
neuromuscular mechanism of the intestinal tract. 
There is probably no agent more efficient for this 
purpose than the sinusoidal current, administered 
at first daily, and later with diminished frequency, 
until tone is restored with a routine habit, after 
which the patient should regulate the diet and exer- 
cise so as to maintain normal daily movements. 

An inactive liver will fail to perform the impor- 
tant function of converting the toxins into innoc- 
uous bodies. According to the researches of Som- 
crville, seventy-five per cent, of toxins are de- 
stroyed by the liver. When hypertension is discov- 
ered it is fair, therefore, to suppose that the liver 
function is not normal. There is no measure at our 
disposal so effective for restoring the liver to its 
normal function as the static wave current with a 
metal electrode approximately five by eight inches 
in size, placed over the lower margin of the liver and 
epigastrium, employing a spark gap four to eight 
inches for twenty minutes. Some physicians em- 
ploy thermal penetration through the liver. In the 
writer's experience the former is far to be pre- 
ferred. This constitutes a part of the routine treat- 
ment in all cases of hypertension that come under 
our observation, and probably contributes more, to- 
gether with the regulation of diet, than other meas- 
ures in controlling the toxin irritation. 

Advancing or advanced arteriosclerosis is evi- 
denced by the fact that pressure cannot be lowered 
to normal and varies with the different stages of the 
condition. This condition rarely occurs, according 
to our observation, before pressures have exceeded 
160 to 170 mm. Hg. In the most advanced cases 
it may be impossible to lower the pressure, as may 
also be the case in conditions of cerebral pressure. 
The differential method for diagnosing the degree 
or extent .of arterial degeneration will usuallv be 



SNOW: TREATMENT OF HYPERTENSION. 



[New York 
Medical Journal. 



determined by observing the response to treatment. 
As already stated, the advanced case may not re- 
spond, whereas the degree of reduction in mm. ?lg. 
will vary with the extent of the sclerotic process. 
The prognosis as to the frequency of treatments 
and the control of the condition will be governed 
by the resistance to treatment. 

One class in which pressure may be very 
high and maj- respond \ery rapidly, and in 
which a diagnosis is imperative since the danger 
of lowering pressure is imminent, is parenchyma- 
tous nephritis. It becomes of the utmost impor- 
tance, therefore, to the physician who employs the 
high frequency current for hypertension to be able 
to differentiate such cases. In these cases the low- 
ering of the blood pressure must depend upon the 
removal of the inflammatory process in the kidney, 
and not upon the relaxation of the arterial circula- 
tion ; and, furthermore, if the pressure is lowered 
under the.se conditions, uremia will intervene, with 
a diminution of solids in the urine. 

A complication which is present in some cases of 
hypertension and may be found present with a mod- 
erate degree of hypertension is dilatation of the 
splanclinic area. This is a condition which Dr. Al- 
bert Abrams and Dr. Mary Arnold Snow have de- 
scribed as splanchnic neurasthenia. These cases 
are promptly relieved by the employment of me- 
chanical vibration between the second and third, 
third and fourth, fourth and fifth dorsal vertebrx, 
for five minutes daily, followed by the application 
of the static wave current with a metal electrode 
over the lower margin of the liver and epigastrium. 
The pathognomonic symptom of this condition is a 
reverse relation of the pressure and pulse, the pres- 
sure and often the pulse also being higher, when 
the patient is lying down than when he is sitting. 

Interstitial nephritis as a condition resulting from 
])rolonged conditions of hypertension and associated 
\f\t\\ the advanced stages of arteriosclerosis is one 
of the grave sequels of the autotoxemia and the 
resulting hypertension. Its treatment in the early 
stages by the employment of the high fre(iuenc\- 
autocondensation current, together with the appli- 
cation over the kidneys and liver of the static wave 
current with a metal electrode large enough to cover 
both kidneys and the employment of a spark gap 
that will cause a distinct throbbing of the overlying 
muscles, or of thermal penetration, passing a tol- 
erant direct d'Arsonval current through the kidneys, 
is followed frequently by a disappearance of albu- 
min and casts. This is true in the early stages of 
interstitial nephritis. 

Contrary to the statements of those who are not 
fully informed as to the results, there is a steadv 
increase in the elimination of solids up to normal 
in the urine associated with this plan of treatment, 
showing conclusively that there is no interference 
with the compensaton- functions and the elimina- 
tion due to the lowering of blood pressure, but on 
the contrary a favorable increase. It becomes then 
a matter of the greatest importance with these ad- 
vanced cases of nephritis that receive the autocon- 
densation together witli the static, or high fre- 
quency current, that a means of relieving them of 
impending uremia is afforded by increasing the elim 



mation of solids with a coincident lessening of the 
congestion in the kidney itself. The latter effect is 
derived from the electrical treatment, for which in 
our experience the static current is most efficient. 

Gangrene is another one of the conditions of the 
late stages of arteriosclerosis in the aged. I refer 
to it here oidy in order to call attention to the fact 
that together with the other treatment of the general 
condition, the application of radiant light and heat, 
making one or several one hour applications daily 
will in most cases promptly create a reactive hyper- 
emia, which will heal the part, and the gangrene 
disappears. This is rational treatment and has been 
used by the writer with success in several cases. 

Diabetes in one or another form may be asso- 
ciated with hypertension rather as a result of the 
condition. We make this statement because in 
these cases, though the amount of sugar may be 
very great, after lowering of the pressure sugar 
will disappear from the urine. These cases are also 
liable to be complicated by albumin and casts in the 
urine, indicating that the diabetes is due to pres- 
sure coincident in some cases with nephritis. In 
the earlier stages these cases may be controlled by 
autocondensation alone, as has been verified in a 
number of cases that have come under our observa- 
tion. 

Early senility is one of the earlier indications of 
advancing arteriosclerosis. This is probably due 
largely to the impaired function of the secretions 
caused by disturbances in the circulation and also 
to a lowered production of important internal se- 
cretions, particularly of the thyroid gland. Kere- 
tosis and brown spots in the skin of the face may 
be abundant in these patients. We find that after 
fifty years of age, particularly in cases of arterio- ^, 
sclerosis, small doses of thyroid extract accomplish 
much to improve the vital resistance of the patient 
and may well constitute a part of the treatment in 
advancing cases. 

Before concluding, T wish to refer to one prin- 
ciple in the employment of apparatus for the treat- 
ment of hypertension and arteriosclerosis. As re- 
ported by the committee of the American Electro- 
therapautic Association in a report given two years 
ago, it has-been our experience that to get the best 
effect upon the metabolism and to lower blood pres- 
sure, a true d'Arsonval current is necessary. It is 
a subject of regret that most of the manufacturers 
at the present time are putting out for high fre- 
quency treatments closed or open circuit transform- 
ers which produce only oscillating currents. With 
this type of apparatus the current passing to the 
condenser is always alternating and the quality of 
the current produced is likewise oscillatory and can- 
not be rendered directional or pulsatory as it can 
with the true type of d'Arsonval apparatus. A 
Kuhmkoff coil with a mechanical interrupter and a 
resonator is an ideal apparatus for the administra- 
tion of autocondensation, when operated on a direct 
current circuit or high speed static machine. This 
with an autocondensation couch provided with a 
thick cushion and proper resonator is in accord with 
the physical law, as described in the Report of the 
Committee of Phvsicisls. which gave us a most val 
liable key for the employment of electric current. 



January 6, 1917.] 



PRICE: PATHOLOGY OF POLIOMYELITIS. 



and in the presidential address of Dr. Edward C. 
Titus, delivered before the association in 1900. It 
was distinctly shown in the report and address that 
with the true d'Arsonval current administered with 
the patient seated upon the thick dielectric and his 
body capacity on one side of the dielectric and a 
fairly long spark gap in the circuit, the current be- 
comes largely pulsatory, the inverse current being 
slight. If the apparatus is connected in such a man- 
ner that the positive phase of the current is admin- 
istered to the patient, there is no doubt in my mind, 
and I have carefully investigated from both points 
of view, and as the Committee on Standard Ther- 
apeutic Measures reported in 1914, that tlie effects 
are far more benelicial. With this arrangement it 
is necessar)' to administer but 500 milliamperes for 
the conventional twelve minutes to obtain the max- 
imum effects upon the pressure, and this without 
overheating or surcharging the patient, which in 
my opinion is objectionable. 
2020 Broadway. 



THE PATHOLOGY OF POLIOMYELITIS 
AND ITS RELATION TO THE VIRUS.* 

By George E. Price, M. D., 
Philadelphia. 

Acute poliomyelitis, so called, but in reality a 
meningoencephalomyelitis, is a general infection in- 
volving the entire cerebrospinal axis with its mem- 
branes. Certain other viscera may also be affected, 
as the lungs, heart, intestines, spleen, liver, and kid- 
neys. 

The process is at first one of inflammation, the 
cord and meninges in the preparalytic stage becom- 
ing hyperemic, the bloodvessels of the cerebral cor- 
tex^ basal ganglia, brain stem, and cord are congest- 
ed, and edema is present to some extent throughout 
the entire central nervous system. In the cord all 
levels are affected, but the changes are most conspic- 
uous in the cer\'ical and lumbosacral regions. 

The meninges bear the brunt of the invasion, the 
earliest changes being seen in the vessels of the pia 
as it extends into the anteromedian fissure of the 
cord. An acute interstitial meningitis occurs, which 
is not associated with the formation of fibrin or with 
exudation on the membranes. Along the sheaths of 
the vessels of the pia appears a cellular infiltration 
which extends into the anterior horns. The peri- 
cellular lymph spaces of the posterior root ganglia 
are also involved early, these changes occurring, ac- 
cording to Neustaedter (i), as soon as the third day 
after infection. 

The grav matter of the cord shows, in addition to 
the congestion of the bloodvessels, edematous soft- 
ening with here and there minute hemorrhages, cel- 
lular infiltration (chiefly lymphocytic) and later de- 
generation of the nen-e cells, irregular in distribu- 
tion and rarely affecting all the cells in a given level. 
Still later, if the destructive changes have been 
marked, the characteristic cells of the gray matter 
are replaced by neuroglia and connective tissue, and 

♦Read before the Philadelphia Pathological Society, October 26, 
1916. 



the horns become shrunken and atrophic in appear- 
ance. 

In the white matter are found edema, congestion, 
lymphocytic infiltration of the adventitial lymph 
spaces of the bloodvessels, and rarely degenerative 
changes have been found in the anterior roots. 

The pons and medulla present similar but less ex- 
tensive lesions, the ganglia cells as a rule not being 
affected to the same extent as corresponding cells of 
the cord. Changes in the brain are usually limited 
to congestion, edema, minute hemorrhages, and cel- 
lular infiltration, the latter chiefly in the vessel 
sheaths. The spinal ganglia present marked cellular 
infiltration without much change of the ganglia cells. 
Outside of the meninges and nervous tissue, the 
changes that have been found are such as are com- 
mon to acute infectious diseases in general. Of 
these, the most frequent and conspicuous is a hyper- 
plasia of the lymph nodes of the intestines, mesen- 
terj-, and spleen. Similar changes have been found 
in the bronchi. Rarely, acute degeneration has been 
observed in the liver, kidneys, and myocardium. 

As the cells of the anterior horns are trophic in 
function, it follows that when destroyed, their de- 
pendent fibres and muscles degenerate and atrophy 
with resulting permanent palsy and deformity. The 
cerebrospinal fluid in acute poliomyelitis shows an 
early lymphocytosis, the number of cells varying 
from thirty to several hundred per c. mm., the globu- 
lin content is increased, as is also the property of 
reducing Fehling's solution, owing to the presence 
of dextrose. A fibrin clot appears in the prodromal 
and early acute stage, but disappears later. Eraser 
has shown that comparatively mild or even abortive 
cases presented just as marked abnormalities of the 
cerebrospinal fluid as cases fatal during the acute 
stage, and moreover, that the cases presenting the 
most extensive changes in the cerebrospinal fluid did 
not always give characteristic clinical symptoms. 

The blood in the preparalytic stage does not show 
a total leucocytic count in excess of what might be 
considered normal, but as the infection progresses 
there is a constant and marked leucocytosis, with 
an increase of ten to fifteen per cent, of polymorpho- 
nuclears and a decrease of fifteen to twenty per cent. 
of the lymphocytes. 

Whether the virus of poliomyelitis results from 
the activities of the ultramicroscopic, filterable mi- 
croorganism described by Flexner and Noguchi (2), 
the peculiar streptococcus of Rosenow, Towne, and 
Wheeler (3), the Gram positive micrococcus of 
Nuzum and Herzog (4), the organism found by 
Dixon (5), or the germ of which reports are now 
emanating from Johns Hopkins, we do not know. 
W^e fail to become enthusiastic over the coccus idea, 
however, and as a betting proposition would feel 
inclined to place our money on the Rockefeller 
entry. 

Nor is the portal of entrance removed entirely 
from the realm of uncertainty. Koplik (6), as far 
back as 1909, offered two theories — entrance by way 
of the tonsils, and entrance by way of the gut. 
Strauss (7), in 1910, after a post mortem study of 
six cases of poliomyelitis, concluded that the in- 
vasion of the virus occurred through the gastroin- 
testinal tract. Flexner (8), however, has shown 



PRICE: PATHOLOGY OF POLlOMyELlJlS. 



I New Vo» 
Medical Jouk 



experimentally thai the virus of poliomyelitis is in- 
capable of being taken up from the stomach or in- 
testines of monkeys unless the functions of these 
organs are previously disturbed or arrested by 
opium. 

Flexner and Lewis (9) feel that their experi- 
ments support the view that the infection in epi- 
demic poliomyelitis is local and neural and through 
the lymphatics, and that the "infection atrium" is 
the upper respiratory mucous membrane. Flexner 
(lo), however, in another communication, says: 
"The facts known concerning the relation of the 
nasal mucosa to the virus of poliomyelitis must be 
taken at precisely their true value, and must not be 
considered to exclude other modes of infection by 
way of other channels in human beings." 

Neustaedter ( i ) considers it as accepted that the 
point of entrance of the virus is the nasopharynx, 
and points out that while nearly all investigators 
have considered the nasopharynx as being negative 
in poliomyelitis because it is not reddened as in or- 
dinary infections of the throat, he finds it constantly 
edematous in the early stage, with a serous, frothy 
transudate. This he considers pathognomonic of the 
earliest prodromal stage. He attributes the foci of 
congestion in the lungs and alimentary tract to the 
swallowing of the nasal discharges. 

The view that the virus of poliomyelitis travels 
along the nerves as does the virus of hydrophobia, 
is generally accepted. Flexner and Amoss (11) be- 
lieve that in all of the external modes of inoculation 
practised in their experiments, excepting when di- 
rect intravenous injections were made, the virus 
penetrated to the central nervous system by way of 
the nerves, and Flexner and Clark (12) have shown 
experimentally that when the virus was introduced 
into the upper nasal mucosa in monkeys, its propa- 
gation could be followed from the olfactory lobes 
of the brain to the medulla and spinal cord. Had 
the virus reached the nervous axis by way of the 
general circulation, the different areas of nervous 
tissue involved should have been attacked almost 
simultaneously. By injecting an emulsion of virus 
from the spinal cord into the vitreous humor of the 
eye, Flexner and Amoss (13) have been able to 
demonstrate that the virus readily reaches the cen- 
tral nervous system by the neural route, while Land- 
steiner and Levaditi (14) have produced paralysis 
by inoculating the virus into the anterior chamber 
of the eye. 

The experimenters at the Rockefeller Institute 
(11) have further shown that small or even infini- 
tesimal doses of virus will induce infection when 
inoculated endoneurally, while large quantities of 
the virus given intravenously will only occasionally 
cause paralysis. This is due, it is assumed, to an 
inability of the virus to enter the substance of the 
brain and spinal cord directly from the blood, hav- 
ing first to penetrate the choroid plexus. They 
have shown also that the permeability of the men- 
inges for the contents of the blood is increased by 
inflammation of these structures. 

Some of the cases seen by the writer in the pres- 
ent epidemic of poliomyelitis diflfered clinically from 
the familiar endemic cases of past years. Many 
presented an extreme tenderness or hyperesthesia. 



which, while more or less general, was greatest in 
ihe paralyzed e.xtremities. This suggests strongly an 
extension of the virus along the sheaths of the 
nerves from their roots to the periphery, with a re- 
sulting neuritis of the terminal nerve filaments. 

Other cases, instead of giving the usual history of 
paralysis occurring within twenty-four or forty- 
eight hours after the first symptoms of illness, would 
not have any evidence of palsy until seven, ten, or 
even twelve days after the appearance of definite 
symptoms of general infection. This can hardly be 
due to a primary blood infection with delay in pas- 
sage of the virus through the choroid plexus, as 
Clark, Fraser, and Amoss (15) have shown that the 
virus, when inoculated intravenously, remains but a 
short time in the circulating blood. It would seem 
more probable that the infective agent in these cases 
was increasing in numbers and virulence during the 
latent period, until able to overcome the resistance 
of the nerve tissue. 

The whole question of immunity is one of great 
interest and importance. It would seem probable 
that the development of the disease in so compara- 
tively few and scattered cases in a general epidemic 
must be chiefly due to the fact that many have ac- 
quired immunity through having had the disease in 
the so called "abortive" form — or is it not possible 
that, like influenza, the infection may be protean in 
its clinical manifestations and that "poliomyelitis" 
is only one form, other nonparalytic forms being 
also capable of conferring immunity? 

In a recent publication, Taylor (16) reports a 
case having had two attacks of poliomyelitis three 
years apart, and reviews the literature on the sub- 
ject. He concludes that while "an attack of polio- 
myelitis in the great majority of cases confers a 
lasting immunity ; that it is definitely established 
that exacerbations or relapses may occur at short 
intervals of time after the primary onset ; and final- 
ly, that evidence is accumulating to show that an 
actual second attack with reinfection from an ex- 
ternal source may and probably does occur in rare 
instances." 

In closing, I wish to express my indebetdness to 
Doctor Coplin for his kindness in placing numerous 
reprints and references at my disposal. 

REFERENCES. 
I. NEUSTAEDTER: International Clinics, iv, 24. 2. FLEXNER, 
SIMON, and NOGUCHI: Jour. Exfer. Med., .xviii, 461, igu- 
•1. ROSENOW, TOWNE, and WHEELER: Journal A. M. A.. 
Ixvii, n, October 21, 1916, p. 1202. 4- NUZUM and HERZOG: 
Ibidem, Ixvii, 17, October 21, 1916, p. 1205. 5. DIXON: Amer. 
Jour. Dis. of Children, ii. 4, October. 1911. 6. KOPLIK: Arch. 
of Pediat., xxvi, 5, Mav, 1909. 7. STRAUSS: New York Medical 
Journal, January 8, 1910. S. FLEXNER: Journal A. M. A., lix, 
15, October 12. 1912. 9. FLEXNER and LEWIS: Jour. Exper. 
Med., xii, 2, March 14, 1910. 10. FLEXNER: Amer. Jour. Dis. 
of Children, ii. 2. August, 1911. 11. FLEXNER and AMOSS: 
Jour. Exper. Med., xix, 4, 1914. 12. FLEXNER and CLARK: 
Proc. Soc. Exper. Biol, and Med., 13, 1912. 13. FLEXNER and 
AMOSS: Jour. Exper. Med., xx, 249, 1914- i4- LANDSTEINER 
and LEVADITI: Compt. Rend. Soc. de Biol.. Ixvii, 798. 1909- 
15. CLARK, FRASER. and AMOSS: Jour. Exper. Med., xix, 223, 
1914. 16. TAYLOR: Jour, of Nerv. and Ment. Dis., xliv, 3, -Sep- 
tember, 1916- 

1830 South Rittenhouse Square. 



Air and Rhinitis. — Walter J- Wurtz (Annals 
of Otology. Rhinology, and Laryngology. Jime, 
IQ16) states that hygiene of the body, as well as of 
the home, schools, and other public buildings, is 
necessary to prevent "cold in the head." 



January 6, 1917. j 



HYDE AND LO GRASSO: HELIOTHERAPY IX TUBERCULOSIS. 



THE ROLLIER TREATMENT OF TUBER- 
CULOSIS.* 
By Clarence L. Hyde, M. D., 
Perrysburg, N. Y., 

Superintendent, J, N. Adatu Memorial Hospital. 

AND Horace Lo Grasso, M. D., 
Perrysburg, N. Y. 

Assistant Superintendent, J. X. Adam Memorial Hospital. 

Although heliotherapy has been practised for 
some years in this country, so far as can be learned, 
it has been carried out only during the summer 
months and in a more or less haphazard way with 
no regard for system and no attempt at control. The 
results are apt to be inferior under these circum- 
stances, and, as might be expected, have not been 
sufficiently promising to warrant general application. 
The solar rays, just as with any other therapeutic 
agent, if improperly administered and the dose not 
controlled, may be unsatisfactory and even most 
harmful. The unsatisfactory results must be at- 
tributed to the improper application of heliotherapy 
or its abuse, or the failure to use the proper appli- 
ances. 

It was not until two years ago last November that 



tients, we have had to refuse admit' ance to others. 
It is unfortunate that there is no place where these 
patients can receive proper treatment. 

The J. N. Adam Memorial Hospital, a municipal 
institution of the city of Bufifalo, is situated at Per- 
rysburg, in a most ideal spot for carrying out helio- 
therapy. It has an elevation of 1,650 feet above sea 
level and stands on the north slope of a hill over- 
looking the beautiful Cattaraugus valley. ISesides the 
protection from the prevailing winds by a large tract 
of woods and the brow of a hill, we have a most 
extensive view unexcelled in this part of the coun- 
try. It is forty miles from Buffalo and fourteen 
miles from Lake Erie. Its close proximity to the 
lake moderates the temperature, and the continuous 
circulation of land and lake breezes modifies the hu- 
midity to a considerable extent. The mean relative 
humidity for the year 191 5-16 was at 8 a. m. 77.1 
per cent, and at 8 p. m. 78.1 per cent. The mean 
temperature for the same year was 47° F. The 
highest temperature was 88° F. and the lowest — 4°. 
We had 1,729 iiours of sunshine. 

The plan antl construction, original with Dr. John 
H. Prj'or, is of the old English architecture, simple 
and attractive. There are two pavilions, one for 

















^^^m 


■E^ 


' rfll Ji'iiiiiiiliff"- 


.. '^"^^.u^ J|| 


^ 




ll^JUH? 


f^t!a![ffl)fe 


''''IJrT 1 






..-,... 


!«M«»«-i«U»T •■ 


s 


ISB 



Fic. I. — The north side of 



cure building A. the open air school at the extreme right end and the walk leading to sun cure building B. 



Doctor Rollier's method of treatment by helio- 
therapy was introduced at the J. N. Adam Memo- 
rial Hospital by Dr. John H. Pryor, then chairman 
of the hospital commission. As far as can be ascer- 
tained, this marks the introduction of the Rollier 
method of solar radiation to this countrv-, in an ex- 
tensive and complete manner, although as men- 
tioned, it has been employed in a crude way during 
the summer months by several institutions. 

We are happy to note that, since the inauguration 
of this mode of treatment at Perrysburg, it has 
awakened considerable interest throughout the coun- 
try'. Physicians who have come from all parts of the 
United States to see the work carried out at the 
hospital, not only have gone back full of enthusiasm, 
but have introduced it into their private practice. 
and those connected with institutions have used 
their efforts to have it introduced in hospitals. 

We hope that it will not be long before sanatori- 
ums will be established in the various States and 
municipalities to carry out heliotherapy for the cure 
of surgical tuberculosis. There is a great demand 
by physicians and patients outside of Bufifalo for 
treatment at Perrysburg, but as the institution has 
always been filled beyond capacity by Bufifalo pa- 

•Read before the Buffalo Academy of Medicine. April 3, 1916. 



the males and one for the females. They are one 
story high and have terraces on all sides twenty-one 
feet wide, twelve feet being covered and nine feet 
uncovered. This is a most convenient type of build- 
ing, allowing full advantage of the direct rays of the 
sun during the whole day, and at the same time af- 
fording protection from wind and snow. Each 
pavilion has central administration quarters, with 
the kitchen and dining room in the rear and a wing 
at either side. Each wing has two large wards and 
four private rooms. This allows the separation of the 
bedridden from the ambulant cases and also the seg- 
regation of the children according to age. These pa- 
vilions were equipped by the school children of Buf- 
falo through the sale of Red Cross seals. The struc- 
tures cost $100,000 and the furnishings $IO,000. 
They were built to accommodate 128 patients. The 
buildings are fully equipped and every effort has 
been made to make them comfortable and cheerful 
for the children. It has been the aim of Doctor 
Pryor to make the environment of the whole institu- 
tion as homelike as possible. 

Two teachers have been assigned from the school 
department to take care of the education of the chil- 
dren. As far as possible, the teaching is done in the 
open fields and woods. A large open air school room 



HYDE AND LO GRASSO: HELIOTHERAPY LV TUBERCULOSIS. 



[New York 
Medical Journal. 



is used for a certain class of work and when the 
weather is inclement. 

Doctor Pryor remarked in the discussion of our 
first paper, read before the Buffalo Academy of 
Medicine, "If we can relieve these crippled, emaci- 
ated, and bedridden children of their pain, and im- 




FiG. 2. — The teacher taking the 
instruction. 



valescents into the woods for 



prove their general condition and thus make their 
lives happy and comfortable, even without getting 
brilliant results, we are sufficiently justified in pro- 
nouncing the treatment successful." Our results 
show more than that. Not only has this mode of 
treatment relieved the children of pain, and wrought 
•a change for the better both in their physical and 
mental condition, but the results attained in most of 
the cases could not have been secured by any other 
method. 

It is well to note that solar radiation is of benefit 
not only in cases of so 
called surgical tuber- 
culosis, but is being 
applied with excellent 
results in cases of 
puerperal sepsis, ane- 
mia, c o n V a le scence 
from infectious dis- 
eases, and in fact in all 
diseases where the re- 
sistance of the patient 
is below par. It is be- 
ing used in the Euro- 
pean war in the treat- 
ment of all kinds of 
wotmds. 

While heliotherapy 
cannot be carried out 
in winter as success- 
fully as in greater alti- 
tudes on account of 
the small amount of 
sunshine and the 
weakness of the ultra- 
violet ray at this season of the year, in the 
spring, summer, and fall, the treatment can be em- 
ployed most successfully. Last winter we made use 
of the artificial ultraviolet ray generated by means 
of mercury vapor lamps, and although we are not 
ready to report fully on its value, it has proved an 



important aid at this season of the year and in 
cloudy weather. Notwithstanding the handicap ex- 
perienced in winter, taking the twelve months of the 
year as a whole, heliotherapy combined with the 
open air treatment, has produced upon surgical tu- 
berculosis satisfactory results. The success, so tar, 
has exceeded our expectations, and the longer we 
practise heHotherapy the more convinced do we feel 
of its efficacy. 

For the sake of those who are not familiar with 
heliotherapy, we will briefly outline its historj', mode 
of action, and technic as it is employed at the J. N. 
-Vdam Memorial Hospital and carried out by its 
greatest exponent. Doctor Rollier, of Leysin, Swit- 
zerland. 

The beneficial effect of the sun was known as 
far back as the time of the Greek, Herodotus, the 
father of history, who lived between the years 484- 
425 B. C. It was not until receiitly, however, that 
its therapeutic value was recognized so fully as to 
cause it to be used in a systematic and scientific man- 
ner. With due credit to Bonnet, Poncet, Oilier, and 
Bernard, who used solar radiation in chronic ulcers 
and bone tuberculosis years ago, we owe its general 
introduction to Doctor Rollier, who placed heliother- 
apy on its present scientific footing. 

Doctor Rollier became a great enthusiast concern- 
ing heliotherapy during his four years' assistantship 
to Professor Kocher. He noticed that in spite of 
the excellent technic and wonderful knowledge of 
this surgeon, the results of operation on bone and 
joint tuberculosis were not satisfactory. He attrib- 
uted the unsatisfactory results to the fact that all 
attention was paid to the local condition and very 
little, if any, to the general state and resisting power 
of the patient. The disease was treated purely as a 
surgical one. 




Fig. 3. — At play in the winter. 

These observations, the favorable results by 
Bonnet, Poncet, and Oilier in chronic ulcers and 
bone and joint tuberculosis, the discovery about the 
same time by Finsen of the germicidal action of the 
solar rays, and the fact that pulmonarj' tuberculosis 
improved so well under the out of door treatment. 



January 6, 1917.] 



HYDE AND LO GRASSO: HELIOTHERAPY IN TUBERCULOSIS. 



13 



especially in great altitudes, convinced Doctor Rol- 
lier so strongly of the value of heliotherapy that, in 
1903, he established at Leysin, Switzerland, the first 
sanatorium of its kind for the treatment of bone and 
joint tuberculosis by means of solar radiation. He 
started with a small crude building, caring for a few 
cases; now he has several large buildings at dififerent 
heights ranging from 3,500 to 5,000 feet above sea 
level and housing more than a thousand patients. 




Fig. 4. — Patieni with Pott's disease. Shows the ventral position. 



He has made this region a famous health resort for 
the treatment of tuberculosis in general, and surgical 
tuberculosis in particular. This was the starting 
point of the systematic treatment of surgical tuber- 
culosis by heliotherapy. 

The favorable results achieved with solar radia- 
tion are attributed to the luminous or short length 
waves of the sun's rays, of which the ultraviolet 
plays the most important part. These rays have a 
threefold effect upon the skin. They cause a latent 
hyperemia, a pigmentation, and a thickening of the 
epidermis, considered by Doctor Rollier as processes 
of defense. The hyperemia permits the easy absorp- 
tion of these rays, and the pigment converts them 
into longer ones, thus giving them greater penetra- 
tive power, so that they can be more easily absorbed 
into the blood. What changes occur in the blood 
through them are problematic ; let it suffice that this 
absorption of the luminous rays plays a physiolog- 
ical part. These rays are more abundant and more 
powerful in summer than in winter, and in great 
than in lesser altitudes. Dr. Rollier recommends 
that the treatment be carried out in all altitudes and 
climates, and throughout the whole year whenever 
possible, and also that every hospital that desires to 
assume the responsibility of the treatment of sur- 
gical tuberculosis shall have spacious and well 
sh.ltered terraces where the patients may be rolled 
out in their beds, and where they may get, from 
early sunrise, the beneficial action of complete aera- 
tion, and when atmospheric conditions permit, gen- 
eral insolation. 

When using heliotherapy, certain precautions 
must be used and the directions must be followed 
minutely, as otherwise we may have reason to regret 
omission of the slightest detail. Sun baths may 
prove verv' injurious when given improperly. 

No insolation is attempted from three to ten days 
after a patient's admittance to the institution, but 
during this period the patient gradually becomes ac- 
customed to the action of the air and sun and to 
the out of door life in general. He is at first made 
to rest and sleep in bed in his room with windows 



or doors open. Then his bed is rolled out on the 
open porch for about an hour the first day, and the 
time is increased daily until he is able to be in the 
open air practically the entire twenty-four hours of 
the day. During this time a record is made of the 
temperature, pulse, respiration, and of the urine and 
blood findings. After this preliminary observa- 
tion period, the patient is ready for the real solar 
bath. 

No sun bath is given later than one half hour be- 
fore a noon meal and not sooner than two hours 
afterwards. The treatment is carried out in bed or 
on a flat couch and is always started by exposing the 
feet first, without regard to the site of the lesion. 
Sinuses and ulcers are exposed to the sun after the 
whole body has been gradually insolated. In cooler 
weather, in order that chills may not occur and thus 
lower the patient's resistance, care must be exercised 
that no breeze strikes the body. This can be accom- 
plished by wind breaks or screens. " The head is pro- 
tected by a linen cap, an umbrella, or a small awning 
at the head of the bed, and the eyes are shaded by 
means of colored glasses. We use a towel over the 
eyes and forehead, which serves to protect them 
very satisfactorily. 

First day: The patient is dressed in a fabric or flan- 
nel garment according to the season, and the head and 
eyes are protected as mentioned above. The feet are 
exposed and bathed in the sun's rays for five minutes, three 
or four times at hour intervals. 

Second day : The feet are insolated ten minutes and 
the legs from ankles to knees five minutes, three or four 
times at hour intervals. 

Third day; The feet are insolated fifteen minutes, the 
legs from ankles to knees ten minutes, and the thighs 
five minutes, three or four times at hour intervals. 

Fourth day: The insolation of the previously exposed 
parts is increased by five minutes, and the abdomen is 
exposed five minutes, three or four times at hour in- 
tervals. 

Fifth day: Again the insolation of the previously 
exposed parts is increased by five minutes, and the chest is 
exposed five minutes, three or four times at hour intervals. 

Sixth day: If the condition allows it, the patient is 
turned on his abdomen, and the same course as described 
above is repeated. 

Instead of waiting for the sixth day to turn the patient 
on his abdomen in order to insolate the back of the body, 
from the first day we insolate the front and back of 




Fig. 5-- 
cyphosis. 



-Patient with Pott's disease, lying on board to correct the 



every exposed part alternately tliree or four times a day 
at hour intervals. 

The solar radiation is increased five or ten minutes 
each time until three or four hours daily are taken. Dur- 
ing insolation sinuses and ulcers are covered only by a 
wire screen so as to allow the rays of the, sun to play 
upon the lesions. 

After each insolation the patient is vigorously rubbed 



14 



HYDE AND LO GRASSO: lIlil.IOTHERAPY IN TUBERCULOSIS. 



(New York 

Medical Journal. 



with spirits of camphor, using a glove made of rough 
material. 

If during this preliminary treatment, for any reason, 
the sun bath is interrupted, the insolation should be re- 
sumed at a stage a little earlier than from where it was 
stopped. 

Great care must be exercised during the first 
formation of pigment and while the patient is be- 
coming accustomed to the sun. We must watch that 
no dermatitis and that no reaction such as high 




Fig. 6. — Boy in traction. Notice i' 
foot and the side extension. The patiei 
of webbing attached to the sides and 



z fxtt-iisioit .ivparatus at tlu- 
t is Iield in position by band*; 
;nds of the SDring. 



pulse, rise of temperature, headache, nausea, or 
other constitutional disturbance takes place. In 
feeble patients and where there is considerable fever 
the insolation must be of shorter duration and reg- 
ulated very carefully, and if any reaction is noticed 
the exposure is stopped or the dose decreased. It 
is at this stage that a patient is likely, in his enthusi- 
asm, to overexpose himself, and needs most careful 
watching. 

In summer it is not advisable to take sun baths 
during the hottest hours of the day, as at this time 
solar radiation is depressing and fatiguing and likely 
to produce serious reactions. 

After the treatment has progressed for some time, 
and weather conditions are such that the sun cure 
cannot be taken, an air bath is given, the time of 
which is regulated in each case. This depends 
upon the general condition and resisting power of 
the patient. Usually an air bath of ten to twentv 
minutes is sufficient. 

In winter, when the days are pleasant and the sun 
is not strong enough for a bath, we allow our chil- 
dren who can stand exercise to play naked in the 
open for as long as an hour, while during the sum- 
mer months they go about with only their trunks 
the whole day long. 

In the course of treatment the skin surface grad- 
ually takes on a bronze hue, then a copper color, and 
finally becomes a chocolate brown. As pigmentation 
progresses the skin becomes soft and velvety and 
very healthy looking, and seems to acquire consid- 
erable resistance to bacterial infection. There has 
not been a case of skin infection after abrasion in 
any of our patients, although, especially during the 
summer, the children, through climbing trees and 



roaming around the woods naked had every chance 
of becoming infected. 

Furthermore, it has been noticed that these chil- 
dren are not subject to the usual winter infections 
of the respiratory tract. It is a remarkable fact that 
the children who have taken the sun treatment rarely 
contract a cold, while other children and adults who 
have taken only the out of door treatment have ac- 
quired respiratory infections moderately often. Last 
winter there were several outbreaks of influenza, 
but none of the sun cure patients contracted it. 

Besides increasing the resisting power and thus 
acting as a prophylactic to the usual infections, he- 
liotherapy is a most enjoyable recreation if properly 
carried out. The most annoying condition that 
must be avoided and one that will make the sun 
cure both uncomfortable and possibly unsafe is 
a cold wind, however slight, striking the naked 
body. This is avoided as mentioned above by proper 
screening or wind breaking. If caution and com- 
mon sense are practised and the patient is faithfully 
watched, sun exposure is usually safe. 

During the winter months we insist most emphati- 
cally upon the nurses, that no matter how strong 
the sun may be, as soon as a child feels or looks 
chilly he must be taken into a warm room and the 
treatinent temporarily discontinued. 

The gradual pigmentation of the skin is in direct 
proportion to the favorable progress of the cure : 
in fact. Doctor Rollier uses the degree of pigmenta- 
tion as an index to prognosis. We have noticed 
ourselves that the patients with the darkest tan make 
the best progress. 

The effect upon the general condition of the patient 
is most remarkable. There is a rapid disappearance 
of pain. fc\-cr. and chills, there is a return of appe- 




FiG. 7. — The bed. sliowinc the- liar.l •-i.riiii;, which can he raised 
or lowered at the head or foot for counter extension. The nurse 
raises the spring to the level of the side bars for ease in making 
up; lowers it at night so that it oecoTnes a crib. The bars at the 
foot are for extension apparatus and the large rollers rentier it easy 
to move. 

tite, an increase in the body weight and strength, and 
an improvement in the blood condition. Both hemo- 
globin and red cells increase, leucocytosis, if present, 
becomes reduced, and an actual lymphocytosis takes 
place as pigmentation progresses. A slight eosino- 
philia is also present. 

Some of the patients, on admission, present a 



HYDE AND LO GRASSO: HELIOTHERAPY IX TCBERCULOSIS. 



IS 



pitiful picture. They are anemic, emaciated, and 
fever ridden and with features suggestive of suf- 
fering ; yet, in a few weeks, these patients go 
through a complete transformation. The pain, often 
intense, disappears in about ten days ; the tempera- 
ture takes a steady drop, weiglit is taken on rapidly. 




Fig. 8.— The 
be aerated and 
tissues. 



creen. which allows the wound to 
gauze pads tend to macerate the 



the features return to normal, and the blood condi 
tion is improved. 

The most characteristic local result that stands on 
foremost in the treatment of 
joint tuberculosis by helio- 
therapy and one of the great- 
est importance and advantage 
is, according to Doctor Rol- 
lier, the return of motion in 
the affected joint. He has 
attained this motion even in 
cases of fibrous ankylosis 
where the condition has ex- 
isted for years. Although we 
have not had such results in 
cases of existing fibrous ankv- 
losis, we have attained good 
motion in early joint tubercu- 
losis. 

Whereas in the ordinary ex- 
pectant treatment of fixation 
by casts or by the operative 
procedure the prognosis de- 
pends upon the completeness 
of the ankylosis, in heliother- 
apy the gradual establishment 
of motion goes hand in hand 

with the healing process. In the former, ankylosis 
and the destruction of function is the aim ; in the 
latter, the return of the full function of the joint. 
Besides this return of motion in the joint, the mus- 
cles of the affected limb do not suffer atrophy 
under heliotherapy. 



The action of the sun upon the bone tissue is one 
of repair. There i^ a separation and painless spon- 
taneous expulsion of sequestra and an intense re- 
calcification. The point of origin of these sequestra 
may be quite remote from the point of expulsion. 
They may follow a sinuous tract for some distance. 

The etfect upon sinuses and ulcers is one of 
marked reaction on the tract or ulcer, causing at 
first a profuse discharge, this is followed by slough- 
ing, the formation of healthy granulation, and 
the gradual drying up and healing of the sinus or 
ulcer. 

In abscesses, heliotherapy usually reduces the vol- 
ume of pus and frequently causes complete absorp- 
tion. 

The effect upon the nodes is a gradual reduction 
in their size, and in broken down nodes very often 
an absorption of their contents. 

The effect on effusion, in joints, peritoneum, and 
pleural cavity, is one of absorption. This is best 
noticed in peritonitis. 

A special bed is employed in the bone and joint 
cases so that the patient's posture can be properly 
controlled. It has a surgical spring made of strong 
interlacing steel bands. This spring can be raised at 
the foot or head at will and to whatever height de- 
sired. A hard mattress is used so as to avoid possi- 
ble yielding. We follow Doctor Rollier's advice in 
discarding casts entirely and in using splints only in 
exceptional cases. 

Immobilization is accomplished by means of 
straps made of webbing placed around the chest and 
legs and fastened to the side of the spring. Trac- 
tion is accomplished by braces that grip the knee 
and ankle. These are connected by straps that 
buckle at the side, so that the pull will be at both 
the knee and ankle and may be increased or de- 
er. rKfil ;it pitber joint at will. This will allow in- 




Fjg. 9. — Heliotherapy in the winter. 

solation of a considerable part of the extremity- 
In cases of spondylitis, immobilization is instituted 
as stated above and the deformity gradually reduced 
by means of millet down filled pillows placed in such 
position as to produce a compensating lordosis. 
Doctor Rollier uses over the mattress three pillows 



i6 



HYDE AND LO GRASSO: HELIOTHERAPY IN TUBERCULOSIS. 



[New York 
Medical Jouknal. 



of millet down, and those arc so arranged and of 
such a size that the uppermost supports the head 
and shoulders, the middle one the dorsal and lum- 
bar spine, and the third one, which has a central 
opening like our ordinary air cushion, supports the 
pelvis. When the back is to be insolated, the three 
pillows are removed and a three cornered one in the 
shape of a headrest is substituted, which is placed 
under the arms and chest so as to give the amount 
of anterior curvature necessary to correct the de- 
formity. 

In coxitis the safne special bed is used, but instead 
of the three pillows only one is employed and this is 
placed under the buttocks so that the pelvis is slight- 
ly raised and the hip joint put in hyperextension to 
correct the flexion usual in these cases. Continu- 
ous traction is employed by the braces that grip the 
knee and ankle as stated above. Adduction and ab- 



is open in front so as to give free access to the sun's 
rays. 

In tuberculous peritonitis, epididymitis, and orchi- 
tis, rest in bed is essential. 

In tuberculosis of the genitourinary tract rest is 
confined to cases in which the lesion is serious. 

In adenitis rest is not enforced as in the other 
cases unless the general condition of the patient de- 
mands it. 

In tuberculous scleritis and other tuberculous eye 
conditions no special rest is required unless the gen- 
eral condition demands it. It is necessary, in these 
cases, that the eye be kept at rest and not unduly 
exposed to the sun. The local eye insolation is given 
with lids closed. 

Doctor Rollier does not use, in fact, condemns 
injections of any kind in sinuous tracts. Besides the 
possibility of infection and intoxication caused by 




^ /O JS 20 25 



30 



From the tenth to the fif- 
teenth day increase accord- 
ing to same scale. 



From the fifteenth day 
complete insolation from the 
beginning of the bath. 



Total duration of the bath 
three to six hours. 



Fig. id. — Schematic diagram of insolation showing the progression bv which the patient is exposed to the 
sun. (From Rollier's La Cure de S'oleil.) 



duction are corrected by means of a side working 
extension that grips above the knee and fastens on 
a roller that runs along the side of the bed. 

In gonitis, the same special bed is used, but no 
sand nor millet down pillows are employed. Immo- 
bilization is accomplished as in cases of hip and 
spine disease. If there is spasm or deformity, trac- 
tion is used as in coxitis. If subluxation of the tibia 
exists, the deformity is corrected by a rubber splint 
suspended on a swing. 

In tuberculosis of the ankle joint and the joints 
of the foot, the leg should be placed on an inclined 
plane. Talipes equinus is avoided by a rectangular 
splint. This is open in front to make insolation 
easy. 

In the treatment of shoulder joint tuberculosis, no 
special immobilization is employed, as the arm itself 
acts as a natural tractor. Only in cases where there 
is considerable displacement are immobilization and 
traction employed. 

In elbow, wrist, and finger joint tuberculosis, im- 
mobilization is obtained by a celluloid splint, which 



these injections, he holds that they stop natural 
drainage. 

He advises against the knife, no matter how sim- 
ple the procedure, for fear of a possible general 
spread of the disease, and because of the secondary 
infection that inevitably follows surgical interfer- 
ence, a condition that makes healing tedious, besides 
leaving unsightly and unnecessary scars. 

Where drainage of an abscess is absolutely neces- 
sary, aspiration is resorted to rather than evacuation 
by incision. If the contents of the abscess are too 
thick to permit of aspiration, he injects a few c. c. 
of a sterile emulsion made of creosote grammes 
four, iodoform grammes ten, olive oil grammes sev- 
enty-five. This emulsion liquefies the thick pus and 
makes the withdrawal of the contents easy. 

We do not fully accept Doctor Rollier's dictum 
that operations should always be condemned. We 
feel that there are cases occasionally in which con- 
servative surgical interference may not only be use- 
ful but necessary. We advise that a patient receive 
both anteoperative and postoperative treatment with 



January 6, 1917.] 



HYDE AND LO GRASSO: HELIOTHERAPY IN TUBERCULOSIS. 



sun baths and open air. We believe that surgen,' 
should be secondary and only an adjunct to helio- 
therapy. 

Although we started heliotherapy only a little over 
two years ago, and are somewhat handicapped in this 
altitude by the lack of the proper amount of sun- 
shine during the winter months, the results obtained 
in most of the cases of surgical tuberculosis have 
been most encouraging. Obstinate cases have been 
encountered only in open bone and joint tubercu- 
losis, especially since a large percentage of these are 
surgical cases of long standing and presented on ad- 
mission severe secondary infection. The improve- 
ment has not been so rapid nor so satisfactory as we 
could wish, but these cases taxed the patience of the 
physician before they were sent to the hospital, so 
that we cannot condemn the treatment. Rather 
should we condemn the cases. The closed bone and 
joint patients have done well and those who have not 
recovered have shown at least great general and 
local improvement. The adenitis patients have all 
done remarkably well and our results compare 
favorably with those of Doctor Rollier. 

The peritonitis cases have been the most amenable 
to heliotherapy. The improvement both in the gen- 
eral and local condition may be noticed in these pa- 
tients from week to week, and we cannot be too en- 
thusiastic in the praise of heliotherapy in tubercu- 
lous peritonitis. The results have been as good in 
operated cases as in unoperated ones. Some patients 
with peritonitis have had the abdomen so distended 
as to interfere considerably with respiration. In 
one of the cases arrangements to open up the abdo- 
men had been made, as it was feared the scar would 
tear open. This case ended in complete recovery. 

We have treated to date ninety cases of surgical 
tuberculosis by heliotherapy and have now under 
treatment 150 cases, 120 of which are of the so 
called surgical type. Forty-three per cent, of these 
presented on entrance abscesses, sinuses, or sec- 
ondarj- infection, and many had been operated upon 
several times. Sixty per cent, presented one or more 
lesions other than the primary one. A large pro- 
portion of the adults showed a pulmonary lesion. 

The average length of stay for all surgical cases 
discharged was 8.4 months, while the average length 
of stay for those who were discharged as apparently 
recovered or arrested, was 13.5 months. Of the pa- 
tients who remained three months or longer, sixty- 
seven per cent, were discharged apparently recov- 
ered or arrested. Of those who remained six months 
or longer, seventy-seven per cent, were discharged 
apparently recovered, and of those who remained 
nine months or longer, eighty-two per cent, were 
discharged as apparently recovered. This shows 
the important bearing that the length of stay has 
upon the results in cases of surgical tuberculosis. 

It is true that the time required under heliother- 
apy is long, nevertheless the results are permanent. 
So far as we have been able to ascertain, there has 
been no recurrence of the disease in cases we have 
discharged as apparently recovered or arrested. It 
is needless to say that the best results have been in 
closed cases. 

STATISTICS. 

Excellent results have been attained at the J. N. 
Adam Memorial Hospital in uncomplicated bone. 



joint, and gland tuberculosis where there is a single 
lesion, and in tuberculous peritonitis. Multiple le- 
sions and secondary infections render the prognosis 
less favorable, as will be seen below. 

Adenitis. — Forty-eight cases of adenitis have been 
discharged, all of which were apparently cured or 
arrested. Twenty-nine were closed cases, three of 
which were complicated with pulmonary tubercu- 
losis and two with a healed coxitis. , Ten had closed 
tuberculous abscesses, four of which had incipient 
pulmonary tuberculosis ; one had advanced pulmo- 
nary tuberculosis and one tuberculosis of the middle 
ear. Nine had discharging sinuses with mixed in- 
fection. 

Fifty-four cases of tuberculous adenitis are under 
treatment and all are improving. Fifteen of these 
have incipient pulmonary tuberculosis, one has in- 
cipient pulmonary tuberculosis and tuberculous epi- 
didymitis, and another incipient pulmonary tubercu- 
losis and lupus erythcmatosis eruption, one . has 
Pott's disease, one a healed tuberculous hip, and one 
tuberculosis of the hand and wrist. 

Pott's disease. Three cases of Pott's disease have 
been discharged, one of which was apparently 
recovered, while two were unimproved. The 
one discharged as apparently recovered also 
had incipient pulmonary tuberculosis. Of the 
two discharged as unimproved, one had incipient 
pulmonary tuberculosis. Pott's disease, einpyema, 
and a tuberculous kidney. The patient died in 
Buffalo shortly after an operation for the removal 
of the diseased kidney. The other had moderately 
advanced pulmonarv tuberculosis, tuberculosis of 
the sacroiliac joint, femur, and kidney. Seven cases 
of Pott's disease are now under treatment ; six are 
making excellent progress toward recovery, while 
the other has improved only slightly. 

Hip. Five cases of tuberculosis of the hip joint 
have been discharged, three apparently recovered 
and two improved. All of the cases discharged as 
apparently recovered were closed, and one had in- 
cipient pulmonary tuberculosis and tuberculous 
glands. Of the two discharged as improved, one 
case did not remain long enough for better results. 
The other also had moderately advanced pulmonary 
tuberculosis and tuberculosis of the knee, bladder, 
and prostate, and was complicated with amyloid de- 
generation. 

Fifteen cases of tuberculosis of the hip joint are 
how under treatment, all improving excellently. 
Three of these have incipient pulmonary tuberculo- 
sis, two tuberculous glands, one Pott's disease, and 
one tuberculosis of both hips with abscess. 

Knee. Three cases of tuberculosis of the knee 
have been discharged. One was apparently recov- 
ered and two were improved. The case apparently 
recovered also had tuberculosis of the wrist joint 
and the lungs. The two improved did not remain 
long enough for better results. We have nine cases 
now under treatment, all but two making good prog- 
ress toward recovei^. Two are unimproved, both 
of the blond type which does not tan well. One has 
remained stationary and the other is progressive. 

Ankle. Three ca^es of tuberculosis of the ankle 
have been discharged, two arrested, and one im- 
proved. Of the two arrested, one had incipient pul- 
monary tuberculosis and a closed lesion of the ankle. 



lyEJNSTEIN: BORDERLINE CASES OF UPPER ABDOMEN. 



[ New York 
Medical Journa 



and the other tuberculous epididymitis with a dis- 
charging fistula. The case discharged as improved 
also had Pott's disease, tuberculous glands with dis- 
charging sinus, and blejjharitis. The glands and 
blepharitis were healed upon her discharge, but the 
woman did not remain in the hospital long enough 
to heal the ankle and spine. 

Six cases of tuberculosis of the ankle are now 
under treatment, and all are making excellent pro- 
gress. They show the following complications : One, 
incipient pulmonary tuberculosis and tuberculous 
glands with sinus } one, tuberculosis of the tibia ; one, 
pleurisy ; one, incipient pulmonary tuberculosis ; one, 
incipient pulmonary tuberculosis, pleurisy with effu- 
sion, and peritonitis. 

Shoulder. Three cases of tuberculosis of the 
shoulder are now under treatment, all with sinus and 
secondary infection, one with moderately advanced 
pulmonary tuberculosis, and one with tuberculous 
ostitis of the tibia. 

EWo'lV. Four cases of tuberculosis of the elbow 
are under treatment. All are making excellent pro- 
gress ; three have marked destruction of the joint, 
two incipient pulmonary tuberculosis, and two tuber- 
culous glands. 

Wrist. One case of tuberculosis of the wrist was 
discharged as improved. This case remained only a 
short time. 

Hand. Two cases with lesions of the hand have 
been discharged ; one apparently recovered also 
had incipient pulmonary tuberculosis ; one unim- 
proved was syphilitic. Two cases of tuberculosis of 
the hands are under treatment, one practically cured 
and the other improving. 

Osteomyelitis. Four cases of osteomyelitis have 
been discharged, two apparently recovered, and two 
improved. Of the two apparentlv recovered, one 
lesion was in the malar bone and the other in the 
tibia. Of the two improved, one was in the tibia and 
the other in the sternum. Three Cases are under 
treatment and improving. 

We recommend with Rollier that nontuberculous 
patients with osteomyelitis be trephined before re- 
ceiving the sun cure, as the sequestra in these cases 
are too many to be eliminated spontaneously. 

Peritonitis. Eight cases of tuberculous peritoni- 
tis have been discharged. Five apparently recov- 
ered, two improved, and one unimproved. Of the 
five apparently recovered, three were closed ; two of 
these had incipient pulmonarv' tuberculosis, and two 
had postoperative sinuses. One of these had in- 
cipient pulmonary tuberculosis, tuberculosis of the 
ilium, and Pott's disease. Of the two improved, one 
had advanced pulmonary tuberculosis and one tabes 
mesenterica with multiple abscesses. The one un- 
improved had acute miliary tuberculosis and was a 
rapidly progressive case. Ten cases of tuberculous 
peritonitis are still under treatment and all are im- 
proving. 

Eye. Two cases of tuberculosis of the eye have 
been discharged as apparently cured ; three cases are 
still under treatment and are making good progress ; 
two have also incipient pulmonary tuberculosis and 
one has tuberculous glands. 

Genitourinary. One case of tuberculous kidney 
and moderately advanced pulmonary tuberculosis 
was discharged as arrested. Two cases of tubercu- 



lous epididymitis are under treatment and improv- 
ing; both have also incipient pulmonary lesions. 
One case of tuberculosis of the uterus, tubes, and 
peritonitis was operated in, and a panhysterec- 
tomy performed ; the patient is not doing well. She 
also has moderately advanced pulmonary tubercu- 
losis. 

This treatment is recommended in pulmonary tu- 
berculosis when chlorosis, anemia, or neurasthenia is 
present, and very successful results have been ob- 
tained in pleuritic and pericardial effusions due to 
tuberculosis. 

We are greatly encouraged with the results as a 
whole, and feel sure that these results could not have 
been attained with out of door treatment alone, nor 
could they have been accomplished with surgical in- 
terference, for some of the patients who have shown 
marked improvement had been unsuccessfully of>er- 
ated upon several times before they came to us. 

We earnestly plead that surgeons and physicians 
institute the treatment in the closed and early cases 
when possible and do not wait until the cases have 
become advanced. The length of time for an arrest 
or recovery depends upon the extent of the lesion 
and upon the presence or absence of secondary in- 
fection. 

As a large number of cases of surgical tubercu- 
losis show a lung lesion, and all manifest constitu- 
tional disturbances, we think that ward treatment is 
wrong and that these cases should be treated in the 
light of a general disease, and in sanatoriums if pos- 
sible where the air is pure and the surroundings and 
associations most conducive to the carrying out of 
the out-of-door life. 

Of all diseases there is none in which the indi- 
vidual resistance plays a more important part than 
in tuberculosis, pulmonary or surgical. Any treat- 
ment, therefore, which increases this resistance and 
builds up the whole system is the treatment par ex- 
cellence. The goal that we wish to reach is the 
acme of resistance, and general experience has 
taught us that fresh air, solar radiation, rest, and 
sufficient food are the best and most potent weapons 
at our command. 

REFERENCES. 

I. A. ROLLIER: Die Heliolherapie der Tiibercnhs. 2. IDEM: 
La cure de solcil. ,. JOHN H. PRYOR: A Report on the Rollier 
Treatment for So Called .Surijical Tuberculosis, New York State 
Journal of Medicitie, June, 191 s. 



BORDERLINE CASES OF THE UPPER 
ABDOMEN.* 

By Harris Weinstein, M. D., 
New York. 
The application of the proper form of treatment 
in these borderline diseases should not be based on 
preconceived notions as to the propriety of one or 
the other method of therapeutics, as it is never 
wholly surgical or wholly medical. The anatomical 
changes at the critical stage of the disease should 
influence our judgment, reinforced by a knowledge 
of the results to be expected from either method. 
Gastric and duodenal ulcer form an important chap- 

•Read at a meeting of the Yorkville Medical Society, October 
16, 1916. 



Ja 



UEIXSTEIX: BORDERLINE CASES OF UPPER ABDOMEX. 



19 



ler in the consideration of the treatment of border- 
hne diseases of the upper abdomen. 

At the outset I might state tliat a correct medical 
diagnosis is not always possible, despite our fond 
and revered clinical images of the disease. Only 
loo often it proves to be an appendicitis, gallbladder 
condition, gastroptosis, pylorospasm, atonic dilata- 
tion, or a gastric neurosis. 

Simple gastric ulcer cannot be demonstrated by 
any known method short of actual inspection. The 
histor}-, clinical or laboratorj- evidence, and radio- 
graphic findings are alike disappointing. Assum- 
nig the existence of a simple gastric or duodenal 
ulcer without complications, we cannot but admit 
the efficacy of proper medical treatment. Recru- 
descence of the ulcer occurs where the prescribed 
regimen is grossly abused, or where the etiological 
factor is operative and cannot be removed. Heal- 
ing of an ulcer depends upon sparing of the mu- 
cosa, neutralization of hyperacid contents when 
present, improvement of the general nutrition and 
of cell resistance, and removal, if possible, of the 
focus of bacterial invasion. Even in the presence 
of multiple ulcers which constitute about twentj' 
per cent, of the cases, these desirable results 
can be attained by proper management. The 
arguments advanced in favor of surgical interfer- 
ence cannot be lightly set aside. The occurrence of 
a possible hemorrhage, of chronic oozing, and re- 
sulting anemia and debility, of chronic induration 
and subsequent obstruction or hourglass contrac- 
tion, of acute, subacute, or chronic perforation, and 
of probable malignant degeneration, cannot wholly 
be prevented by medical means. Radical surgery, 
which alone can be relied upon to prevent the dan- 
gerous complications above enumerated, suffers 
from a rather bad reputation in point of mortality. 
To make resection still more undesirable, gastric 
ulcers are frequently inaccessible, as they occur in 
about eighty per cent, of the cases on the posterior 
wall of the stomach ; are often imbedded in a mass 
of adhesions, and are just as frequently not found 
at all. 

Gastroenterostomy, the operation of choice, which 
enjoys a very low mortality, offers, however, none 
of the advantages of resection. It does not remove 
the danger of complications or the possibility of re- 
currence, but leaves a balance of two per cent, mor- 
tality against it. To subject a patient to the dan- 
gers of an operation with its attendant uncertain- 
ties as to outcome, wuth no advantages to offer over 
milder and safer treatment, and particularly so in a 
chronic disease in which the power of resistance is 
below par, seems to me unwarranted. Gastroenter- 
ostomy as a curative measure presents advantages 
or disadvantages according to the site or effect of 
the ulcer. The aim of the operation is to divert the 
chyme from the normal channel to the new open- 
ing, in order to protect the ulcer from the irritating 
effect of the hyperacid contents. It is well known, 
however, that the stomach does not drain by grav- 
ity through the stoma, but by muscular effort 
through the pylorus. It is evident, therefore, that 
in the absence of pyloric obstruction ulcers of the 
antrum, pylorus, or duodenum would still continue 
in contact with the acid chyme, and that ulcers situ- 
ated on the lesser curvature, fundus, or at the cardia 



could not escape its irritating effect, even though 
drainage was to occur through the stoma. 

In benign pyloric obstruction, when not due to 
pyloric spasm and consequent gastric congestion, 
gastroenterostomy offers the only effective method 
of treatment. Regurgitation of enteric juice takes 
place in gastroenterostomy and is found in the stom- 
ach years after the operation. It permanently neu- 
tralizes the gastric juice and thus aids the healing 
of the ulcer. Ulcers situated in the fundus cannot 
escape irritation by acid chyme despite gastroenter- 
ostomy and pyloric occlusion ; operation is therefore 
not indicated. Disturbed motility due to pyloric 
spasm should be dift'erentiated from obstructive 
gastrectasia and treated medically, as it yields easily 
to lavage and diet. Study and observation often 
lead to the discovery of the underlying cause of the 
spasm. Gastrosuccorrhea, formerly regarded as a 
neurosis, almost invariably spells ulcer, and its 
treatment should fall imder that category. 

In the treatment of the complications of ulcer, the 
probable results of either method should be consid- 
ered, as dictated by experience. The mortality of 
acute hemorrhages under medical treatment is about 
five per cent, against sixty per cent, surgical. The 
difffculty of finding the bleeding point, the poor op- 
erative risk the patient presents after severe loss of 
blood, and the strong probability of cure by medical 
means should leave no doubt as to the proper course 
lo pursue. In chronic oozing, anemia and debility 
soon follow, and if energetic medical treatment is 
not quickly effective, the aid of the surgeon should 
be invoked without loss of time. Perigastric adhe- 
sions interfere with gastric motility to a greater or 
lesser extent. Unless stenosis dyspepsia has devel- 
oped, surgery should not be resorted to, as new 
adhesions form after shortlived improvement. 

Acute or subacute perforation calls for immediate 
operation. When the ulcer makes its way slowly to 
the surface, plastic peritonitis is excited and the 
stomach adheres to a neighboring viscus, prevent- 
ing the gastric contents from entering the peritoneal 
cavity. Disturbed abdominal function of a serious 
nature often follows chronic perforation because 
of the matting together of the various organs by 
dense adhesions, frequently necessitating operative 
interference We should be on our guard against 
the folly of operating in conditions where the gastric 
symptoms, although severe, are due to venous con- 
gestion of the mucosa in diseases of the heart, lungs, 
liver, or kidney. In gastric neuroses operation is 
nothing short of a catastrophe and should be stren- 
uously avoided. While admitting failure of medical 
and mechanical treatment in prolapse of the stom- 
ach, no more can be said of surgery in this condition. 
Ventrofixation was followed by severe disturbances 
without removing the old symptoms. The only in- 
dication for surgical interference is kinking of the 
pylorus, calling for relief from obstruction. 

The failures of gastric surgery are often due to 
mistaken diagnosis and to operations in conditions 
where the indications are not clear, to inaccessibility 
of the ulcerated area, because of its overwhelming 
frequency on the posterior wall, or of the thickness 
of adhesions surrounding it. In ulcers which do not 
interfere with gastric drainage surgery is not help- 
ful. It is well to remember that resection of the 



HOLLENDER: STITCH SUPPURATION. 



ulcer does not remove the predisposition to ulcer 
formation or of the focus of infection. 

The attitude of the surgeon toward the question 
of early gastric cancer is not justified by practical 
results. Early laparotomy as an aid to diagnosis 
has not come up to expectations. 

Somehow the findings cannot be correctly inter- 
preted in early cases. It has happened, where ex- 
ploration was resorted to on suspicion of malig- 
nancy, and nothing definite was found, later to have 
discovered gastric cancer. Some supposedly early 
cases with no palpable tumor prove inoperable be- 
cause of metastatic deposits in neighboring glands. 
Conversely, a palpable tumor is no contraindication 
to operation, as there may be no metastases, despite 
the presence of a neoplasm. For symptomatic re- 
lief in malignant pyloric obstruction gastroenterosto- 
my is obviously indicated. 

In view of the difficulty of early diagnosis, a few 
practical hints for our guidance may not be out of 
place. Disturbed motility in the absence of free 
hydrochloric acid should arouse suspicion. From 
personal observation, absence of, or greatly reduced 
free hydrochloric acid with a very high total acidity 
is almost diagnostic of gastric carcinoma. Hyper- 
chlorhydria with sarcinas and germinating yeast cells 
does not militate against malignant obstruction. For 
Bnal decision, rational treatment and observation 
are required. If there is a tendency toward aggra- 
vation of symptoms despite treatment, there is a 
strong probability in favor of carcinoma. 

Prolapse of the viscera does not require surgical 
interference unless productive of severe symptoms. 
In the case of the kidney, fixation is indicated in 
Dietl's crises, intermittent hydronephrosis, and in 
pressure of the kidney on neighboring organs, upon 
the sympathetic, or gcnitocrural nerves. 

In the case of the liver hepatopexy should be re- 
sorted to only after failure of mechanical supports 
to relieve pain or attacks resembling hepatic colic. 

Movable spleen does not require treatment, unless 
torsion of the pedicle occurs with swelling and gan- 
grene, when splenectomy should be practised. 

825 Lexington Avenue. 



THE TREATMENT OF STITCH SUPPURA- 
TION. 
Beck's Bismuth Paste, 
By a. R. Hollender, M. D., 
Chicago. 
At the present time, stitch abscesses which occur 
after the operation in a clean case are looked upon 
as a reflection on the technic or on the cleanliness 
of the operator or his assistants. In fact, in many 
m.odern hospitals stitch suppuration is a rare occur- 
rence. That this postoperative complication has 
not been entirely eliminated is well known to any 
one who visits the diflferent clinics. Some hospitals 
even report occasional epidemics of stitch suppura- 
tion, and when the cause is sought for, it is found 
to be some small inconspicuous technical error in 
operative procedure or in sterilization. 

As the infection is usually of a mild character, 
healing which takes a week or longer occurs spon- 



taneously after the removal of the stitches. In cer- 
tain cases, however, the wound will reopen and 
healing by secondary union will take place. The 
healing depends altogether on how extensively and 
how deeply the infection has penetrated. It has 
been found that deep sutures 'of silkworm gut when 
infected carry the suppurative process into the deep 
layers of the wound. On the other hand, when the 
sutures are not deep, the infection is superficial, un- 
der the skin, and the muscles and fascia are not in- 
volved. 

I need not enter into the causes and varieties of 
stitch abscesses. The condition is one with which 
every surgeon is 
more or less famil- 
iar. The object of 
this paper is to de- 
scribe a method of 
treatment w h i c h 
we have used very 
effectively at the 
North Chicago 
Hospital in cases 
of stitch suppura- 
tion. I consider 
this methdod of 
sufficient value to 
bring it before the 
medical profes- 
sion. 

While the meth- 
od does not differ 
from the bismuth 
paste treatment 
now generally 
used, the following 
suggestions as to 
tlie technic are 
made in order to 
emphasize the 
facts more clearly. 
Liquefied bismuth 
paste is injected 
into the channel 
left by the suture 
as soon as it is 
withdrawn. The 
injection is made with a specially devised syringe 
(Fig. i) with a long pointed nozzle, similar to that 
of a hypodermic needle except that the point is 
blunt. The paste will fill out the entire tract left 
by the thread and exude from the opposite opening. 
Within twenty-four to forty-eight hours suppura- 
tion will usually cease. This procedure is so simple 
and so effective that I do not hesitate to recom- 
mend it. 

In cases where the tissues are undermined and 
large abscesses have formed beneath the skin or un- 
derneath the fascia, the paste is likewise very use- 
ful. If these abscesses are filled with the paste, the 
overflow will exude through the stitch holes on all 
sides of the wound, or, if there are no stitch holes, 
the paste will extrude through the opening into 
which it was injected. The pus changes into a ser- 
ous discharge within a day or so, and in a verj' short 
time secretion stops and the wound heals. 

It is needless to describe at length the method and 




Fig. r. — Special syringe used to inject 
bismuth paste. 



January 6, 191 7. 1 



ERSNER: ANESTHESIA IN TONSILLECTOMY. 



its modus operandi, for this has appeared so many 
times in print that 1 have only to refer the reader to 
the latest articles of Doctor Beck (i), in which he 
gives the tecliiiic as used in cases of suppurative 
sinuses and empyema. 

The arrows in Fig. 2 show tlie communicating 
openings of an abdominal incision which opened 
after the patient had been discharged from tlie hos- 
pital for over a month. The case had had no drain- 
age at the time of operation and healing occurred 
by primary union within a very short time. After 
four weeks the wound opened and discharged pus. 
One injection of a ten per cent, bismuth petrolatum 
paste closed both openings within two days and there 
was no further trouble. 

Doctor Beck has employed the method i'or the 
past eight years. He has not published his results, 
but he has demonstrated cases repeatedly to visiting 
surgeons at the North Chicago Hospital. In most 




Fig. 2. — Arrows indicate communicating openings of an abdominal 
incision that opened four weeks after operation. One injection of 
bismuth paste closed the openings in two days. 

instances those who have adopted this form of treat- 
ment as a routine measure in postoperative suppu- 
rations report results which coincide with those ob- 
tained by the writer. 

REFF.RENXES. 
I. Bismuth Paste in Chronic Suppurations, C. V. Mosbv Co. 2. 
The Treatment of Sinuses of the Head by Means of Bismuth Paste, 
Dental Rez'iew. February, iqi6. 3. Bismuth Paste in Chronic Sup- 
purative Sinu'^es and Empyema, Journal A. M. A.. July i, 1916. 
4. A Report of a Series of tlnusual Fecal and Genitourinary Cases 
Treated with Bismuth Paste, Surgery, Gynecology, and Obstetrics, 
May, 1916. 

2t East Washington Street. 



INFILTRATION ANESTHESIA FOR TON- 
SILLECTOMY, TOGETHER WITH THE 
EMPLOYMENT OF NORMAL 

SALINE SOLUTION. 

Bv M.^tthevv S. Ersner, M. D., 

Philadelphia, 

Lar\-n?olo?ist, Tuberculos's Department, Philadelphia General Hos- 
pital; Instructor. D'S'-ases of the Ear. Patholo^ and Bac- 
teriology, Philadelphia Polycl'nic; Ass'stant. Ear, Nose, 
and Throat Department, Pennsylvania Hospital. 

The subject of local anesthesia, or infiltration 
anesthesia, has been variously disctissed, and mam- 
papers have been written upon the subject We 
often fear to tread upon such thoroughly studied 
pathways ; however, keeping in mind that the last 
word has not been said upon any subject, I took 
courage to studv newer and safer methods, and am 



bringing forth this new, simple, sane, and safe 
method of normal saline infiltration for local ton- 
sillectomy. 

Among the various substances in vogue at pres- 
ent are: i. Cocaine; 2, novocaine ; 3, beta eucain ; 
and, 4, quinine and urea hydrochloride. 

1. Cocaine is the ideal substance as an analgesic, 
but we never know which patient has an idiosyn- 
crasy for it and recently several fatalities have been 
reported; therefore, we hesitate to take the chance 
of using such a dangerous though otherwise good 
method. Until a method is developed whereby we 
can determine definitely which patient is susceptible 
to cocaine, just as we are able to tell by subcuticular 
anaphylactic tests to which foods a patient may be 
sensitized, cocaine will remain a bugaboo as a local 
anesthetic. 

Again, a danger in using cocaine is that at times 
an anomalous vein or venule may be injected, the 
solution thus rapidly taken into the system pro- 
ducing death. 

2. Novocaine was for a time considered the only 
safe anesthetic on account of its being less toxic, but 
it has the following disadvantages: It is difficult to 
sterilize and we arc never sure of its sterility ; in our 
clinic we had one fatal, and another grave infection 
follow novocaine anesthesia tonsillectomy. All other 
aseptic precautions were observed, so we could 
blame only the novocaine. Many patients show an 
idiosyncrasy to novocaine, although in a lesser de- 
gree than to cocaine ; nevertheless, it should be taken 
into account and not dispensed freely. The slough- 
ing is sometimes severe, especially when large quan- 
tities are used. This is also the case when cocaine , 
is used, and a complete preoperative anesthesia 
should be sacrificed to eliminate postoperative pain 
and secondary hemorrhage, and to assist healing. 
Cocaine and its alkaloids are primarily stimulants, 
and as many local tonsillectomies are performed on 
adults who at one time or another had a myocardial 
or endocardial involvement, the sudden strain of co- 
caine stimulation thrown upon the heart, plus the 
nervous element and secondary depression, exclu- 
sive of the fact that an anomalous vein may be in- 
jected, gives fatal results. 

I had often observed that patients complained of 
pain when novocaine was used unless in large quan- 
tities. I therefore inferred that the volume injected 
in a limited area caused pressure, and, which we 
afterward proved to our satisfaction, that the latter 
(pressure) played a greater role than the novocaine; 
as will be demonstrated later on. The present 
scarcity and the soaring price of novocaine naturally 
drove us to look for substitutes, and I believe that 
we have found one its equal if not its superior, in 
our saline infiltration. Betaeucaine can briefly be 
disposed of, as it belongs to the cocaine alkaloid 
group and has practically most of the disadvantages 
enumerated above. 

Quinine and urea hydrochloride has the disadvan- 
tage that the edema caused by it is extreme, the 
sloughing considerable, and when it is not properly 
injected, the patients complain of pain. ' 

When I first began to try pressure anesthesia, I 
used sterile water which gave gratifying results, but 
water being a hypotonic solution, when injected be- 



DUNCAN: A NEW GALACTOGOGUE. 



[New York 
Medical Journal. 



twcen the capsule and the interpharyngeal aponeu- 
rosis, the patient complained of a peculiar tearing 
pain shooting toward the occiput, feeling, from the 
patient's description, as though water had been aspi- 
rated into the nose. It was simply a question of 
osmosis which was soon eliminated by using an iso- 
tonic solution (normal saline). This pecuHar sen- 
sation was a sign that the solution was retrotonsillar, 
and I therefore concluded, and afterward proved to 
my own satisfaction, that the normal saline disposed 
of this annoying inconvenience. 

TECHNIC. 

1. The anterior and posterior tonsillar pillars are 
swabbed with a ten per cent, cocaine solution. The 
swab is very thin and thoroughly squeezed so that 
no excess of cocaine is spread over the tonsillar area. 
Just enough cocaine is applied to take ofT the sharp 
sting of the needle when the saline is injected. 

2. About two and one lialf to three drams of nor- 
mal saline are injected back of each tonsil in the fol- 
lowing manner: Superior pole, inferior pole, one 
injection each; anterior pillars and posterior pillars 
two injections each. In buried tonsils it is often 
advisable to catch the tonsil with the tenaculum and 
pull it forward to inject as described above. When 
infiltration is perfect, the tonsil bulges out and be- 
comes pale owing to retrotonsillar pressure. 

When the myocardium is good, two minims of 
adrenaline hydrochloride, one in 1,000, are added to 
the solution for each tonsil, but recently the adrena- 
line has been dispensed with, although since then pa- 
tients have expectorated from two to three drams of 
blood. However, this lessens the danger of post- 
operative hemorrhage, which is most dreaded. 
Again, adrenaline hydrochloride is a vasomotor con- 
strictor and, as described above, many patients upon 
whom local tonsillectomy is performed, are adults 
who at one time or another have had some involve- 
ment of the myocardium or endocardium. By elim- 
inating the adrenaline the danger from strain upon 
the heart is avoided. 

We at present have seventy-two patients subject- 
ed to tonsillectomy, most of them at the Out-Patient 
Department of the Pennsylvania Hospital; fifty-five 
of them I operated on personally, seven were at- 
tended by Dr. George Morrison Coates, and the 
rest by other assistants in the clinic. All patients 
recuperated rapidly without untoward effects. 

I SUMMARY. 

1. The saline solution is freshly prepared and 
sterilized, and thus we avoid infections from this 
source. 

2. The saline solution being isotonic, really acts 
as a cleansing tonic to the tissues, for there was no 
appreciable sloughing, except from extreme pressure 
in a few of the very earliest cases, but it was not 
very marked. 

3. The saline can be used to excess without any 
fear of toxicity. 

4. When the tonsils are properly infiltrated, there 
is absolutely no pain, except in a few cases due un- 
doubtedly to the nervous element. 

5. Last, but not by any means least, postoperative 
sloughing is avoided, healing is promoted, and most 
natients are able to take food without difficulty with- 
in the next twenty-four hours. 



The Fielding O. Lewis incision, which consists of 
an inverted U, with eversion of the tonsil, was used 
in all cases. The snare used is either the Eve's for 
rapid tonsillectomy, or the Fielding (J. Lewis for 
the slow constriction or so called bloodless tonsil- 
lectomy. 

I wish to express my appreciation and gratitude 
to my chief. Dr. George Morrison Coates, for his 
kind encouragement and the opportunities afforded 
me to pursue my study of this subject. 

iqi8 North Sixth Street. 



A NEW AND POWERFUL GALACTOGOGUE. 
By Charles H. Duncan, M. D., 

New York. 

In treating a case of mastitis by means of auto- 
therapy, that is, by injecting subcutaneously the 
filtrate of the discharge from the nipple, it was no- 
ticed, in addition to curing the mastitis quickly, that 
the quantity of milk rapidly increased until it be- 
came more than the patient, a multipara, had ever 
previously given. The question arose. Was it the 
milk in the exudate that caused the stimulation of 
the mammary glands? Several tests convinced the 
writer that it was, and he appended a footnote to 
several articles on the subject of autotherapy, men- 
tioning this fact; this was some years ago. At the 
present time, the writer is pleased to report that 
these tests have been confirmed, in several inde- 
pendent quarters, in this country and in France. It 
is the desire still further to disseminate the knowl- 
edge of this simple treatment that suggested this 
present article. This treatment is particularly ap- 
plicable in cases where the delivery has been recent 
and in which the supply of milk is quickly dimin- 
ished. 

The technic consists in injecting one c. c. of the 
mother's own milk into her subcutaneous tissues, 
under strict asepsis. In two days, repeat, and, if 
necessar}', in five days repeat again. Under ordi- 
nary conditions the results are sure. 

Dr. A. J. Nossman, of Pasoga Springs, Colorado, 
reports the following cases : 

C.\SE I. Atypical case. Primapara, aged thirty-five 
years, in very bad condition. Milk failed on the third day, 
so I had difficulty in obtaining the twenty drops to inject. 
There was a slight chill in twelve hours. The milk came 
in thirty hours. She is, now at nine months, still nursing 
her baby. 

Case II. Milk failed in about two weeks. The injection 
brought on a temporary increase. This patient did not 
want to nurse her baby. 

Case III. Milk failed in three months. Injection nega- 
tive. 

The criticism offered to Doctor Nossman's tech- 
nic is that he did not repeat the injections in the 
two latter cases. Had he done this, it is probable 
that the second patient would have been able to 
nurse her child, and a bare possibility that the third 
one would ; for, as stated above, the treatment is 
particularly indicated in the recently delivered. 

Dr. Harvey D. Morris, of Port Arthur, Texas, 
says: "The injection of mother's milk into herself 
will stimulate the mamman,^ glands when all other 
known methods fail." He reports several cases 
treated successfullv. 



THOMPSOX: MERCURIALIZED SERUMS. 



Dr. Alexander L. Blackwood, of Chicago, author 
of several widely used medical textbooks, and Dr. 
Clement A. Shute, of Pottstown, Penn., and other 
physicians and veterinarians in the United States 
vouch for this treatment. 

R. Becerro, in the Revue de tlicrapeutiqiie medico- 
chirurgicale, reports favorable results in two out of 
three cases, of sudden cessation of milk, "a condi- 
tion before which the practitioner is frequently help- 
less. Dietetic measures, and the administration of 
thyroid and placenta extract, as advised by Her- 
toghe and Bouchacourt, are available where there is 
merely a slow diminution in the milk secretion, but 
of no value where there is a sudden decrease or 
complete cessation of the mammary function." Be- 
cerro recommends twenty c. c. of the milk injected 
subcutaneously. He states : "A single such injec- 
tion in the majority of cases is followed in thirty 
hours by an abundant secretion of milk." The 
writer prefers tlie smaller dose repeated in two days, 
and if necessary again repeated in eight or ten days. 

This treatment should be brought to the attention 
of the cattle raisers, stockmen, farmers, dairymen, 
etc., for if this treatment is judiciously given it will 
insure the animal giving the maximum amount of 
milk of which she is capable. If this can be done 
by the Department of Animal Industry, or the De- 
partment of Agriculture, at Washington, it seems 
that they should look into the subject at once in 
view of the increased price of milk, and the scarcity 
of milk on the continent of Europe. The technic 
suggested by the veterinarians is to inject each cow 
with a half ounce or more of her own milk on the 
third, fifth, and tenth day after delivery. The 
writer suggests that practically every cow be treated 
as indicated to insure her doing her duty toward 
supplying milk. We never know whether a 
cow or other animal is supplying her full quota 
of milk until after the treatment is given. If she is. 
there is no evidence that harm will result, if the 
treatment is judiciously employed. If she is not, 
this treatment, under ordinary conditions, will speed 
up quickly the supply of milk until it reaches 
the maximum capacity. Some animals may not re- 
quire three injections, others may not require two. 
It is the part of wisdom to individualize each ani- 
mal and treat it according to its needs. 

The attention of veterinarians is directed partic- 
ularly to the simple method of treating mastitis 
mentioned in the opening paragraph of this paper, 
and the application of this principle as developed in 
human beings, to highbred animals in the care of 
their young. 

Case IV. Mrs. O., aged thirty-two years ; ten days after 
delivery of her second child, her breasts became flabby 
and the milk was markedly diminished. The child cried 
most of the time when oflF of the breast and sucked its 
fist. The breasts were cleansed with boric acid solution 
and sterile water, and by gentle massage about one c. c. 
was obtained with difficulty in a sterile receptacle. Under 
strict aseptic precautions this was injected subcutaneously 
in the gluteal region. Within twenty-four hours the breasts 
Ijecame so distended that milk dropped freely from both 
nipples. She had no difficulty in nursing her child for 
over six weeks. This patient received two other injections 
in the manner indicated. 

Case V. Patient, aged twenty-eight years; seven days 
after her second child was born, her supply of milk be- 
came greatly diminished. She received two injections, 



two days apart, and as a result nursed her child with no 
further trouble for two months. The child was soon very 
fat. 

It is not proposed in this article to say anything 
about the value of autotherapy because that seems 
to me to be a self evident proposition. What im- 
presses us today is the ever widening scope of its 
therapeutic range, embracing practically all of cura- 
tive medicine and much tliat lies entirely without its 
border. Particularly is this natural galactogogue 
interesting, for the pathogenesis of the condition is 
obscure. It is valuable, not only in relieving the 
condition quickly, but also for the fact that it shows 
how profoiuidly the system may be affected by th'e 
injection of a sexual secretion subcutaneously. 

It is stated by some enthusiastic confreres that 
amniotic fluid injected subcutaneously or taken by 
the mouth acts as a powerful uterine contractor, 
greatly facilitating labor. With this the writer has 
had no experience. 

2612 Broadway. 



Examination of the Abdomen and Tongue in 
the Typhoid Group of Infections. — Leon Mac- 
Aulifte {Paris medical, November 18, 1916) lays 
stress on abdominal distention as an early sign of 
typhoid and paratyphoid infections. The distention 
increases with the fever in the first week and a half 
of the disease ; then, about the twelfth or fourteenth 
day in mild cases, and about the thirtieth day in 
grave cases, the abdomen softens and imparts a 
pasty sensation, which persists up to convalescence. 
The distention is best perceived about the umbilicus, 
the pasty condition in the iliac fossae and flanks. 
The distention is due, not to sudden gas production, 
but to diminished gastrointestinal tonus, while the 
pasty condition arises from infiltration and tumefac- 
tion of the gastrointestinal and parietal tissues, due 
to stasis of blood and lymph in these structures. In 
conjunction with the distention, there exists a state 
of tension or slight rigidity of the abdomen which 
persists for from twenty to forty days. This is 
noted especially in the cecal region, and is practi- 
cally constant at the start of the infection. In the 
second and third weeks this tension is often such as 
to render deep palpation impossible. In threatened 
perforation or hemorrhage, this rigidity becomes 
general. Deep palpation in typhoid reveals the 
cecum and descending colon large, pufTed out, and 
gurgling in the beginning of the disease. At the end 
of the second week the cecum tends to collapse, and 
the descending colon to become smaller and crepi- 
tant ; these conditions become more and more 
marked tmtil the end of the second week. Recovery 
is signalized by a return to regularity of calibre of 
the previously irregular palpable intestines. Ab- 
dominal percussion in typhoid reveals a tendency to 
uniformity of the sound elicited all over the abdo- 
men in the second and third weeks. During recov- 
ery the normal differences in the gastric, cecal, and 
ileal percussion notes return. The appearance of 
the tongue during typhoid varies with the severity 
of the disease. In the more severe cases it exhibits 
evidences of irritation, especially at its tip and in- 
ferior surface. 



Our Readers' Monthly Prize Discussions 

Twenty-Five Dollars Is Awarded for the Most Satisfactory Paper 

All persons, whether subscribers or not, arc invited to compete for the prize of $25 ofFered for the 
reply deemed best by the editors to the following questions : 

CLXXVIl. — How do you treat delirium tremens? (Closed.) 

CLXXVIII. — Ilotv do ynu treat acne vulgaris? (Answers due not later tluin January ij, 1917.) 
CLXXIX. — How do you treat eczema in children? (Answers due not later than February 15, 1917.) 
The award will be based solely on the value of the information contained in the answer. No im- 
portance will be attached to literary style. Answers should preferably contain not more than six hun- 
dred words, and should be written on one side of the paper only. All papers submitted become the 
propert}' of the Journal, and should bear the full name and address of the author for publication. 
The prize will not be awarded to the same person more than once within a year. 

The prise of $35 for the best answer to Question CLXXVI has been award- 
ed to Dr. Robert T. Morris, of New York city, luhosc paper appears belozv. 



PRIZE QUESTION NO. CLXXVI. 

THE TREATMENT OF COLLES'S 

FRACTURE. 

By Robert T. jMorris, M. D., 
New York, 

In Colles's fracture, injury to the soft parts is 
more important than injury to the hard parts. Ergo: 

1. Always anesthetize the patient and make such 
correct adjustment of fragments that soft structures 
within the annular ligament will be freed from com- 
pression or angulation. This idea includes the step 
of freeing the external lateral ligament of the wrist 
when it has been buttonholed by the ulnar styloid 
process. 

2. Apply a very short and light moulded splint of 
cardboard to the posterior aspect of the fragments, 
and a small loose roll of gauze to the anterior aspect 
of the fragments. If this does not suffice to hold 
the fragment nicely in place, add a cardboard splint 
to the anterior aspect after removing the gauze roll. 
If muscle spasm is present in the case, add a light 
long basswood splint to the posterior aspect of the 
fragments, reaching to the knuckles. Without mus- 
cle spasm and without a tendency for the fragment 
to become displaced readily the Colles's fracture pa- 
tient will do best on the smallest and lightest spHnt- 
ing which will suffice for immediate needs in any 
given case. 

3. Suspend the arm at easy elbow flexion in a 
sling. 

4. Extend and flex the fingers very gently once a 
day at first, in order to prevent plastic exudate from 
sealing the tendons in their sheaths, in the vicinity 
of the fracture. Increase the finger motion later. 

5. Extend and flex the hand on the carpus gently 
once a day at first in order to avoid carpal adhesion 
formation. Increase the carpal motion later. 

6. At the end of three weeks remove the splints 
permanently, but retain the sling for another week. 

7. At the end of three weeks excite a Bier's hy- 
peremia daily with the rubber bandage, or excite a 
hyperemia by plunging the hand and wrist alter- 
nately into hot and cold water for five minutes 
morning and night. A hyperemia thus induced will 
favor rapid absorption of interstitial and synovial 
exudates. It will also stimulate activity of injured 
nerves. 

8. Add massage to the hyperemia resource for as 
long a time as appears to be desirable. 



9. Do not swear in a court of law that this is the 
best treatment for Colles's fracture. State that it 
is first rate routine for the average case. 

Dr. F. H. McMeehan, of Avon Lake, Ohio, re- 
marks: 

Colles's fracture is caused either by falls on 
the outstretched hand or by back firing in cranking 
a motor (chaufl:'eur's fracture) or by some other 
direct violence. Colles's fracture is immediately 
suspected from the manner in which the injury has 
been sustained. It is diagnosed by the silver fork 
deformity of the hand and forearm; by palpation 
of the displaced fragment ; by crepitus between the 
ends of the fractured radius ; by pain and swelling 
of the traumatized area. Dubious cases call for 
verification of the diagnosis as a matter of self pro- 
tection. X rays of all cases should be taken as a 
matter of record for compensation in accident and 
industrial insurance. Originals or copies of x ray 
plates should only be submitted to those legally en- 
titled to them and competent to interpret their evi- 
dence. 

If the fracture is of recent occurrence the dis- 
placed fragment may be reduced without difficulty or 
with the aid of anesthesia or analgesia, by the method 
of Chainpionniere. His method of mobilization 
consists in stroking the injured limb in the direction 
of the venous flow and the underlying muscles, so 
lightly at first that pain is not felt even over the 
fracture area. This stroking massage is continu- 
ously applied, in a slow, methodical manner, with 
increasing pressure, for ten to fifteen minutes on 
each aspect of the arm, at the end of which time 
the muscular contractions due to the fracture itself 
and the patient's efifort to hold the limb in a fixed 
position, are so relaxed that frequently the reduc- 
tion occttrs during mobilization, or upon flexing or 
extending the wrist. When reduction cannot be ob- 
tained in this manner or without great pain, anes- 
thesia or analgesia must be utilized. 

While nitrous oxid oxygen anesthesia is the 
method of choice in hospitals and clinics, ethyl 
chlorid anesthesia alone or supplemented by the 
drop method of etherization is preferable for emer- 
gency practice. While the injection of novocaine 
provides sufficient relaxation and obtunding of the 
parts to permit of painless reduction, the use of 
local analgesia involves a slight but definite risk of 
infection. Chloroform anesthesia should never be 



January 6, 1917-] 



OUR READERS' PRIZE DISCUSSIONS. 



used in the reduction of fractures on account of the 
danger of cardiac fibrillation during light or incom- 
plete narcosis. In all cases anesthesia should be 
continued until the operator has delinitely conclud- 
ed that the reduction is satisfactorj-. 

In reducing the displaced fragment in Colles's 
fracture it is necessary and extremely helpful to 
have the patient's forearm and elbow firmly held by 
an assistant. The operator then grasps the patient's 
hand with his opposite hand, making traction in a 
straight line and manipulating the displaced frag- 
ment with the thumb and fingers of the other hand 
until it snaps back into place. Occasionally the frag- 
ment can be more readily reduced by flexing or ex- 
tending the patient's hand on the wrist, depending 
on the direction in which the fragment is displaced. 

The fragment should be so perfectly reduced that 
the bony contour of the radius is restored to normal. 
To assure himself that the reduction is sufficiently 
correct for the restoration of normal function, it is 
not enough to palpate the contour of the bony struc- 
tures involved, but the fracture area must be firmly 
fixed between the thumb and fingers of one hand, 
while with the other the patient's wrist joint is put 
through all the motions of which it is capable. If 
all these motions can be accomplished without a ten- 
dency on the part of the distal fragment to become 
displaced, reduction is as nearly perfect as surgical 
skill permits, and barring a tendency to displace- 
ment of the fragment, a single, posterior retentive 
appliance will suffice. 

The Walker splint in its five sizes (rights and 
lefts), accommodates itself to the retention of the 
fragment and the successful treatment of Colles's 
fracture, better than any other device. Emergency 
splints of Yucca or pasteboard will answer, if 
moulded on the same anatomical lines of the Walk- 
er splint. ■'Vhile the fiat anteroposterior sphnts with 
padding under the wrist and in the palm, may effect 
retention of a fragment that has a tendency to be- 
come displaced, their use prolongs the period of 
treatment and delays the restoration of functional 
utility. 

The Walker splint is covered with a good thick- 
ness of absorbent cotton held in place by several 
turns of gauze bandage. The splint is applied so 
that the fingers get a firm grip on the handle, and 
the flange of the radial side accurately supports the 
fracture area, while the body of the splint extends 
at least two thirds of the distance toward the elbow. 

As a result of some falls or direct violence, a 
Colles's fracture may cause excruciating pain and se- 
vere traumatism and swelling of the adjacent parts. 
In such instances opiates should be administered, 
hypodermically, before instituting any treatment at 
all, so that by the time reduction is accomplished 
and the anesthetic withdrawn, the patient is under 
the influence of the preliminary narcotic, and after 
pain is negligible. Strict attention to this detail is 
deeply appreciated by all patients. 

The swelling due to traumatism should be par- 
tially relieved by the method of Championniere, be- 
fore any dressings are applied. Then a compress, 
consisting of several flat gauze sponges are laid over 
the fracture area, extending down to the flange of 
the splint. This compress is held in place by a 



rather broad strip of adhesive tape carried to the 
under surface of the splint on each side of the wrist, 
but not encircling it. This band of adhesive tape 
serves remarkably well in preventing upward dis- 
placement of the distal fragment. The splint is 
further held in place, midway in the forearm and 
toward the upper end of the splint by similar strips 
of adhesive tape. The compress is now saturated 
with a warm solution of aluminum acetate or opium 
and lead wash, and a one and a half inch gauze 
bandage snugly applied from the hand grip of the 
splint to its upper end. As the bandage is applied 
the compress area is saturated with the antiphlogis- 
tic solution. Only those who have tried these com- 
presses and solutions in the handling of Colles's 
fracture can appreciate to what an extent and with 
what rapidity pain and swelling are controlled and 
reduced. Gauze rather than muslin bandages are 
used not only to facilitate the moistening of the 
compress, but also because they allow aeration and 
are far more comfortable, while being sufficiently 
retentive. The injured arm is now hung in a sling 
that extends to the knuckles and includes the elbow, 
and is so carried for a few days until the swelling 
at the site of fracture is under control. During 
sleep the injured arm should be rested on an in- 
clined pillow. 

If the fracture shows little tendency to the re- 
production of deformity, dressings should be re- 
newed daily. The bandage is removed and the 
hand and forearm washed with soap and water and 
rinsed with alcohol, after which it is dusted with 
talcum powder and mobilized according to the 
method of Championniere. Twenty to thirty min- 
utes should be consumed in this form of massage. 
With the splint reapplied, with or without the com- 
press, depending on the subsidence of pain and swell- 
ing, passive movements are instituted, but they must 
be slow, gentle, and methodical, and include every 
joint in the extremity. The amplitude of these 
movements is governed by the first sign of resist- 
ance on the part of the patient. The wrist' joint, 
especially, must be put through all its motions, the 
amplitude of the motions increasing as resistance de- 
creases. With the Walker splint securely in place, 
the patient may utilize the hand grip for active move- 
ments of the fingers almost immediately, without 
any danger of displacing the distal fragments, and 
the continued suppleness of the fingers will auto- 
matically assist in the resorption of the inflamma- 
tory exudate about the tendon sheaths crossing the 
wrist joint and fracture area, and in the earliest 
restoration of functional activity. Nor must the 
elbow be permitted to become stiff, especially if this 
joint has received part of the traumatism of the fall . 
causing the Colles's fracture. Supination and pron- 
ation of the hand and forearm are the last passive 
and active motions to be instituted. 

Unless there is a marked tendency to displace- 
ment of the fragment, the hand grip portion of the 
Walker splint may be dispensed with after ten days 
or two weeks, the remaining portion being reapplied 
until the end of the third week, after which a leath- 
er wristlet is substituted. 

Treatment must be continuous and unremitting 
until functional utility of the fractured arm has 



26 



OUR READERS' PRIZE DISCUSSIONS. 



[New York 
Medical Journal. 



been completely restored. With the Chanipionniere 
method of mobilization, combined with the use of 
the Walker splint and the other details of treat- 
ment outlined, it may be anticipated that full, func- 
tional utility will be restored after CoUes's fracture, 
for domestic, clerical, and other nonlaborious oc- 
cupations, in four weeks, and occasionally in three; 
for ordinary labor in six weeks ; and for work of 
any kind in two months. 

Dr. Rollin 0. Baker, of Montour Falls, observes: 

To successfully treat Colles's fracture, it is neces- 
sary to accomplish three things : i. Complete reduc- 
tion preferably under general anesthesia or else after 
sufficient moriphine has been given to benumb sensi- 
bilities. 2. Fixation in a dressing making an even 
pressure conforming to the normal contour of the 
forearm especially at the site of fracture. 3. Active 
and passive exercise, massage, and manipulation 
must be instituted early, and as little disability as 
possible allowed to continue during the process of 
repair. 

Reduction: In reducing a fracture the direction 
and application of the force producing it should 
first be considered and then the force applied to re- 
duce should be directed along opposite lines, taking 
into consideration the pull of the muscles. These 
latter however may be disregarded in the reduction 
of Colles's fracture with the exception of the binding 
action of the torn posterior ligaments and perios- 
teum, which tend to keep up the impaction^ of the 
fractured parts. The force producing Colles's frac- 
ture is exerted upward, backward and to the radial 
side upon the pronated and extended hand and wrist. 
Result is upward and backward displacement of the 
fragments, with or without impaction, broadening 
of the wrist and more or less dislocation backward 
and to the radial side, constituting the so called sil- 
ver fork deformity. 

Reduce as follows : Standing to the outer side of 
the arm, grasp it with both hands, backs upward, 
one at the site of fracture with its thumb overlying 
displaced fragments, the other grasping hand and 
wrist below fracture. First hyperextend hand and 
wrist to lessen tension upon posterior ligaments, torn 
periosteum, etc. Continuing extension make strong 
longitudinal traction and forcibly abduct and carry 
hand to ulnar side to reduce lateral dislocation and 
break up impaction. Still keeping up traction 
and abduction, twist and pronate the hand and 
displacement, and continuing same flex hand and 
wrist and carry them forward to reduce backward 
dislocation and displacement. Reduction should al- 
ways be confirmed by the fluoroscope and x ray when 
possible. Complq^ely reduced, there is little or no 
tendency for the deformity to recur. 

Fixation: Use two light splints of box wood, one 
anteriorly, one posteriorly, tapering with and no 
wider than the normal forearm, equal in length, and 
long enough to extend from the bend of the wrist 
(anteriorly) to near the bend of the elbow, but not 
so as to interfere with flexion of either wrist or 
elbow. First make two wedge shaped pads of gauze 
or cotton cloth and secure them to the lower ends 
of the splints. They should extend the entire width 
of splints and taper from about three eighths of an 



inch down to a couple of thicknesses of the material 
used and should be wide enough to extend from 
lower ends of splints to about three fourths of an 
inch above site of fracture. The thick end of the 
pad on anterior splint should be on the ulnar side 
to prevent depression of the lower end of ulna and 
to allow for the greater prominence of the radial 
styloid. That on posterior splint should have its 
thick portion on radial side to allow for the greater 
prominence of the ulnar styloid and to make* pres- 
sure upon the fragments of lower end of radius and 
prevent a recurrence of the deformity. 

Then pad the surface of the splints and pads with 
one half to three fourths inch thickness of cotton, 
making the cotton thicker above the pad on anterior 
splint where it will impinge on depressed surface on 
front of forearm just above the wrist. Then wrap 
splints smoothly with bandage. Splints thus padded, 
should when applied conform to the normal con- 
tour, especially at the site of fracture, and will 
exert an even pressure. Secure them in posi- 
tion with three one inch strips of adhesive plas- 
ter, one binding lower ends, one the middle, and 
one the upper ends of the splints to forearm. They 
must not interfere with flexion of either wrist or 
elbow. Wrap whole with bandage. Pressure 
should not be so great as to cause discomfort. Ad- 
herence to forearm between splints will prevent 
shifting. Allowance should be made for swelling. 
The forearm is carried at right angles, with its an- 
terior surface to body, in a narrow sling pinned to 
under side of dressing just above wrist. The hand 
must be unsupported and free, when it will naturally 
fall into a position of pronation and abduction and 
flexion, its weight making a constant traction pre- 
venting any tendency to recurrence of the deformity. 

Care: Fingers should be moved passively and ac- 
tively from the first. The hand should be massaged 
frequently, and as pain and swelling decrease should 
be passively exercised in flexion and extension. 
Later, in ten days to two weeks, these motions 
should be actively done and also adduction and ab- 
duction be gently passively carried out. 

After twelve to fourteen days, I sometimes apply a 
plaster cast, but I prefer to use the splints through- 
out when the patient can be seen every day or two, 
and upon these occasions I remove the splints, mas- 
sage and manipulate muscles, and gently pronate and 
suppinate wrist. By the time the process of repair 
is complete if the proper care has been given, there 
should be no deformity and very little passive dis- 
ability. Care and judgment in such treatment of 
Colles's fracture will in my opinion greatly lessen the 
number of unfortunate results which have been a 
source of regret to all of us. 

Dr. Edward Adams, of New York, observes: 

The most important factors in the treatment of 
Colles's fracture are: i. To correct the deformity 
by the reduction of the fragments ; 2, to maintain 
them in accurate position until firm union takes 
place. Reduction should be made as soon as pos- 
sible after the injury, and if necessary under an 
anesthetic. The method that I employ for the re- 
duction is as follows : The patient is seated, with 
the injured arm flat upon the table and the wrist 



January 6, 1917. J 



OUR READERS' PRIZE DISCUSSIONS. 



Z? 



slightly flexed over the edge. The doctor is seated 
opposite the patient, and a friend or an assistant 
grasps the injured arm, one hand near the elbow 
joint but below it, and the other hand near the site 
of the fracture. The doctor grasps the injured 
hand as if to shake hands and hyperextends the 
hand. The second movement is to flex the hand, 
making ulnar abduction at the same time. Direct 
pressure is made over the displaced fragment of 
the radius with the thumb and fingers of the sur- 
geon's other hand. By a little gentle manipulation 
the fragments can usually be pushed in place. 

Fixation by splints is best accomplished by means 
of a posterior plaster of Paris splint moulded di- 
rectly to the part. An ordinary plaster of Paris 
bandage about two to two and a half inches in width 
is used for this purpose. This is best put on after 
reduction has taken place and can be removed for 
the first ten days in order to have the aft'ected part 
massaged for that length of time in order to get rid 
of the swelling. At the end of that time the splint 
is applied and left in place for a period of twenty 
days, and passive motion and massage are then 
used. During the entire time of the application of 
the splint, the fingers should be moved as in play- 
ing a piano. Usually at the end of four weeks bony 
union has occurred and no further splint is neces- 
sary. Bier's arterial hyperemia can now be em- 
ployed in the form of baking, as this is of great 
benefit. An x ray picture should be taken at the 
time the reduction is made in order to see that the 
fragments are in good apposition. 

Dr. Thomas S. Cusak, of Brooklyn, mrites: 

CoUes's fracture is a fracture directly across the 
lower end of the radius within three quarters of an 
inch of its articular surface. In young people the 
line of fracture generally runs through the epiphy- 
seal cartilage. The displacement in this fracture 
is classical. The lower fragment is or may be dis- 
placed backwards, but it is usually tilted in that di- 
rection. Owing to the tilting of the lower frag- 
ment of the radius the bones of the carpus are car- 
ried backward, causing a projection on the back of 
the wrist with a corresponding depression anterior- 
ally, with abduction of the hand radially, termed the 
"silver fork deformity." 

Treatment of Colles's fracture consists in : i. Re- 
duction ; 2, immobilization : 3, aftertreatment. 

Reduction: For reduction of Colles's fracture 
primary- anesthesia in the form of ether or chloro- 
form is, to my mind, a very essential prerequisite ; 
then, understanding thoroughly the deformity, re- 
duction is very easy. Clasp the patient's hand in 
your palm, in other words, shake hands with the 
patient, and with the other hand grasp the patient's 
injured hand above the wrist, placing the thumb 
over the displaced fragment, then with the lower 
hand make traction, and with the upper hand make 
countertraction, inclining the hand to the ulnar side 
and at the same time pushing down the displaced 
fragment by the thumb that is upon it. This com- 
bined traction, countertraction, ulnar flexion, and 
pressure on displaced fragment will reduce the frac- 
ture, though at times we may require force to aid 
us in our technic. If deformity is properly re- 



duced then fixation or immobilization can be easily 
accomplished. 

Immobilization: As soon as the fracture is re- 
duced place the hand midway between supination 
and pronation with a little ulnar flexion, supporting 
the injured wrist in the palm of the hand. Apply 
anterior and posterior board splints, each a little 
wider than the arm, with a little cotton wadding 
along the surface of the splint next the skin. The 
anterior splint should extend from the middle third 
of the forearm to the middle of the metacarpal 
bones of the hand; in this manner, the fingers may 
close. The posterior splint should extend from tire 
middle third of the forearm to the carpometacarpal 
articulation. Pad lightly the anterior splint at a 
point corresponding to the upper fragment, and the 
posterior splint thickly, at a point corresponding to 
the lower fragment. Now keep the splints in place 
by three circular strips of adhesive, each two inches 
wide, one at each end, and two in the middle. The 
adhesive is applied in this manner; apply one end 
of each strip to the outer side of anterior splint ; let 
it overlap the inner side, the adhesive surface being 
next the splint. Apply the anterior splint and bring 
the adhesive strips over the outer side. This being 
done, apply the posterior splint, bringing the adhe- 
sive strips down over its outer side, and this com- 
pletes the dressing. This can be reinforced by a 
few rolls of gauze bandages, but not including the 
thumb in this dressing. The advantage of this stage 
of the treatment is that if the dressing is tight, it can 
be loosened very easily, and fingers and wrist have 
a certain amount of free motion, thus overcoming 
any possibility of ankylosis. 

The forearm is flexed upon the arm at right angles 
and placed in a semiprone position in a sling. After 
a day or two I usually have an x ray taken, an an- 
teroposterior, and lateral view. After this if the 
X ray does not show complete reduction, or proper 
alignment, I reduce the fracture further and try to 
secure perfect alignment. If, however, reduction is 
complete and proper alignment is secured, I leave 
the fracture in splints for about a week, at the end 
of which time I am fairly sure of bony union and 
then proceed to the second stage of the treatment. 

At the end of a week I remove the boarded splints 
and use anterior and posterior moulded splints in 
the same way as the boarded splints, keeping the 
hand in ulnar flexion. These moulded splints are 
reinforced by a few turns of a plaster bandage leav- 
ing the thumb free, and supporting the forearm in 
the sling as before, special attention being paid to 
the fact that the splints be not applied too tightly, 
and that the fingers can close. 

After-treatment: The patient ought to be seen 
rather frequently after the moulded splints are ap- 
plied, to see that no complications arise in the shape 
of pressure symptoms, etc. If so, cut down on the 
cast and relieve tension, and reapply again a little 
looser. Keep the wrist in this cast for about two 
weeks, at the same time advising the patient to begin 
passive motion of the fingers and thumb. At the 
end of the two weeks cut down on the cast and begin 
passive motion and massage of the wrist. This can 
be done almost everv' day for a week, at the end of 
which time the cast can be removed entirely, and the 



28 



ABSTRACTS AND REVIEWS. 



[New York 
Medical Journal. 



patient begin active flexion and extension of the 
wrist with caution. Then gradually the patient can 
use the wrist in lifting light articles and work back 
the joint to its normal use. 

{To be concluded.) 

Abstracts and Reviews 



GROWTH CHANGES IN THE MAMMALIAN 

NERVOUS SYSTEM.* 

By Professor Henry H. Donaldson, 

The Wistar Institute of Anatomy and Biology, 

By way of introduction Professor Donaldson said 
that tlie greater part of the studies which he was 
about to report had been carried out on the albino 
rat by his associates and himself. He pointed out 
that there might be some question as to the justifica- 
tion for attempting to transfer these results to the 
growth processes of the nervous system in man. 
There was more justification for such a transfer, 
however, than seemed evident at first glance. Pri- 
marily it had been determined that an albino rat six 
days old corresponded in development to the human 
being at the age of i8o days, and that an adult 
white rat of three years agreed closely with a man 
at ninety years of age. There was a constant ratio 
between their ages, therefore, one day of rat age 
being equivalent to thirty days of human age. In 
studying the growth changes in the albino rat the 
results obtained could be transferred to the human 
animal at a corresponding age period, and such 
transfers had been found to agree extremely closely, 
as would be shown later. 

Growth in the nervous system, as elsewhere, was 
concerned with the number and size of the indi- 
vidual cells, and the size and weight of the organ as a 
whole. In both man and the rat the weight of the brain 
at a given age period varied rather widely in a group 
of brains, although an average might be stated. 
Very careful observations, however, on the nerves 
and brains of adult rats showed that for any given 
portion there was a characteristic number of cells 
and that the variation in a series of animals of the 
same age was very slight. A similar characteristic 
number of cells for a given portion was demon- 
strated for each of several age periods before ma- 
turity in the rat. The same facts were observed to 
be true of the human species at different age peri- 
ods. It was found, further, that the characteristic 
number of cells remained constant for a given age 
irrespective of the weight of the brain, that is, that 
the number of cells was not related to the size of 
the structure. The cells here dealt with were the 
neurons, which were regarded as the units of which 
the nervous system is composed. 

Using these facts observations could be made 
upon the growth changes of the mammalian nervous 
system which would have considerable claim to ac- 
curacy. In the white rat at birth cell division in the 
brain was going on actively, and while there was a 
characteristic number of cells present for a given 
age this number was less than was found in the 

•Summary of a lecture delivered before the Harvey Society at 
the Academy of Medicine, New York, December i6. 1916. 



adult, or after multiplication had ceased. It had 
been found that this multiplication of neurons con- 
tinued active for several days, then began to decline 
and by about fourteen days had ceased, at which 
time the number of cells present was that charac- 
teristic for the adult. Along with the multiplica- 
tion of the cells in the cerebrum, which at birth oc- 
cupied the outer zone, there was a migration of the 
cells inward, so that at the end of the period of 
multiplication all of these cells occupied an inner 
zone characteristic of the adult brain. 

When the stage of cell multiplication had been 
completed, that is, at about the fourteenth day of 
life in the rat, the animal had already acquired 
fairly well developed powers of locomotion. In the 
human being parallel observations showed a parallel 
in development which was strikingly close. Thus, 
the child was found to have acquired very fair 
powers of locomotion by the fourteenth month of 
life, which corresponded to the fourteenth day of 
rat life and development, as already mentioned. At 
the fourteenth month in man the multiplication of 
cells in the nervous system had just ceased, which 
made the parallelism the closer. 

At the time when cell multiplication had ceased — 
in the rat the fourteenth day, and in man the four- 
teenth month — the brain was not as heavy or as 
large as at maturity by about sixty per cent. Since 
there was to be no further increase in the number 
of the cells the subsequent gains in weight and vol- 
ume had to be accounted for on the basis of an in- 
crease in the size of the cells. A study of the curve 
of weight increase of the human brain showed that 
the increase was very rapid in the first years of life 
and reached its maximum between the ages of seven 
and ten years. The increase continued at a slower 
rate from then to about the fifteenth year, at which 
time the brain reached the full adult weight. The 
usual curves presented for the course of the changes 
in the weight of the human brain showed that after 
reaching its maximum at the age of fifteen years it 
steadily declined in weight, although very slowly, 
until the age of fifty years. Such curves were 
thought to be incorrect in showing a decline in brain 
weight before about the fiftieth year. The error 
arose from the failure to recognize the fact that the 
weight of the brain is very easily aiifected by the 
fatal disease, the more so if it were chronic. Study 
of the brain weights of organs removed from per- 
sons who had met almost instantaneous accidental 
death showed that the curve should remain flat be- 
tween the fifteenth and fiftieth years of age. After 
the end of that period there was an actual slow de- 
cline in weight due to the inception of senile 
changes. These observations, including the influ- 
ence of disease on the weight of the brain, were con- 
firmed by careful observations on the white rat. 

The cortex of the brain was found to reach its 
maximum thickness in the rat by the fifteenth day 
and in the man by the fifteenth month. From then 
until maturity, however, while retaining its thick- 
ness unchanged it increased sixty per cent, in area. 
This was accomplished by the growth in size of the 
individual cells. 

The growth changes dealt with concerned the 
anatomical features alone, but along with the ana- 



Januarj* 6, 191 7.] 



CONTEMPORARY COMMENT. 



29 



toniical changes there went certain changes in the 
chemical constitution of the brain and nervous sys- 
tem. Thus the brains of both rat and man were 
found to lose water from birth onward. This loss 
of water continued in tlie rat through the first forty- 
days, at the end of which time it had reached its 
maximum. The maximum was reached in man be- 
tween three and three and a half years of age. Syn- 
chronously with the loss of water there was an in- 
crease in the myelin substance of the cells, that is, 
of their sheaths. The cell bodies themselves, how- 
ever, did not lose water. The accumulation of 
myelin, although producing a loss of water in the 
total brain, led to an increase in its size and weight. 

The results of these studies on the growth changes 
in the nervous system and their bearing in man 
were stated as follows : At birth cell division is pro- 
gressing. This division is completed by about the 
fourteenth month of life. From then to the fif- 
teenth year the brain and nervous system grow in 
bulk and weight, lose water, and accumulate mye- 
lin. By the time of the completion of the multipli- 
cation of the cells the power of locomotion has be- 
come manifest, but it is very imperfect and is but 
a model of what will later be developed. At this 
stage fatigue is very easily induced. At this period, 
too, some of the cells have reached a stage of devel- 
opment in advance of the rest, and from this time 
on to brain maturity the remainder of the cells ac- 
quire their full development with the perfection of 
function and an increase in the ability to resist 
fatigue. 

During the growth and developmental periods the 
cytoplasm of the cells grows more rapidly than their 
nuclei. Long after the cell bodies have reached 
their full growth their axons continue to grow and 
the myelin sheaths increase to four times their orig- 
inal size. After full growth is reached, that is, 
after cell division has been completed, the size and 
weight of the brain continues to increase, due to al- 
terations in the chemical constituents. After the 
maximum weight is reached it remains constant un- 
til about the fiftieth year of age, after which senile 
changes begin to make their appearance with a slow 
decline in the brain weight. During adult life the 
weight of the brain may be readily influenced by the 
occurrence of disease, the influence being greater in 
chronic than in acute diseases. This influence has 
led to the erroneous belief that the brain weight 
steadily decreases after it has once attained its max- 
imum. 

Contemporary Comment 

Read the Journals. — This is distinctly the era 
of periodical literature. Some people read books, 
and books will always be read, but the busy man 
will read ten times as much periodical literature as 
he will read books. This is true also of the pro- 
fessions, especially of the medical profession. What 
busy doctor, with the incessant demands upon him 
and interruptions to which he is constantly subject- 
ed, can take the time to pore over the cumbersome 
books that are written upon the hundreds of sub- 
jects of interest to the profession? The physician 



must keep up, and about all that he can do is to 
read the brief discussions that are found in the med- 
ical journals, referring to the big textbooks only 
when he finds that a necessity. Whether this is 
best or not need not be discussed, but it is true that 
it is the almost universal custom among successful 
physicians to try to keep up with the current prob- 
lems as set forth in the periodicals, and they are 
forced to do this almost to the exclusion of the 
book discussions. Of course, a few physicians 
do not read much of anything, but they are a negli- 
gible quantity so far as professional progress goes. 

Another reason why the periodical has become 
so popular, observes the Texas Medical Journal fo'r 
November, 1916, is that many diseases become prev- 
alent and then subside before books treating of them 
can be published. A few months ago the whole 
country was wrought up over infantile paralysis, 
and there was great fear that it would spread all 
over America, but it appears to have been checked 
almost as quickly as it came. The journals of the 
country discussed it freely then, but books on the 
subject are still in the making. The great advan- 
tage of the periodical is that it handles issues while 
they are alive, and handles them in such a pointed 
way that the busy practitioner has the time to keep 
informed. The physician or surgeon who boasts 
that he hasn't the time to read medical journals is 
boasting of his lack of information upon the things 
in his profession which every one should know. 

Those Were Happy Days. — The editor of the 
Buffalo Medical Journal, in his December, 1916, 
issue, writes ironically of tempus actum. He says, 
days were happy when the doctor could shake his 
head sadly and murmur that there was nothing to be 
done — and do so with a clear conscience. 

When almost any well informed physician could, 
in his spare time, do research work that deserved re- 
spectful consideration. 

When almost any group of seven physicians could 
hire a building and start a medical college that would 
pay expenses and even salaries. 

When social position, a little money, and an ag- 
gressive disposition would not only secure a large 
practice but professional prestige. 

When almost any practitioner could speak patro- 
nizingly and sceptically of germs and bacteriologists. 

When we could sit on the branch of preventable 
diseases, saw away on it, on the side nearer the 
trunk, have a sense of personal righteousness, and, 
at the same time, the comfortable economic assur- 
ance that it would be a long, long time before we 
produced any weakness of our support. 

When the quack traveled with a tent, a band, and 
a ventriloquist's outfit, instead of having a college 
degree and a better x ray equipment than our own. 

When a doctor could make more of an impression 
with a $350 horse and buggy than he can now with 
an $800 automobile. 

When the boy who restrained his impatience to 
study medicine till he had done three years' high 
school work, could feel that he had voluntarily made 
a heavy sacrifice to the cause of educational pre- 
paredness. 

When internships were frankly stated to go, like 
kisses, by favor and not according to merit. 



Editorial Notes and Comments 



NEW YORK MEDICAL JOURNAL 



INCORPORATING THE 



Philadelphia Medical Journal 
and The Medical News 

A Weekly Re'vieiv of Medicine 



EDITORS 

CHARLES E. de M.SAJOUS, M.D.,LL. D.,Sc. D 
CLAUDE L WHEELER, A. B., M. D. 

Address all communications to 

A. R. ELLIOTT PUBLISHING COMPANY, 

Publishers, 

66 West Broadway, New York. 



Subscription Price : 

Under Domestic Postage, $5; Foreign Postage, $7; Single 

copies, fifteen cents. 

Remittances should be made by New York Exchange, 
post office or express money order, payable to the 
A. R. Elliott Publishing Co., or by registered mail, as the 
publishers are not responsible for money sent by unregis- 
tered mail. 



Entered at the Post Office at New York and admitted for transporta- 
tion through the mail as second class matter. 



Cable Address, Medjour, New York. 



NEW YORK, SATURDAY, JANUARY 6, 1917. 



CLAUDE LAMONT WHEELER. 

With the closing of the year Claude Lamont 
Wheeler, for fourteen years on the editorial staff 
and for the past five years junior editor of the 
Journal, passed to his rest. With regard to his 
ability as an editor, the Journ.\l itself supplies the 
best evidence. 

He was a man of striking physique and com- 
manding appearance, and was endowed with many 
qualities which endeared him to those with whom 
he worked. He possessed a keen and subtle wit 
which, however, was always tempered with kind- 
liness, and he always showed unfailing courtesy to 
all with whom he came into contact and especially 
to the members of the staif, each of whom feels in 
his death a deep sense of personal loss. 

Carefully trained by Dr. Frank P. Foster, the 
dean of medical journalists, and intimately associ- 
ated in his work on the Journal with the brilliant 
and scholarly Kenneth W. Millican, who recently 
died in London while associate editor of the Lancet, 
and with the present senior editor. Doctor Wheeler 
ably performed his part in the perpetuation of those 
ideals and traditions which have for the past forty 
years maintained for the New York Medical 
Journal a unique place in medical journalism. 



SUNLIGHT AND TUBERCULOSIS. 

It is undoubtedly true that physicians do not pay 
deserved attention to sunlight as a therapeutic agent. 
Its disinfecting properties and its vitalizing activity 
are theoretically recognized, but advantage is not 
sufficiently taken of them in actual practice. With 
the increasing role assumed by svmlight in the treat- 
ment of tuberculosis, it is worth while for the gen- 
eral practitioner to take to heart the lesson to be 
learned. In nonpulmonary tuberculosis particularly 
has heliotherapy won a richly deserved position as a 
powerful remedial agent. 

Among a number of communications recently on 
this topic is one of practical interest by C. F. Gar- 
diner (Interstate Medical Journal, July, 1916), de- 
scribing the use of sunlight in Colorado, chiefly in 
the treatment of tuberculosis. He points out the 
advantage of a fairly high altitude such as 5,000 to 
6,000 feet, because the actinic rays are not absorbed 
by the denser and more humid air of lower eleva- 
tions. A large proportion of clear sunny days is 
also a desideratum. Gardiner states that the heat 
rays serve their therapeutic fimction by bronzing 
the skin, in this process causing first a superficial 
congestion with definite nervous and circulatory re- 
flexes whicli affect the metabolism and benefit the 
entire body. The white skin reflects the chemical 
or actinic rays, but after tanning or bronzing by the 
heat rays, the actinic rays are absorbed and have an 
additional beneficial effect on the tissues. It may 
be said that opinion dift'ers as to how these various 
elements of simlight act and the subject is a feiiile 
field for investigation ; but it is abundantly demon- 
strated that good clinical results are obtained. 

Gardiner believes that the brilliant results ob- 
tained by the use of sunlight in surgical tuberculosis 
should not obscure the possibility of securing bene- 
fit also in pulmonary tuberculosis, although in the 
presence of fever especially the utmost caution is 
requisite. The cases must be selected, carefully 
watched, and the regime long continued and care- 
fully graduated. He describes cases of pulmonary 
tuberculosis which under such controlled conditions 
have experienced decided benefit. 

With the progress of exact therapeutic knowl- 
edge, sunlight is being found of increasing impor- 
tance in medicine, and the sun is to be recognized 
not only as a tremendous source of potential phys- 
ical energy, but also as a tremendous potential 
source of health. The physician must make this 
potential source actual. 



EDITORIAL ARTICLES. 



3^ 



THE PRACTITIONER AND THE LABOR.\- 
TORY. 

Although the clinical laboratory- has many prob- 
lems of technical nature to solve, not one of them is 
so difficult as the problem of the uninformed prac- 
titioner. In many instances the laboratory worker 
is looked upon in the same light as a post office ex- 
pert or a Scotland Yard detective ; an authority by 
whom unanswerable questions are answered or un- 
decipherable ciphers are translated. The unfortu- 
nate technician is called upon to perform miracles. 
He is given little or no information concerning the 
case, but if he does not make a diagnosis, outline the 
treatment, and give a prognosis, his intelligence is 
considered distinctly below par. 

It would be a most excellent thing if the profes- 
sion at large could be taught, qjearly and plainly, the 
limitations as well as the capabilities of the labora- 
tory. It is common knowledge that there are many 
tests that to all intents and purposes are mathemat- 
ical in performance and results. Yet there is a large 
number in which many facts must be correlated be- 
fore a decision can be given, and even then the lab- 
orator\' finding should be considered merely a link 
in the chain. 

There is probably no branch of laboratory- work 
that requires more care in the interpretation of re- 
sults than serology-. Much depends upon the skill of 
the technician and in equal degree upon the ability of 
the physician to appreciate the relative value of the 
laboratory reports. A negative Wassermann is ob- 
tained from the serum of a patient who has distinct 
nervous symptoms, and the laboratory as well as the 
reaction is damned. A similar test of the spinal 
fluid might have cleared up the situation ; or, what 
may be worse, the patient is not treated for syphilis 
because the Wassermann is negative. 

It is the same in other laboratory branches. One 
is given a tonsil, is asked to isolate the particular 
organism that is causing the trouble, and then make 
a vaccine. Incidentally full instructions as to the 
dose are asked and a guarantee of a cure. As a 
rule the work is expected to be done inside of 
twenty-four hours. 

The roentgenologist, also, suffers from the same 
troubles. A negative finding is given commonly just 
as much weight as a positive. If nothing is found 
to substantiate the physician's preconceived idea the 
roentgenologist is incapable ; or else complete faith 
is placed upon the result and the patient goes un- 
treated. 

From the point of view of the laboratory there is 
a large and serious hiatus in medical education, both 
of the past and of the present. It may appear very 
flattering to be looked upon by some as almost om- 



niscient ; but it is far from pleasant to be considered 
by others as lacking in the ordinary attributes of 
human intelligence. Most men would prefer more 
of a medium position, and to that end one labora- 
tory worker puts in a plea for better instruction re- 
garding the correlation of the laboratory with the 
practice of medicine. The former should be con- 
sidered as a valuable adjunct, but not as an infalli- 
ble court of last appeal. 



THE FIRST DESCRIPTION. 

We are obliged to Doctor Jelliflfe for calling our 
attention to our inaccuracy in stating that polio- 
myelitis was "hardly known before 1840." We had 
in mind the statement introductory to every essay 
we have seen on the subject, that the disease was 
"first described" by Heine in that year. Although 
we fortified our own remark by the conveniently 
indefinite adjective "hardly," we ought, from gen- 
eral knowledge, to have guessed that it was not only 
known but described long before. Tracing such 
matters of first description is not unlike hunting for 
a needle in a haystack. Underwood (1784) considers 
that he was giving the earliest description, although 
such was by no means the case. 

Our modem indexes and bibliographies in 
part prevent the repetition of these errors of 
chronology and spare the repetition of experimental 
work which has been already well done. Much 
has been lost, however, that must now be repeated 
with great inconvenience and much unnecessarj' 
puffing up of the discoverer of something or other 
long since known and forgotten. Recently some 
investigators went to much pains to prove that the 
urine does not under normal conditions back 
up from the overfilled bladder into the ureters — in 
fact, cannot be forced into them. Th^y were re- 
peating an experiment of Galen, but not for the 
purpose of confirming his findings, since they little 
knew it had been done so long ago ; nor would they 
have credited the Greeks with so much experi- 
mental research. After describing an experiment 
on the living animal to show that the urine enters 
the bladder by way of the ureters, Galen in his work 
on The Natural Faculties continues: "Before the 
animal urinates if one ties a ligature round the penis 
and then squeezes the bladder all over . . . noth- 
ing goes back from the bladder into the kidneys." 

Some of us are distressingly jealous lest we will 
not be given due credit for the priority of our sup- 
posed discoveries, and great and time wasting con- 
troversies have been carried on to establish such 
points even for the deceased. What matters it? 
Especially when we may be only rediscovering some- 



32 



EDITORIAL ARTICLES. 



(New York 
Medical Journal. 



thing long ago forgotten, and which will be as 
promptly forgotten again before many moons ? Be- 
sides, all discoveries depend on the work of those 
who go before us and are not so much ours, as they 
are of our age, which makes them possible. 

Nothing takes more of the conceit out of the stu- 
dent of medicine, nor puts more of wisdom into his 
head than the study of the history of medicine, not 
from books or lectures on the subject, but by com- 
ing face to face with the men and medicine of the 
past in their own writings. There may be much to 
smile at, but there is more to arouse our admira- 
tion, to quell our pride in twentieth century wis- 
dom, and to keep us adequately conservative in our 
views. 



CRITICAL POINTS IN A NEUROTIC'S LIFE. 

We all understand fairly well what we mean 
when we speak of a patient as neurotic or neuro- 
pathic. Every doctor has a number of such cases 
on his visiting list and also has the frequent experi- 
ence of cases coming from other doctors to him, 
temporizing with him a little while, and then flitting 
on to another doctor. But when we try to say just 
what the etiology of such cases is and what precau- 
tions we should take to keep them from developing 
serious psychoneuroses or even psychoses, we are 
more at sea. In recent years, however, a great light 
has been thrown on the whole subject by Freud and 
his school. To be sure, he has ardent detractors, 
some of whom go so far as to deny the new psychol- 
ogy any merit whatever. Even those who cannot 
accept psychanalysis in toto are usually willing to 
admit that there is enough truth in it to repay fur- 
ther investigation. 

Besides the disciples of Freud, who, so to speak, 
worship at his shrine, there are others who, starting 
out under his leadership, have gradually developed 
schools of their own, differing from Freudism in 
many fundamental ways. Thus we have Alfred 
Adler, who gives us a theory of the neurotic consti- 
tution based on organic inferiority and overcompen- 
sation through the central nervous system. Not to 
go too deeply into his theory — and indeed it cannot 
be stated succinctly enough to be quoted here — it is 
interesting to the general practitioner to learn that 
there are certain epochs in the life of a neurotically 
predisposed patient when he (or more usually, she) 
is especially liable to develop a neurosis or a psycho- 
sis. He names ten s«ch epochs, as follows: The 
desire for sexual knowledge, the onset of menstrua- 
tion, the epoch of menstrual activity, the epoch of 
sexual activity, the selection of a spouse, pregnancy, 
the puerperal state, the climacteric, the choice of a 
^■ocation, and the danger of death. 

Whether we are inclined to agree with Janet, with 



Freud, Jung, Adler, Ferenczi, Stekel, or any other 
of the psychopathologists who have investigated the 
hysteric from the analytic and genetic viewpoint, or 
whether we are inclined to call such a patient merely 
"nervous" and treat her with ammoniated valerian 
and suggestion, at least it is valuable to know that 
there are definite periods in her life when she is pre- 
disposed to the outbreak of grave disorders, so that 
we can protect her, so far as it is in our power, from 
exciting or precipitating causes at those times. 



VENEREAL DISEASE IN CHRISTIANIA. 

It is perhaps too much to hope, for the immediate 
future anyway, that our country will adopt any sys- 
tem of compulsory notification of venereal disease. 
Perhaps in time a city here and there will adopt it, 
and upon its success in such progressive communi- 
ties will depend its extension to the nation at large. 
If some enthusiasts will brand us as ultraconser\-a- 
tive in this matter, at least we have the support of 
the chief European powers in our attitude. Here 
and there, however, throughout the civilized world, 
countries are beginning to adopt measures looking 
to the safeguarding of their citizens from these in- 
sidious and prevalent dangers. Frequently we find 
the progressive offspring of a conserv'ative parent 
welcoming such public health measures, as witness 
Australia. Then, to jump nearly the length of the 
globe, there is Christiania, which has been reporting 
venereal diseases since 1876. 

In the report of the medical officer of health, Dr. 
Yngvar Ustvedt, for 1915, there are reported 2,424 
new cases of venereal disease. This is more than 
twice as many as were reported in 1876, but since 
that year the population of Christiania has more 
than tripled. In other words, the percentage of ve- 
nereal disease to the population had fallen from 1.28 
to .96. The percentage of syphilis itself has fallen 
from .53 to .25 per cent. It is not probable, from 
what we know of lues, that these figures represent 
an actual decrease in the prevalence of the disease. 
It is more likely that with the advent of the Was- 
sermann reaction and other diagnostic refinements 
many cases were definitely decided not to be syphi- 
lis, but chancroid or some skin disease. The day 
has gone by, we hope never to return, when the 
medical student learned two kinds of skin disease, 
eczema and syphilis, and every case was certain to 
be either one or the other. 

Doctor Ustvedt's report mentions that during the 
year seven women were convicted in the courts of 
knowingly exposing others to the infection. It does 
not mention how many men were brought to trial 
who were directly responsible for complete hys- 
terectomies. 



January 6, 1917.] 



OBITUARY. 



33 



Obituary 



CL.A.UDE LAMONT WHEELER, A.B., M. D., 
of New York. 

On Saturday morning, December 30, 1916, Dr. 
Cl.-\ude L.\mont Wheeler, editor of tlTe New 
York Medic.xl Journ.\l, died of bronchopneumonia 
at his residence, 418 East Sixteenth street, Brooklyn, 
in his fifty-third year. 

Doctor Wheeler was the son of Dr. Thomas 
Brown Wheeler, of 
Montreal, and a 
nephew of William 
Wheeler, a former 
Governor of the 
State of Rhode 
Island. He was 
born in Montreal on 
March 5, 1864, was 
educated in the pub- 
lic schools of that 
city, and took the 
degree of Bachelor 
of Arts at Laval 
University in Que- 
bec. He was grad- 
uated in medicine 
from McGill Uni- 
versity, Montreal, 
in 1889 and served 
as intern in the 
Royal Victoria 
Hospital in that 
city. He practised 
medicine for a short 
time in Burlington, 
Vt., and twenty-six 
years ago came to 
New York city, 
where he serv^ed in 
the Manhattan Eye 
and Ear Hospital 
and in the New 
York Polyclinic 
Hospital. •Later he 
engaged in private 
practice, specializ- 
ing in ophthalmol- 
ogy. In 1902 he 
joined the editorial 
staff of the New 
York Medical 

Journal as an assistant editor, and on the death of 
Dr. Frank P. Foster in 191 1 became editor, with Dr. 
Charles E. de M. Sajous, of Philadelphia, as super- 
vising editor. Doctor Wheeler was an accomplished 
Unguist, speaking French with remarkable fluency 
and having an unusual knowledge of Latin and 
Greek, which was most useful in his editorial work. 
He also had a fair knowledge of German, Italian, 
and Spanish. 

Doctor Wheeler was a man of fine presence and 
charming manners, which won for him many friends 
both in and out of the medical profession. He was 
a member of the Players' Club, the British Schools 




and Universities Club, and the Canadian Society 
of New York, in both of which he had been an 
officer; the Fendsoplis Club, of which he was presi- 
dent ; the Hospital Graduates' Club, the Loyal 
Legion, the Masonic Order, the McGill Graduates 
Club of New York, and the American Medical Edi- 
tors' Association, and was a Fellow of the American 
College of Physicians. 

Notwithstanding the strenuous nature of the tasks 
which he performed in his editorial work, Doctor 
Wheeler found time to keep in touch with current 
literature, and had a 
cultivated and dis- 
criminating taste in 
literary matters. He 
was particularly fond 
of poetry and famil- 
iar with the works 
of the modern as 
well as the classic 
poets. His literary 
taste found expres- 
sion in the series of 
interclinical notes 
wliich have been an 
interesting featuire 
of the New York 
Medical Journal 
for many years 
under this title and 
earlier under that of 
M e d i c o 1 i t erary 
Notes. These notes 
gave opportunity for 
the play of the facile 
wit and delicate hu- 
mor which were so 
characteristic of his 
writings. His artis- 
tic temperament like- 
wise found expres- 
sion in music, as he 
was an accomplished 
pianist and had a 
well trained voice of 
great beauty and vol- 
ume. 

Doctor Wheeler 
had been a sufiferer 
from bronchial asth- 
ma for several years 
and about a year ago 
his general health be- 
gan to fail. He continued in the active discharge 
of his duties, however, up to within a week of his 
death, when an attack of acute indigestion was fol- 
lowed by bronchopneumonia, under which he grad- 
ually sank, dying early Saturday morning. 

The funeral services were conducted at his late 
residence on Sunday afternoon, December 31st, a 
distinguished company being present, including rep- 
resentatives of the various organizations to which he 
belonged. The body was buried in the family plot 
in Montreal. Doctor Wheeler is survived by his 
widow, a young daughter, and a sister, Miss Annie 
Wheeler, of Montreal. 



34 



NEIVS ITEMS. 



[New York 
Medical Journal. 



WENDELL REBER, M. U., F. A. C. S., 

of Philadclpliia. 

One of Philadelphia's most distinguished ophthal- 
mologists, Dr. Wendell Reber, passed away on De- 
cember 30th from i)neumonia, contracted while at- 
tending the annual meeting at Memphis, Tcnn., of 
the American Academy of Ophthalmology and Oto- 
laryngology, of which he was a former president. 

Doctor Reber was born in St. Louis, April 3, 
1867. He was a graduate of the medical depart- 
ment of Washington University, St. Louis, class of 
1889, and of Jefferson Medical College, class of 1893. 
After serving a year as hospital intern, he began 
practice in Philadelphia, where he has been located 
for the last twenty years. He became professor of 
ophthalmology in the Temple University Medical 
School, and visiting ophthalmologist for the Samar- 
itan, Garretson, Polyclinic, and Philadelphia Gen- 
eral hospitals. He was also professor of ophthal- 
mology at the Philadelphia Polyclinic Post Gradu- 
ate School, and consulting ophthalmologist to the 
State Flospital for the Insane, Norristown, and to 
the Friends' Asylum, Frankford. 

Doctor Reber was the American representative on 
the council of the Ophthalmological Congress, at 
Oxford, England. He was ex-president of the Phil- 
adelphia Clinical Association, a member of the 
Philadelphia County Medical Society, the Pennsyl- 
vania State Medical Society, the American Medical 
Association, the Philadelphia Medical Club, and a 
fellow of the American College of Surgeons. 

Among his very large circle of friends Doctor 
Reber was universally esteemed for his charm of 
character and goodness of heart. To his profes- 
sional colleagues he had endeared himself for his 
unfailing devotion and scientific acumen. Doctor 
Reber is survived bv his widow. 



PAUL M. PILCHER, M. D., F. A. C. S., 
of Brooklyn, N. Y. 
Dr. Paul M. Pilcher, a son of Dr. Lewis S. 
Pilcher, died at his home, 405 Grand Avenue, 
Brooklyn, on Thursday, January 4th, of pneumonia. 
Doctor Pilcher, who, with his brother. Dr. James 
T. Pilcher, conducted a private hospital, occupied 
a front rank among Brooklyn surgeons. He was 
born in Brooklyn in 1876, and received his early 
education in the Polytechnic Institute. He was 
graduated from the College of Physicians and Sur- 
geons (Columbia University), and studied at the 
universities of Michigan, Berlin, and Vienna. He 
was a Fellow of the American Medical Associa- 
tion, and of the American College of Surgeons, and 
a member of the American Urological Society, of 
the Brooklyn Gynecological Society and of the 
Pathological Society. 

News Items 



Changes of Address.— Dr. F. William Stechmann, to 
147 East Eighteenth Street, New York. 

Dr. James T. Fisher, to 1012 Brockman Building, Los 
Angeles, California. 

Dr. Henry W. Berg and Dr. Albert A. Berg, to 10 
Fast Seventy-third Street, New York. 



Harvey Society Lectures. — The fifth lecture of the 
series will be given at the New York Academy of 
Medicine, Saturday evening, January 13th, by Professor 
v.. V. McCollum, of the University of Wisconsin, his 
subject being The Supplementary Dietary Relationships 
Among Our Natural Foodstufifs. 

Efficiency and Inefficiency. — At a stated meeting of 
the New York Academy of Medicine, held in Hosack 
Hall, Thursday evening, January 4th, Dr. Pearce Bailey 
read a paper on Efficiency and Inefficiency as a Medi- 
cal Problem, which was discussed by Dr. Lee K. Fran- 
kel, Dr. Charles L. Dana, Dr. Stewart Paton, and Dr. 
Thomas G. Salmon. 

Meetings of Medical Societies to Be Held in Phila- 
delphia during the Coming Week. — Monday, January 
8th, Samaritan Hospital Medical Society, Academy of 
Surgery; Tuesday, January 9th, Aid Association of the 
County Medical Society (directors), Pediatric Society; 
Wednesday, January loth. County Medical Society; 
Thursday, January nth. Polyclinic Ophthalmic Society, 
Pathological Society, Medical Examiners' Association; 
Friday, January 12th, Psychiatric Society, Northern 
Medical Association. 

Philadelphia County Medical Society. — At the annual 
meeting of the West Branch of this society, held on 
December 19th, Dr. Samuel McClary was elected vice- 
president of the county society. Dr. John Welsh Cros- 
key was elected chairman, and Dr. J. Morton Boice, 
clerk. The Southeast Branch of the society recently 
elected officers as follows, to serve for the year 1917: 
Chairman, Dr. Charles Mazer; chairman of committee 
on scientific program, Dr. M. Ginsburg; vice-president 
of the county society. Dr. Aaron Brav. 

Eastern Medical Society. — A special meeting of this 
society will be held at the Hotel Brevoort, Monday 
evening, January 8th, at 8:15 o'clock. The purpose of 
the meeting is the consideration of the medical pro- 
visions of the proposed health insurance act and action 
on certain resolutions relating to a measure providing 
for compulsory health insurance which will be intro- 
duced at the next session of the legislature of the State 
of New York. Dr. Alexander Lambert, Dr. Sigmund 
S. Goldwater, Dr. John B. AndreAvs, and Professor J. B. 
Chamberlain have been invited to address the meeting, 
and there will be a general discussion. 

Annual Dinner of Women's Medical College Alumnae. 
— The alumna; of the Women's Medical College of the 
New York Infirmary for Women and Children will have 
a reunion dinner at the Hotel McAlpin. New York 
city, Monday evening, June 4, 1917. This date has been 
chosen as convenient for those physicians who wish to 
attend the meeting of the American Medical Associa- 
tion, which will be held in New York during that week. 
An effort has been made by the class secretaries to 
reach every graduate and those physician* who were 
students in the college at the time of its closing, but 
some addresses are lacking. Consequently, every 
alumnus not otherwise notified is asked to consider 
this item her invitation and for further information to 
write to the secretary, Dr. Ethel D. Brown, 26 Gramercy 
Park, New York. 

The Ear in Diagnosis. — .\t a meeting of the Section 
in Otology of the New York Academy of Medicine, to 
be held on Friday evening, January 12th, the program 
will consist of a symposium on the ear in relation to 
medical and surgical diagnosis. Dr. Isaac M. Jones, of 
Philadelphia, will read, by invitation, a paper on the 
Practical Application of Recent Work on the Internal 
Ear; Dr. Lewis K. Fisher, of Philadelphia, will read, by 
invitation, a paper on Vertigo; Its Causes and Methods 
of Diagnosis by Ear Tests. Dr. B. Alexander Randall, 
of Philadelphia, will open the discussion, and among 
those who will take part in the discussion are Dr. 
Charles A. Elsberg, Dr. Frederick Tilney, Dr. Arnold 
Knapp, and Dr. Isadore Freisner. The papers will be 
illustrated with motion pictures showing the normal 
vestibular reactions and also the variations from the 
normal as found in a series of cases where diagnosis 
was confirmed by subsequent operation, 



Modern Treatment and Preventive Medicine 

A Compendium of Therapeutics and Prophylaxis, Original and Adapted 



SODIUM BICARBONATE IN GASTRO- 
INTESTINAL DISORDERS. 
By Louis T. de ^L Sajous, B. S., M. D., 

Philadelphia. 

Few drugs retain so completely the confidence of 
the practitioner for the rehef of certain definite 
croups of cases as does sodium bicarbonate. Hu- 
chard and Fiessinger, planning a small therapeutic 
handbook entitled La Thcrapeiitiqtie en Vingt Me- 
diccmcnts, in which twenty drugs were to do serv- 
ice in the whole gamut of internal disorders requir- 
ing medical treatment, did not hesitate to include 
this agent, along with the true specific remedies, and 
devoted a lengthy chapter to the indications for its 
use and modes of administration. Uncertainty is 
still at times manifest as to some of the details of 
its pharmacological action in gastrointestinal affec- 
tions, and in our discussion of its uses, a brief con- 
sideration of the chemical and physiological changes 
underlying its effects will be considered. 

That the initial and chief step in the action of 
sodium bicarbonate consists in its neutralization by 
acids and the liberation from it of carbon dioxide is 
self evident. There is in many instances, however, 
room for doubt as to which of the two results of 
the chemical reaction with acids, neutralization of 
the acid or carbon dioxide production, is the main 
factor in the beneficial effect exerted. The former 
origin of its analgesic action is generally accredited 
ns the actual one, excess of hydrochloric acid being 
supposed to irritate the sensory terminals of the 
gastric mucous membrane, especially when the stom- 
ach is empty, the sodium bicarbonate being added to 
neutralize the irritant. Leon Meunier, however, 
having noticed that in many instances pain is most 
severe when the hydrochloric acid in the stomach is 
at a minimum, and is nevertheless easily relieved by 
the alkali, has ascribed the action of the latter rather 
to the carbon dioxide set free, which gas both he and 
others believe to exert a sedative action on the stom- 
ach. Such a conclusion directs attention to the ad- 
visability, in gastric pain occurring when the amount 
of hydrochloric acid in the stomach is small, of not 
depending upon this acid to liberate the carbon di- 
oxide from the bicarbonate, but administering at the 
same time an organic acid, e. g., tartaric acid, in such 
a way that the two shall react chemically in the 
stomach, and give off the gas at any desired amount 
and rate. 

Meunier discredits sodium bicarbonate for inter- 
fering with gastric and pancreatic digestion by neu- 
tralizing the hydrochloric acid which activates pep- 
sin and the pancreatic secretion, but in doing so he 
lays stress on a condition which he has himself men- 
tioned as being devoid of any great significance, the 
amount of hydrochloric acid in the stomach being, as 
he states, usually small at the time when gastric pain 
arises and sodium bicarbonate is given to relieve it. 
.'\t all events, this author reports good results from 
tartaric acid in one gram powders, given in conjunc- 



tion with alkaline powders each containing sodium 
bicarbonate, 0.4 gram, calcium carbonate, 0.3 gram, 
and hydrated magnesium carbonate, 0.2 gram. The 
acid and alkaline powders are dissolved separately 
b_, the pa-tient in two half glassfuls of water, and 
when pain is experienced alternate tablespoonfuls of 
the two solutions are taken until relief has been ob- 
tained. The correctness of his views, Meunier as- 
serts, is shown by the fact that the results thus se- 
cured are much better than if the alkaline solution 
is taken alone. The carbon dioxide produces relief, 
in his estimation, not by a direct sedative action on 
the mucous membrane, but by augmenting gastric 
peristalsis and hastening the passage of irritating 
material into the intestine. \Miile such a myotonic 
action of carbon dioxide is generally recognized to 
occur, a partial discrepancy in Meunier's view will 
appear when it is pointed out that lime water, con- 
taining calcium hydroxide as its main constituent, 
also relieves gastric pain — albeit less perfectly — in 
spite of the fact that no carbon dioxide is liberated 
in its reaction with hydrochloric acid. The same 
thought applies in the case of magnesium oxide, 
though the argument here is confused by the fact 
that magnesium excites peristalsis and thus might 
bring relief. On the whole, it would seem, granting 
the accuracy of Meunier's clinical observations, that 
both carbon dioxide liberation and hydrochloric add 
neutralization mav take part in the analgesic action 
of sodium bicarbonate, and therefore, that the 
mode of procedure which will bring these two in- 
fluences simultaneously into play will, in many cases, 
procure the maximum results. 

We are next led to inquire whether any additional 
actions are exerted by sodium bicarbonate and, if so, 
in what classes of cases and by what procedures 
these actions may be therapeutically employed. 
{To he continued.) 



Surgical Correction of the Obese and Relaxed 
Abdominal Wall. — W. Wayne Babcock {Ameri- 
can Journal of Obstetrics, October, 1916) writes 
concerning weakness of the anterior abdominal wall, 
such as occurs chiefly in women of middle age or 
advanced years, and arises either congenitally, 
through overdistention from pregnancy, ovarian tu- 
mors, ascites, or general debility, or through nerve 
injury or paralysis, especially postoperative. These 
patients suffer from indigestion, headache, flatti- 
lence, constipation, etc., and often are greatly handi- 
capped when in the erect posture. Corrective oper- 
ative measures include resection of an elliptical or 
otherwise shaped area of skin, lipectomy, recon- 
struction of the fascial and muscular planes of the 
anterior abdominal wall, and reinforcement of the 
latter bv the implantation of new tissue or such for- 
eign substances as silver wire and kangaroo tendon. 
Imbrication of one or more layers of the parietes 
mav be employed to strengthen the deeper abdom- 
inal wall, but' often conditions are such that this 



36 



MODERN TREATMENT AND PREVENTIVE MEDICINE. 



[New Yobk 
Medical Journal. 



procedure is not sufficient. In these cases a buried 
filigree of fine silver wire, as suggested by Willard 
Bartlett, has proved of great value, but in Babcock's 
experience, the delicate transverse loops of soft sil- 
ver are easily distorted and displaced both during 
and after the operation. To overcome this defect 
a time consuming anchoring of each loop to the un- 
derlying tissues is alone efficient. In time, more- 
over, such filigrees become fragmented and tlie 
sharp ends of broken wire may cause pain. Bab- 
cock has therefore in the last two years been sub- 
stituting fine sterling silver chain, as supplied by jew- 
elers, for tlie filigree with marked success. The 
abdominal wall is reinforced either by transverse 
strands of silver chain fastened in position by cat- 
gut or fine silver wire sutures, or, preferably, by 
means of a continuous, broad right angled suture 
of buried chain. The latter is readily carried 
through the tissues when attached to a round needle, 
and its ends are fastened to the aponeurosis with sil- 
ver wire or chronic catgut. Being threaded through 
the tissues, the chain has firm support and is not 
readily displaced. A single piece of chain five feet 
or more in length may be introduced. It may be 
embedded in the form of a broad open mesh. The 
advantages of the chain are its flexibility, high ten- 
sile strength compared to virgin silver wire, perma- 
nency, and almost complete lack of irritation. 

Venereal Diseases. — J. E. R. McDonagh 
{Practitioner, December, 1916) presents views on 
the causative agent of syphilis, the Wassermann re- 
action, and salvarsan that are considerably divergent 
from the German theories which have gained wide 
acceptance throughout the world. His paper should 
be read in full, for it is impossible to give the force 
of the arguments in an abstract. His claims are 
that the spirochaeta pallida is only the male form of 
the protozoon of syphilis, the function of which is 
to fertilize the female form, that salvarsan does not 
cure the disease because its action on the other 
forms of the protozoon is not as destructive as on the 
male form, and that while a positive Wassermann 
reaction allows the presumption to be made that the 
patient has had syphilis, it does not necessarily sig- 
nify that the disease is active, or that the patient 
requires treatment. In place of the Wassermann re- 
action he proposes what he calls the "Gel" test. 
From five to twenty c. c. of blood are taken from a 
vein and allowed to clot in order to separate the 
serum. It is better not to use a centrifuge, and the 
serum should not be incubated. An opaque serum 
or one tinged with hemoglobin may be used, but it 
should not be more than a few days old. Both a 
negative and a positive control are necessary, i. e., 
a known nonsyphilitic and a known syphilitic serum, 
because the time of year and the temperature of the 
room have an influence on the results. Four c. c. of 
glacial acetic acid are placed in a clean dry test tube, 
one c. c. of the serum to be tested is added, and the 
tube is shaken. Four test tubes are thus prepared 
for each serum to be tested. One c. c. of glacial 
acetic acid is placed in each tube ; then two drops of 
the acid serum are added to the A tube, four drops 
to the B, six drops to the C, and eight drops to the 
D. The tubes are then shaken, 0.2 c. c. of a satu- 
rated solution of lanthanum sulphate in glacial acetic 



acid is added to each, the tubes are shaken again, 
and then left to stand. In the positive control a pre- 
cipitate soon forms in D, then in C, A, and B, or C, 
B, and A. Half an hour or so later the precipitate 
has fallen in all four tubes, leaving a clear solution 
above. In the negative control the precipitate forms 
slowly, and the supernatant liquid does not become 
absolutely clear, even if left over till the next day. 
Hence it is easy to differentiate a syphilitic from a 
nonspyhiltic serum, and also to tell the grades of 
positivity, so that the effect of treatment can be ac- 
curately gauged. The results obtained by this test, 
under control of the Wassermann reaction, he avers 
to be more than satisfactory. McDonagh maintains 
that arsenic is not the most important part in the 
salvarsan molecule, but that its therapeutic action is 
mainly due to its orthoaminophenyl groups. He 
gives a list of bad results, including six of sudden 
death, from treatment with arsenic substitution 
products since the war began. He finds sulphur 
and iron better fitted for the purpose of the treat- 
ment in syphilis when in forms that furnish these 
orthoaminophenyl groups. The most suitable sul- 
phur compound so far prepared is diorthoaminch- 
thiobenzene, or intramine, as it is called for short. 
Over five hundred injections of this substance have 
convinced him of its efficiency. He believes it to be 
not only one of the most active drugs we have, but 
one of the least toxic, and one that has a much wider 
sphere than salvarsan. He says that it should suc- 
ceed in early syphilis, but that in recurrent and late 
syphilis it should precede a metallic compound. Its 
therapeutic effect is enhanced by the previous use of 
iodine. The best organic compound of iron pre- 
pared was the ferric triparaamino sulphonate, 
which he calls ferrivine. This has not yet proved 
as satisfactory as intramine, though its therapeutic 
action was in many cases superior to that of salvar- 
san. Collosal iodine, a colloidal iodine, he prefers 
for the administration of this drug. An outline of 
the way in which he uses all of these substances in 
the treatment of syphilis is given. 

Pathogenesis of Asiatic Cholera. — G. Sanarelli 
(Presse mcdicalc, November 16, 1916) reports ex- 
periments in newborn rabbits, which showed that 
cholera organisms introduced by the mouth never 
reach the intestine by way of the stomach. Even in 
these young animals the hydrochloric acid of the 
gastric juice kills all the bacteria. The latter, in- 
stead, enter the circulation by absorption through 
the buccal mucosa and settle in elective fashion upon 
the intestine, the walls of which they traverse. They 
appear first near the ileocecal valve — in the ileum, 
cecum, and appendix. Since in suckling rabbits the 
ordinary intestinal flora also appears at this point, 
such an elective occurrence of bacteria in the ileo- 
cecal region is seemingly a general law. Elective 
intestinal involvement from the blood in this man- 
ner occurs not only in cholera, but perhaps also in 
typhoid fever, dysentery, appendicitis, certain forms 
of diarrhea, and other microbic diseases considered 
intestinal because their causative factors are found 
in the feces. In some of the young rabbits used, the 
cholera infection traveled up the small intestine, but 
only very rarely did it reach the duodenum. Typi- 
cal cholera was induced in newborn rabbits whether 



January 6, 191 7.] 



MODERN TREATMENT AND PREVENTIVE MEDICINE. 



37 



the germs were taken by mouth or administered sub- 
cutaneously or intravenously. On the other hand, 
in rabbits bom of mothers vaccinated against the 
disease, no form of introduction was followed by 
development of cholera, thus showing that active 
immunization through the blood is capable of pro- 
tecting against the intestinal involvement. The nor- 
mal adult (unvaccinated) rabbit is completely re- 
sistant naturally to intestinal cholera. Sanarelli 
found that susceptibility to the infection could be 
artificially induced by following the cholera organ- 
isms with an injection of living colon bacilli into the 
wall of the appendix or the sacculus rotundus, or of 
colon bacillus toxin into a vein. Typical cholera 
symptoms and pathological changes follow such a 
procedure. The colon injections, though per se 
producing no apparent effect, evidently predispose 
the intestinal tissues to elective attack by the cholera 
organisms circulating in the blood. Sanarelli ex- 
presses the hope that improved prophylactic and 
therapeutic methods in cholera and other intestinal 
diseases will result from tiie above observations. 

Weak Feet in Pregnancy and the Puerperium. 
— Jacob Grossman (Medical Record, December i6, 
1916) pleads for greater attention to the feet during 
pregnancy and the puerperium. Prophylactic treat- 
ment involves the use of proper footwear wMth room 
for expansion at the top — a raising of one eighth of 
an inch of the inner border of the sole and heel to 
prevent or overcome valgus, with rounded heel edges 
and nonslip soles to avoid accidents by catching in 
carpets, etc. It also includes exercise twice daily 
without tiring the patient, using tip toe exercises and 
walking as much as possible. Curative treatment 
depends on the type of weak foot in question, the 
nonspastic type being amenable to the use of proper 
shoes and exercises while the spastic cases require 
strapping shoes, and Whitman's braces. Neuralgic 
pains in the legs, back, sciatic region, and edema of 
the ankles should arouse suspicion of weak feet in 
pregnant or puerperal cases. 

Scientific Treatment of Urethral Stricture. — 
G. S. Peterkin {Northwest Med., December, 1916) 
states that erroneous conceptions of the mechanism 
of urination so far as the parts from the bladder ex- 
ternally are concerned underlie the prevailing meth- 
ods of treatment of urethral strictures and render 
them far less satisfactory than should be anticipated 
by the conditions. It should be borne in mind that 
the meatus is the most constricted portion of the 
urethra, constructed so in order to secure force for 
the stream and to dilate the whole course of the 
urethra. For adequate treatment stricture should 
be diagnosed before it has become cicatricial. This 
can be done by determining the presence of a zone 
or of zones of resistance to the passage of a bougie 
a boule. At this stage the stricture is due to the 
presence of cellular infiltration which will become 
cicatricial later. Treatment should aim at curing this 
condition before the scarring has occurred, and for 
this purpose the constriction at the meatus must be 
preserved. Hence no sound of greater size than 
No. 20 F should ever be passed. When a forming 
stricture is encountered on the passage of a bougie 
a boule treatment should be instituted immediately 
by dilatation of the stricture with a Kollman dilator. 



This instrument is about 20 F. in size, but its inner 
portion can be dilated by means of a thumb screw 
on the handle. Combined with the mechanical di- 
latation of the forming stricture the patient should 
be taught to irrigate his urethra several times daily 
with water as hot as it can be borne, injected under 
pressure with a hand syringe having a glass nozzle. 
A mild antiseptic can be added to the water if de- 
sirable. Such an irrigation should be taken at least 
four times a day so long as the mechanical dilatation 
is being continued, after which it is to be stopped. 
This method of treatment is essentially a prophylac- 
tic one and aims to prevent the formation of true 
strictures. It has given the best of results. 

The Conservative Treatment of Congenital 
Clubfoot. — Eben W. Fiske {American Journal of 
Orthopedic Surgery, December, 1916) states that by 
means of the nontraimiatic treatment he obtained ex- 
cellent results in several rigid noncorrective clubfeet, 
and in ten cases of relapsed postoperative feet. He 
first increases the flexibility and corrects the foot by 
the use of a walking plaster dressing which is ap- 
plied in three sections. The foot cast is made with 
a pad under the prominence of the external border 
of the foot ; the leg cast is made and then the two 
casts are joined by a third while the foot is being 
held in the corrected position. An external wedge 
of plaster is placed beneath the sole of the cast. 
Having obtained some flexibility and correction by 
the above procedure, he overcorrects by means of 
another plaster in which he makes a "thigh cui?" 
and foot cast. Then he joins these two by a third 
plaster, making forcible eversion, abduction, and 
dorsiflexion of the foot. He uses a brace which 
permits function, in overcorrection, for the retention 
of the position. 

Boric Acid Poisoning. — George C. Maguire 
{Practitioner, December, 1916) reports a case of 
crushed leg which was treated in the ordinary man- 
ner surgically and with antiseptic dressings for 
eighteen days, until the wound showed a complete 
covering of healthy granulations. The treatment 
then was changed to fomentations of lint wrung out 
of a saturated solution of boric acid. That evening 
the patient complained of a slight headache, which 
persisted. Two days later a macular and papular 
rash appeared over the body, the patient was much 
depressed, and vomited dark green fluid. The next 
day the temperature began to rise, on the next ecchy- 
moses appeared under the eyes, the depression deep- 
ened, and death followed on the next day. Autopsy 
showed all of the organs normal except the brain, the 
surface of which was congested and covered with 
plastic lymph. No septic focus could be found and 
the cause of death was left in doubt. The question 
is raised whether the boric acid might have caused 
the meningitis The following passage is quoted 
from Hale White's Materia Medica concerning the 
therapeutics of boric acid : "It may cause a scaly 
eruption. In exceptional cases, when applied in 
large quantities to raw surfaces or mucous mem- 
branes rise of temperature, depression of spirits, fee- 
ble pulse, ecchymoses, lumbar pain, albuminuria, 
nausea, vomiting, and diarrhea have supervened." 
No other reported case of death was found in the 
literature. 



MODERN TREATMENT AND PREVENTIVE MEDICINE. 



[New York 
Medical Jouhnal. 



Oxygen in the Treatment of Purulent Pleurisy. 

— Dehau and J. C. Roiix {Paris medical, November 
J I, 1916) state that even after rib resection and de- 
pendent drainage in these cases the general condi- 
tion of the patient may remain grave for several 
weeks or even months. Fever persists, dyspnea ex- 
ists and is sometimes very marked, the, patient be- 
comes emaciated, copious suppuration continues, 
and the pus often remains malodorous. In their 
experience, antiseptic washings of the pleura gave 
little result in such patients, but as soon as oxygen 
was used an improvement, sometimes extremely 
rapid, was observed. The temperature returned to 
normal in a few days, the discharge and odor quick- 
ly diminished, and the general state improved in a 
striking manner. In a case in which the oxygen 
insufflations had to be interrupted for four days, 
fever at once returned, only to disappear again when 
the procedure was resumed. The oxygen was passed 
through a wash bottle and out through a number 
eighteen or twenty Nelaton catheter. The latter 
was passed through the pleural drain and pushed 
into the pleural cavity as far as possible. Insuffla- 
tions lasting one hour were practised once or twice 
daily, under low pressure. In eleven patients thus 
treated suppuration ceased within a few weeks. The 
gas seemed to exert far greater benefit in the pleura 
than in wounds of the extremities and suppuration 
of the knees . 

Soap in the Treatment of Wounds. — Walther 
{Presse medicale, November 16, 1916) reports for 
Ratynski and Bergalonne, the results obtained with 
a procedure in which soap is used as the chief reme- 
dial agent in the treatment of wounds. The hands 
having been disinfected, pieces of white Marseilles 
soap to the amount of about twenty to forty per 
cent, are dissolved in lukewarm, distilled, or boiled 
water. Pledgets of sterile gauze dipped in this so- 
lution are first used to wash the raw surfaces. Co- 
pious irrigation with the soapy water is next prac- 
tised, and the woimd then embalmed with soap. 
For this purpose one or more compresses of gauze, 
sixteen to twenty layers thick, are dipped into the 
solution already mentioned, then rubbed vigorously 
against a piece of soap until saturated. The com- 
presses are next rolled and squeezed between the 
palms of the hands until a fine, abundant froth is 
obtained in the gauze interstices. A spongy tissue 
of innumerable, minute soap bubbles is thus pro- 
duced, the bubbles rendering the dressing porous. 
The recesses and interstices of the wound are finally 
covered with this porous dressing, which is spread 
so as to remain everywhere at least one centimetre 
thick. A thick layer of absorbent cotton and a 
tarlatan bandage complete the dressing, which 
should be renewed every two or three days. Imme- 
diately after the first application of the dressing a 
marked diminution or complete disappearance of 
local pain was always observed. At subsequent 
dressings the fact was noted that the soapy froth 
fails to adhere, either in or arovind the wound. 
When removed the dressing caused no bleeding. 
The wounds healed very rapidly, the red. edematous, 
irritated surfaces very early assuming a healthy, 
reddish color. Granulations showed marked vital- 
ity from the beginning of the treatment. 



Treatment of Poliomyelitis. — Royal Whitman 

(Medical Record, December lO, 1916) states that 
preventive treatment of deformity consists in mov- 
mg the joints of the affected part through their full 
range of motion at least twice a day that all muscles 
may be extended to their normal Hmit. Attitudes 
that lead to deformity must be avoided and the child 
must not be allowed to stand or walk on weak or 
uncontrolled limbs. Nutrition must be preserved in 
the paralyzed limbs and this may be aided by gentle 
massage, hot baths, and electricity. Electrical treat- 
ment is merely a local stimulant of nutrition and is 
better adapted to adults than to children, as the lat- 
ter are usually frightened by its application. Muscle 
training, while of value, has its limitations, as par- 
alyzed muscles cannot be trained. However, in suit- 
able cases if properly applied it lessens the tendency 
to deformity and aids restoration to muscles where 
they are susceptible to restoration. Braces are used 
to prevent deformity and to prevent locomotion. 
Plaster supports may be applied temporarily to rest 
the inflamed spinal cord and hold the uncontrolled 
and sensitive limbs in position. Braces are employed 
to protect the weak muscles and lessen the strain on 
joints which otherwise would induce deformity. 
Properly regulated functional use of muscles is the 
most powerful aid to recovery, and it is often neces- 
sary to use supports to aid such exercise. Operative 
treatment may be indicated after several years when 
the amount of permanent paralysis can be accurately 
determined. 

Treatment of Infantile Paralysis. — F. E. Peck- 
ham {American Journal of Electrotherapeutics and 
Radiology, October, 1916) urges great care to pre- 
vent overstretching of the aftected muscles during 
the acute stage of infantile paralysis. Removable 
braces should be employed to keep the strong mus- 
cles stretched out. To relieve pain and dissipate 
infiltrations and edema in various parts of the body 
Peckham recommends the use, as early as practicable, 
of the static wave current and light wave treatment. 
The static wave current is applied over the lumbar 
spine for twenty minutes and the weakened or para- 
lyzed muscles then exposed to a 500 candle power 
lamp, screened with blue glass, for a like period. 
This blue light causes pain to disappear in the pain- 
ful stage of the disease. The lamp is also applied 
over the lumbar spine. Immediately after, the pain 
and tenderness in the affected muscles having been 
thus removed, vibration treatment is applied to these 
muscles, followed by gymnastic movements. The 
splints are removed for these treatments, which are 
given three times weekly. The manipulations ren- 
dered possible by the relief of pain and tenderness 
resulting from the blue light lead to preservation of 
the elasticity of the strong muscles. The apparently 
paralyzed muscles often respond promptly to the 
treatment, which, by permitting of earlier mechan- 
ical care of these muscles, tends to prevent or re- 
duce deformity and obviate subsequent surgical pro- 
cedures, such as tenotomy, for its correction. The 
gymnastic exercises with or without resistance, are 
of great importance and should never be neglected. 
In neglected cases, especially where the weakened 
muscles have been pulled around by the strong, the 
stretched muscles show prompt response. 



Ja:iuary 6, 1917.] 



MODERN TREATMENT AND PREVENTIVE MEDICINE. 



39 



Treatment of Asthma with Autogenous Vac- 
cines. — Truman C. Terrell {Texas State Journal 
of Medicine, December, 1916) collects the specimen 
in a sterile receptacle after the mouth has been thor- 
oughly cleansed and the gums and teeth painted with 
tincture of iodine. The specimen is collected imme- 
diately after arising in the morning. Three smears 
are made and stained, one with methylene blue, one 
with Gram's, and one with Ziehl-Neilson. The bac- 
teria are planted on suitable culture media. At least 
eight tubes should be planted, one half of them be- 
ing grown anaerobically and the other half aerobi- 
cally, at ^j° C. In preparing the vaccine the media 
is washed off with 0.9 per cent, salt solution that 
contains 0.5 per cent, phenol, or one per cent, 
quinine. The colonies of bacteria are broken up by 
being transferred to a shaking bottle and shaken for 
some time. Later they are centrifugated. The 
supernatant fluid is poured off and the proper dilu- 
tion made. It is then either heated to 60° C. for one 
hour on a water bath, or placed in an incubator for 
twenty-four hours at 38° C. The initial dose should 
be from fifty to 300 million bacteria. In tuberculosis 
cases we must be especially careful witli the size 
of the dose, always starting with the minimum. 
The left arm is usually selected as the site for the 
first injection, followed by the right arm, left thigh, 
right thigh, and finally the shoulders. The intervals 
should never be less than five days, usually from 
seven to nine days, depending upon the reaction. 

Wounds of the Spinal Cord and Their Treat- 
ment. — G. Guillain and J. A. Barre (Presse medi- 
cale, November 9, 1916) lay stress on the following 
complications as the chief causes of death from 
spinal wounds in military practice : Purulent men- 
ingitis; disturbances of sympathetic innervation in 
the ahmentarj- tract, abdominal viscera, and duct- 
less glands resulting in cachexia from failure of 
assimilation : and anemia of the cerebral centres 
and medulla. Cervical spinal wounds are the 
gravest because they entail maximal sympathetic 
disturbances. All spinal wounds should be explored 
as soon as possible — -within a few hours. The dor- 
sal orifice of entrance should be opened up, the 
wound disinfected, and the bony parts examined. 
Bone fragments, bits of clothing, missiles, and other 
foreign bodies should be removed, and the wound 
then treated like other mihtary wounds, viz., bv free 
irrigations with warm saline solution. All operative 
work should be done in ven,- warm rooms, nervous 
tissue being sensitive to cold. Local anesthesia 
should be as much as possible substituted for chloro- 
form or ether anesthesia, which seems greatly to im- 
pair the general condition and bring on death in 
these cases. If the dura is found untorn, it should 
never be opened, even if subdural or intraspinal 
hemorrhage is suspected, such opening always influ- 
encing the operative prognosis unfavorably. If the 
dura is found torn and the spinal tissue is visible, 
prolonged washing with warm saline solution is the 
only rational treatment. A projectile posterior or 
lateral to the cord, or in the cord, should be re- 
moved, but where it is anterior to it and has cut 
through it, perhaps incompletely, finding and re- 
moving it is of doubtful propri^tv, increased injurx' 
or complete section of the cord being a certain re- 



sult of such interference. The nursing is of ex- 
treme importance in these cases. The patient, placed 
on a special bed, must be kept scrupulously clean at 
all times. Infection of the skin from contact with 
fecal matter is avoided by local ablutions with soap 
and water and alcohol many times a day and even at 
night, followed by sterile talcum powder. Careful 
catheterization four times a day is required. Food 
should be given to the extent that patient's appetite 
demands. In the first few days or in the terminal 
stage saline or glucose hypodernioclysis, often with 
one c. c. of adrenaline solution added, is very useful. 
Camphorated oil, caffeine, sparteine, ether, and mor- 
phine may also be required. 

Autogenous Defibrinated Blood in the Treat- 
ment of Bronchial Asthma. — M. H. Kahn and 
H. W. Enisheimer {Archives of Internal Medicine, 
October, 1915; report six cases treated by this new 
method. In each case twenty to thirty c. c. of blood 
were withdrawn from a vein with a sterile needle 
and received in a sterile one ounce flask containing 
glass beads. The contents were agitated for from 
five to seven minutes to separate the fibrin, and the 
defibrinated blood then drawn into a thirty c. c. 
syringe and inmiediately injected subcutaneously 
into the loin of the patient. Ten injections at week- 
ly intervals were made in each case. No local or 
immediate general effects followed the injections. 
Whenever possible the blood was obtained during 
an asthmatic attack. The procedure is based on the 
consideration of the asthmatic paroxysm as a spasm 
of the bronchioles due to anaphylaxis the result of 
protein sensitization. The repeated injections of 
small doses of the causal protein in the patient's 
blood are intended to produce an active immuniza- 
tion. The patients treated all showed definite im- 
provement, as indicated by diminution in frequency 
and severity of the attacks, gain in weight, increased 
ability to work, and improved subjective symptoms. 

Excision of the Knee Joint for Severe Infection. 
— -Andrew Fullerton {Brit. Med. Jour., November 
25, 1916) states that in a large proportion of se- 
rious infections of the knee joint the usual meas- 
ures of treatment, such as aspiration and irrigation, 
or the injection of two per cent, formaldehyde in 
glycerin, or of ether, failed. The anatomical struc- 
ture of the interior of the knee renders all attempts 
at open drainage more or less doomed to failure. 
In such cases, therefore, other methods of treat- 
ment must be adopted. There are but two for con- 
sideration — amputation or excision. The latter has 
proved very successful if undertaken reasonably 
early, and while the patient's general condition was 
such as to indicate his ability to go through a long 
convalescence. It has the advantages, also, of con- 
serving his leg and of being far more acceptable to 
the patient than amputation. The technic of the 
operation of excision is described in detail and con- 
sists, in brief, of the removal of the femoral con- 
dyles just above their cartilaginous surfaces, the re- 
moval of a thin layer from the upper end of the 
tibia and excision of the patella with opening of the 
bursfe in the posterior aspect of the knee joint. The 
total length of bone removed is not over two inches. 
The wound is treated like a compound fracture, the 
leg being fixed in a Thomas splint. 



40 



MODERN TREATMENT AND PREVENTIVE MEDICINE. 



(New York 
Medical Jouknal. 



Treatment of Eclampsia. — Ubaldo Fernandez 
and Torribio J. Piccardo {Clinica Obstetrica y 
Ginecologica del Hospital Alvcar afio 1915) give 
their treatment succinctly and almost laconically, as 
follows : In antepartum cases hysterectomy was 
done usually by the vaginal route before viability 
of the fetus and by the abdominal method after via- 
bility. In eclampsia occurring during actual labor 
they practised accouchement force by manual dila- 
tation with extraction either manual or by forceps, 
internal version or embrj'otomy, according to the 
classical rules depending upon presentation, fetal 
viability, etc. In post partum eclampsia venesection 
was their sheet anchor, up to 1,700 c. c. having been 
drawn off without untoward eft'ect. 

Melena Neonatorum. — Valle y Jove (Revista 
de Medicina y Cinigia Practical, November 28, 
1916) reports a case treated unsuccessfully by abso- 
lute gastrointestinal repose, an icebag to the abdo- 
men, calcium chloride by mouth, and twenty c. c. of 
normal horse serum subcutaneously repeated in 
twenty hours. Then Bendix's treatment by adrena- 
line was tried successfully, one c. c. being given daily 
for two days and one half c. c. on the third day, no 
further hemorrhage occurring. For five days no ali- 
mentation was practised by mouth, but subcutaneous 
injections were given every three hours of twenty 
c. c. of a five per cent, solution of glucose serum. 
For later feeding'mother's milk was used with com- 
plete recovery. 

Foreign Protein in Skin Diseases. — M. F. Eng- 
man and R. A. McGarry {Journal A. M. A., Decem- 
ber 9, 1916) report the treatment of several forms 
of skin disease with the parenteral injection of for- 
eign protein. The protein was obtained by using 
suspensions of typhoid organisms. The results were 
very favorable in such conditions as lupus erythema- 
tosus, psoriasis, and several other types of dermat- 
osis. Although the immediate results were satisfac- 
tory the treatment was often followed by relapse. It 
is not recommended for general use as yet, but its 
results are worthy of much further investigation, in 
the opinion of the authors. 

The Choice of Tuberculins. — Benjamin White 
{N. Y. State Jour. Med., November, 1916) writes 
that for the purpose of diagnosis the original tuber- 
culin of Koch, or "O. T.," is generally accepted as 
the standard, but it is a good practice to determine 
the activity of the sample which is to be employed 
by testing it upon a person whose sensitiveness is 
known. This can be accomplished easily by the in- 
tracutaneous injection of 0.05 mil of each of a se- 
ries of dilutions. For therapeutic purposes "O. T." 
also probably leads in general popularity, but some 
objections have been raised to it on account of the 
denaturalization which it has vmdergone as a result 
of heating. It has been sought to overcome these 
disadvantages by the preparation of a filtrate of 
the broth cultures of tubercle bacilli. This is known 
as "B. F." and is held to have marked antipyretic 
properties, but to be weaker than "O. T." Both 
"B. F." and "O. T." contain the excretory products 
of the growth of the tubercle bacilli and these have 
been eliminated in the preparation of "B. E." or 
Bazillen emulsion, which is merely an emulsion of 



the finely ground bodies of tubercle bacilli. It has 
the possible disadvantage of slower absorption than 
is the case with the other tuberculins mentioned, 
and the production of more or less persistent, tender 
swellings at the sites of injection. An excellent 
combination can be made by mixing "B. F." with 
"B. E.," thereby obtaining the whole bacillary sub- 
stance and the products of its growth, both unal- 
tered by heat. A very large number of more or 
less modified tuberculins has been brought forth 
with claims for advantages in each case, but it is 
probable that the best results are still to be secured 
by the intelligent use of the three old and tried prep- 
arations just discussed. Certainly these three meet 
the theoretical requirements and their use is based 
upon large experience. 

The Use and Abuse of Pituitrin. — A. J. Skeel 
{Ohio State Journal of Medicine, December, 1916) 
states that pituitrin has three distinct fields of use- 
fulness in obstetrics: i. To terminate the second 
stage of labor in cases where no reason exists for 
delay except insufficient uterine activity and pro- 
vided the head has reached the pelvic floor. This 
includes the delivery of the second child in twin 
labors. 2. Laceration of the cervix when used be- 
fore complete dilatation. 3. To limit the bleeding 
in cases of marginal placenta prsevia, and in Cse- 
sarean section. Its possibilities for harm may be 
summarized as follows: i. Rupture of the uterus 
if obstruction of any nature exists. 2. Laceration 
of the cervix when used before complete dilatation. 
3. Laceration of the perineum when precipitate 
labor is caused by a full dose. 4. Occasionally its 
use results in tetanic uterine contractions somewhat 
resembling that produced by ergot, with consequent 
asphyxiation of the child. Before pituitrin should 
be used the following conditions should be fulfilled : 
I. Complete cervical dilatation. 2. The membranes 
must be ruptured. 3. The presentation must be 
longitudinal. 4. There should be no malpresenta- 
tion. 5. There must be no disproportion. 6. The 
presenting ]iart must be completely engaged. It is 
a good plan to use pituitrin in fractional doses, 0.33 
to 0.5 c. c, and repeat when the effect wears off. 
This reduces the risk of uncontrollable action. If 
pituitrin causes excessive pain either chloroform or 
ether should be administered. It has been used as 
a galactagogue and as a substitute for the catheter 
in post partum urinar}' retention. 

Treatment of Tetanus. — David Bruce {Lancet, 
December 2, 1916) states that the prophylactic in- 
oculation of patients which subsequently manifested 
tetanus reduced the mortality only slightly. Thus 
in prophylactically inoculated patients the death rate 
was about forty-three per cent., while in those 
not so treated it was 52.5 per cent. Curative 
treatment with tetanus antitoxin gave a mortality of 
forty-seven per cent, as compared with seventy per 
cent, in those not treated with the antitoxin. No 
advantage was found in the use of intrathecal injec- 
tions over the subcutaneous and intramuscular meth- 
ods of administration. Neither magnesium sulphate 
nor injections of phenol had any effect in reducing 
the mortality, which was seventy-eight per cent, 
after the former arui sixty-eight per cent, after the 
latter method. 



Miscellany from Home and Foreign Journals 



Life History of the Ascaris lumbricoides. — 

F. H. Stewart {Brit. Med. Jour., December 2, 1916) 
states that experiments, in continuation of earlier 
studies, have shown that in the rat and mouse larvae 
of the ascaris persist in the lungs and trachea up to 
the twelfth day following infection, and begin to 
migrate down into the intestine after the ninth day. 
By the next day their migration down the intestine 
is fully established and they begin to accumulate in 
the large intestine. This process continues through 
the next two days, during which large numbers of 
the larvae are passed with the feces. These obser- 
vations seem to show that the larvns reach the foods 
of human beings from the rodents' intestinal tracts 
rather than from their mouths and saliva, as was 
stated earlier in the course of these studies. 

Shrapnel Bullet Free in the Left Ventricle. — 

Lobligeois {Bulletin de I' Academic de medecine. 
November 7, 1916) reports the unique case of a sol- 
dier wounded some months previously who had been 
sent to him for radiosco])ic examination to ascer- 
tain the condition of the left lung and whether a 
projectile which the patient still affirmed to be 
lodged in In's thorax was actually present. The pa- 
tient had completely recovered clinically, and was 
in no way being disturbed by the foreign body. The 
examination revealed a free shrapnel bullet in the 
left ventricle, swirled about at each cardiac contrac- 
tion. At the close of diastole the bullet rested at 
the lower margin of the heart near the apex. In 
systole it rapidly traveled along this margin from 
the patient's left to his right, was arrested at the 
septum, next passed directly upward to the upper- 
most point of the ventricle, and finally, at the con- 
clusion of systole, sank slowly to the apex, .\tten 
lion is called to the fact that this condition could 
not have been discovered by the ordinary procedure, 
viz., making an x ray plate (unless instantancous'y. 
the movements of the bullet being too rapid. 

Relationship of Tuberculosis to Psoriasis. — 

• jaucher (Bulletin de V Academic de medecine, No- 
vember 7, 1916) adduces evidence to show that the 
initial cause of psoriasis is tuberculosis, or, more 
jirecisely, tuberculous toxic infection. From the 
pathological standpoint a bond between the two con- 
ditions is suggested by the cases of psoriasiform 
papules to which the term parapsoriasis has been 
applied and some of which have been thought due 
to a papular skin tuberculosis. The pathogenesis 
of psoriasis may be compared to that of lupus er>'- 
thematosquamosus. many cases of which are un- 
'juestionably of tuberculous causation. The chief 
argimient in favor of the tuberculous origin of 
psoriasis is, however, derived from clinical observa- 
tion. Gaucher has been struck by the frequency of 
psoriasis in tuberculous families. The children of 
a single family often present psoriasis and tubercu- 
losis in different individuals. Psoriasic patients not 
infrcr|uently develop tuberculous lesions. In all 
cases of acute or scarlatinoid psoriasis which had 
become transformer! into secondary pityriasis rubra 



Gaucher witnessed ultimate death from pulmonar\ 
tuberculosis. Many psoriasic patients have lost a 
parent, brother, or sister from the latter disease or 
from tuberculous meningitis, or have relatives witli 
osseous or articular tuberculosis. The children of 
parents with psoriasis not rarely succumb to tuber- 
culous meningitis or later to pulmonary tuberculo- 
sis, or exhibit lymphatic, bopy, or articular tuber - 
cidous disease. Psoriasis patients themselves some-.- 
times develop pulmonary tuberculosis, or, more 
often, show signs of larval tuberculosis, such as 
chronic cervical adenitis, asthmatic states, and 
chronic joint disorders. Similar evidence was, for 
a long time, available to show the tuberculous na- 
ture of lupus, now recognized as tuberculous by all. 
The presence of tubercle bacilli or of the tubercu- 
lous follicle is no longer essential in making the path- 
ological diagnosis of a tuberculous lesion. In fact, 
atypical, inflammatory, or nonfollicular tuberculosis 
appears to occur as frc([uently as the typical form. 

Rupture of the Scar of a Previous Caesarean 
Section. — Palmer Findley {American Journal of 
Obstetrics, September, 1916) points out that there 
is no positive assurance of obtaining a perfect heal- 
ing of the uterine wound after Ceesarean section 
whatever the method of suturing or whoever the 
surgeon. Although a perfectly healed wound may 
be relied upon to resist the forces of labor, in view 
of the fact that the integrity of the wound is an un- 
known factor in all cases the utmost caution is nec- 
essary in the conduct of every case of pregnancy 
and labor following Caesarean section. Failure to 
secure perfect healing is accounted for by departure 
from the principles of suture proposed by Sanger, 
and by septic infection of the uterine wound. Again, 
a latent gonorrheal infection may defeat the most 
painstaking efforts to secure perfect healing. When 
Caesarean section is followed by a fever course the 
uterine wound should be regarded as insecure, and 
Cassarean section again performed at the onset of 
labor in a succeeding pregnancy. When infection 
is known to exist, sterilization and hysterectomy 
should replace conservative Caesarean section. Trans- 
verse fundal, extraperitoneal, and cervical incisions 
do not lessen the liability of rupture in subsequent 
labors, but, on the contrary, probably increase the 
hazard. All cases of pregnancy after Caesarean sec- 
tion should be hospital cases and the operation re- 
peated at the beginning of labor if the uterine wound 
is known to be defective or if some cause of obstruc- 
tion to delivery exists. \^ersion, high forceps, 
uterine tampons, hydrostatic bags, and pituitrin 
should never be employed in the presence of a 
Caesarean scar. Not more than two per cent, of 
ruptures of the uterus occur after Caesarean section 
in subsequent labors ; yet one is not justified in 
voicing the slogan "once a Caesarean section, always 
a Caesarean section." Nor is one to rely implicitly 
upon the uterine scar in any case. The liability to 
rupture, though slight, stands as an argtmient 
against the increasing tendency to widen the scope 
of elective Ca-sarean operations. 



4-2 



MISCELLANY FROM HOME AXD FOREIGN JOURNALS. 



[New York 
Medical Journal. 



Polycythemia. — Rawson J. I'ickard {Journal 
A. M. A., December i6, 1916J reports a case in 
which all the usual therapeutic measures were tried 
without any influence on the progress of the condi- 
tion. Raw spleen and spleen extract were given 
with a gradual reduction in the number of eryth- 
rocytes and an ultimate return of the blood picture 
to normal. There had been a marked increase in 
the resistance of the red cells to the lytic action of 
antihuman amboceptor and this condition also dis- 
appeared with the recovery in the blood. 

Grafting with Frog Skin.— H. W. M. Kendall 
(British Medical Journal, November 11, 1916) 
states that as far back as 1886 he employed fresh 
frog's skin for the purpose of grafting over indo- 
lent leg ulcers with excellent results, and has again 
made use of this method in the treatment of wounds 
encountered in the present war. Fourteen cases thus 
treated are briefly summarized, two of which were 
unsuccessful, the others being strikingly satisfactory 
in rapid healing. The advantages of the method 
are that it is simple, the material is abundant and 
easy to obtain in a fresh condition, the skin used is 
free from hair, healing is greatly hastened, and cica- 
tricial contraction is much reduced. The technic 
consists in gently cleansing the surface of the wound 
without the use of antiseptics, dr^'ing its surface, 
and laying on it a piece of the skin taken from the 
thigh of a living frog. The under surface of the 
frog's skin is applied next to the wound. Over the 
graft a strip of gutta percha tissue, coated with a 
mild and nonirritant emollient, is laid, and fixed in 
place with adhesive plaster. A dry dressing is then 
applied. In three days the entire dressing, including 
the gutta percha, is changed, and after a second 
similar interval the dressings may be made without 
the tissue, the wound surface being covered with 
boric acid ointment or other bland preparation. 

Influence of Age and Sex on Hemoglobin. — 

C. S. Williamson {Archives of Internal Medicine, 
October, 1916) points out that practically all our 
knowledge on this important subject dates back to 
the studies of Leichtenstern in 1878, which were 
made in too few subjects and by antiquated meth- 
ods. Personal studies in 919 subjects with Huef- 
ner's spectrophotometre showed that the amount of 
hemoglobin in the blood of normal persons varies 
greatly at different ages, following a well defined 
curve. The variations, which are greatest from 
birth to the sixteenth year, are so marked as to ne- 
cessitate consideration of the age in comparing the 
hemoglobin with the normal in any given case. The 
amount of hemoglobin falls within the first year 
from twenty-three grams in a hundred c. c. of blood 
to thirteen grams, then rises up to the sixteenth 
year, remains almost stationary until the fifty-fifth 
year, thereafter declining slightly. Between the 
ages of sixteen and sixty there is a distinct differ- 
ence between the two sexes, the average amount be- 
ing seventeen grams in males and 15.5 grams in 
females. This difference grows less after the six- 
tieth year. In view of the above observations Wil- 
liamson recommends that all hemoglobinometres be 
standardized in absolute — not percentage — terms, 
most convenientlv in grams of hemoglobin in a him- 
dren c. c. of blood. 



Six Cases of Esophagectasia. — H. Batty Shaw 
and A. W. Woo {Lancet, December 2, 1916) state 
that dilatation of the esophagus has been known to 
the anatomist and the pathologist for a long time, 
although it has been considered a rare condition 
when not due to some form of anatomical lesion 
producing constriction of the tube. It has however, 
very rarely been diagnosed before death. Six cases 
of the condition are here presented in detail. The 
symptomatology of the condition is very variable, 
but the most striking features are the occurrence of 
obstruction to the passage of solid food with inter- 
\'als during which such food passes freely ; pain in 
the epigastrium associated with the food obstruc- 
tion ; the pain is of a sticking character as described 
by the patients ; it is relieved by regurgitation of the 
food through the stimulation of the desire to vomit, 
or by taking a deep breath or coughing. Eating is 
often followed by a sense of obstruction to the res- 
piration with attacks of asthma, reflex coughing, and 
other respiratory symptoms. There may be a his- 
tory of recurrent attacks for several years, or one 
of dyspepsia of undiagnosed causation. The diag- 
nosis of the condition can be made by studying the 
transit of a bismuth meal through the esophagus. 
The cause of the condition is not known, but it is 
suggested that it may be due to an anatomical ob- 
struction to the cardiac end of the stomach through 
an exaggeration of the normal angulation which oc- 
curs in that location. Several of the patients had 
periods of unconsciousness of unexplained origin, 
and one died after being unconscious for forty 
hours. 

Estimation of the Coagulation Time by the Air 
Bubble Method. — E. Lenoble {Bulletin de I' Acade- 
mic dc mcdccine, November 7, 1916) collects venous 
blood, drop by drop, in the small test tube accom- 
panying Hayem's hematimetre, until the surface of 
the blood reaches the upper margin of the tube at 
the periphery, though a cuplike depression remains 
in the centre of this surface. By occluding the tube 
with a cover glass a small air bubble is thus pro- 
duced, which is extremely mobile, as in a spirit level, 
and remains mobile until the blood begins to clot. 
The start of coagulation is marked by failure of the 
bubble to shift when slight deviations of the tube 
from the horizontal level are made, the bubble show- 
ing at this moment only a tendency to elongate or 
shorten. The completion of coagulation, on the 
other hand, is indicated when the bubble fails to 
change its shape upon movement of the tube. The 
blood interposed by capillarity between the margin 
of the tube and the cover glass seals the tube and 
prevents all evaporation of the blood under exami- 
nation. The air bubble should not be larger than 
a large pinhead. Only slow movements should be 
imparted to the tube ; sharp movements may lead to 
recovery of mobility by the bubble and an error of 
twenty-five to sixty seconds in the results. In one 
hundred subjects in which this procedure was ap- 
plied, the beginning of coagulation was observed to 
occur in from fifty-five seconds to six minutes and 
thirty seconds, averaging tw^o minutes and forty sec- 
onds ; the end of coagulation occurred in from one 
minute and thirtv seconds to eleven minutes, aver- 
• iiring four minutes and thirteen seconds. 



January 6, 1917.] 



MISCELLAXV FROM HOME AND FOREIGN JOURNALS. 



43 



The Influence of the Os Calcis on the Production 
and Correction of Valgus Deformities of the Foot. 
— Perc)- W'illard Roberts {Aincricaji Journal of Or- 
thopedic Surgery^ December, 1916) believes that the 
position of the os calcis has considerable influence 
as an etiological factor on weak feet and certain 
types of paralytic valgus. He suggests the use of a 
metal plate which grasps the os calcis and rotates it 
outward, thereby raising the arch of the foot and 
transferring the strain to the outer border. The 
plate, in addition, extends forward supporting the 
transverse arch. 

Paralysis agitans. — Walter B. Swift {Journal 
A. M. A., December 16, 1916) states that in the 
course of the treatment of the tremulous speech by 
the slow pronouncing of vowels, it was accidentally 
observed that the gaieral tremors were greatly 
benefited. On the strength of this a series of very 
slow exercises were prescribed, and had the eflfect 
of giving complete relief from the tremor, improved 
sleep, and a relief from what the patient described 
as "bad feelings." The results were obtained only 
while the treatment was continued. 

Thyroid Disease in Relation to Rhinology and 
Laryngology. — B. R. Shurly {Journal A. M. A., 
December 9, 1916) states that it is manifestly obvi- 
ous that the physiology of the thyroid and of other 
ductless glands is profoundly affected by toxic dis- 
turbances in general, and especially by those that 
enter the tonsillar chain of lymphatics. The direct 
and definite physiological and pathological relation 
of the tonsils to the thyroid should be realized, and 
a routine investigation of the effects of tonsillitis, 
quinsy, and other infections of the lymphoid tissue 
in the upper respiratory tract should be made. 

An Experience with Epidemic Cerebrospinal 
Meningitis. — A. Azalbert {Bulletin de I'Academie 
dc mcdccine. November 14, 1916) reports on twelve 
cases recently witnessed simultaneously in soldiers. 
.Stress is laid on lumbar puncture as a diagnostic 
procedure, the cerebrospinal fluid losing its cus- 
tomars- limpidity and always issuing under high ten- 
sion. Examination of this fluid showed the meningo- 
coccus in ten cases, a staphylococcus in one, and 
undetermined cocci and rods in the twelfth. Two 
cases were clinically misleading, the one being mis- 
taken on the first day for measles and the other for 
aaite tonsillopharyngeal inflammation ; neither of 
these had meningeal symptoms at first. Azalbert 
advises the use of lumbar puncture in doubtful cases 
in times of epidemic. The disease did not seem, 
especially contagious, none of the men in the neigh- 
boring beds or comrades, of the patients contracting 
the disease ; nor did any of the orderlies acquire it. 
In the treatment, the ten c. c. doses of antimeningi- 
tis serum were soon increased to twenty, thirty, and 
forty c. c, apparently with improved results. The 
senim seemed to do some good even in the two cases 
in which the meningococci had not been found. One 
patient, moribund when admitted, died in a few 
hours. The remaining eleven recovered, seven com- 
pletely, one with residual convergent strab'smus. 
two with unilateral deafness, and one with bilateral 
deafness and disturbances of equilibration. 



Diphtheria Carriers. — Sophie Rabinoff {Journal 
A. M. A., December 9, 1916) concludes that the 
jjresence of a foreign body in the nose may provide 
a favorable environment for the growth of diph- 
theria bacilli. The removal of tonsils and adenoids 
seems to offer a safe and rapid method of elimi- 
nating diphtheria bacilli from the nose and throat 
of carriers, and should finally be resorted to where 
other methods have failed. 

The Pineal Gland. — Frederic Fenger {Journal 
A. M. A., December 16, 1916) states that the ex- 
tensive chemical and pharmacological investigation 
of this gland as obtained from cattle, sheep, and 
lambs, and from adult and young animals showed 
it to be practically devoid of any material pharma- 
cologic action. Further, the extirpation of the 
gland from young animals failed to have any dele- 
terious eft'ect on the animals. It was apparent that 
the gland must be considered as being, in all prob- 
ability, of no medicinal value. 

Urinary Origin of Supposed Intestinal Fevers. 

—.Martinez \argas {.Ircliiz'os dc Mcdicina Interna, 
September, \^)ib) ileclares that modern methods of 
examination and laboratory work show that in many 
cases of supposed intestinal toxemia with fever, the 
urine shows evidence of a cy.stitis or a pyelitis. In 
such urinary infections the usual infective organisms 
are the colon bacilli and less often the bacillus pro- 
teus and the staphylococcus. The treatment of such 
cases is the alkalinization of the urine with potas- 
sium citrate, and two irrigations of the bladder each 
day with permanganate solution one in two thou- 
sand. 

Acute Purulent Infections of the Nose, Throat, 
and Ear. — Hill Hastings {Journal A. M. A., De- 
cember 2, 191DJ states that fresh and salt water 
plunges, contaminated by nasal and throat secre- 
tions, especially during epidemic periods of nose and 
throat infections, are far more dangerous than some 
other conditions for which strict health regulations 
are enforced. Many mastoid cases, and some deaths 
occur that should be and can be prevented by keep- 
ing people with "colds" from swimming, and espe- 
cially from diving. Over ninety per cent, of the 
cases of middle ear abscess and mastoiditis result 
from ordinary "colds" and "sore throats." Nearly 
all cases of suppuration of the frontal, sphenoid, 
and ethnoid sinuses, and the majority of the 
cases of suppuration of the maxillary antrum 
result from neglected "colds in the iiead." The 
best protection against infection of tlie ears, espe- 
cially in children, is the removal of tonsils and ade- 
noids ; but when present, the best protection against 
further spread of the purulent infection of the mid- 
rlle ear is prompt incision of the drum membrane as 
soon as the abscess forms. The dangerous prac- 
tices that tend to the spread of the purulent infec- 
tions of the nasopharynx into the ear are the use 
of nasal douches, with the head thrown back ; also 
the snuffing of salt water up the nose ; the forcible 
douching of the nose with syringes ; the blowing of 
the nasal secretions out of the nose with too much 
force : swimming, and particularly diving, when 
there is a "cold in the head." 



Proceedings of National and Local Societies 



ASSOCIATION OF AMERICAN 
PHYSICIANS. 

Thirty- first Annual Meeting, Held at Washing- 
ton, D. C, May Q, lo, and ii, ipi6. 
Tlie President, Dr. Henry Sewi;ll, in the Chair. 
{Continued from page 1170.) 

The Control of Malaria by Treating Malaria 
Carriers. — Dr. C. C. Bass, of New Orleans, said 
that where malaria prevailed there were many more 
malaria carriers who were not known to be infected 
than tliere were persons who had acute symptoms 
of the disease. In many such localities it was not 
])ractical at present to install or maintain antimos- 
quito measures. Koch advocated the possibility of 
control and eradication of malaria by finding and 
treating all infected persons in the community. Ex- 
periments and a demonstration of this method on a 
large scale was now being made in Bolivar County, 
Mississippi, in the heart of the malaria section of 
tlie South. The work had advanced sufficiently to 
show that in this country, which is believed to be 
representative of a large part of the South in which 
malaria was most prevalent, the cooperation of all 
the people could be secured to the extent of making 
a complete malaria survey and of inducing practi- 
cally all to take quinine as directed. The cost of 
the control of malaria by such a method would be 
very small compared to the cost of applying known 
methods of mosquito control. 

The Main Factors Affecting the Intensity of 
the Sounds as They Pass from the Interior of the 
Lungs to the Periphery of the Chest. — Dr. George 
W. NoRius and Dr. C. iM. M(ixtgomerv, of Phila- 
delphia, stated that the main factors diminishing tlie 
intensity of the sounds as they passed from within 
the bronchi to the external chest surface were reflec- 
tion and diftusion. Reflection might be a potent 
factor where vibrations passed through media of 
different densities, as air and fluid, or air and tis.sue. 
Sound was not much afifected in its jiassage between 
fluid and tissue because the dififerences in density 
were not sufficiently marked. Marked vocal reso- 
nance occurred over solid lung because the peren- 
chyma was airless, thus eliminating reflection in 
this part of the lung. The vocal resonance might 
also be increased when fluid separates a solid lung 
from the chest wall. In the normal lung, on the 
other hand, reflection took place between tlie bronchi 
and the surrounding air, between tlie tense mem- 
branous tissues of the parenchyma and tlie adjoin- 
ing air, and between the air in the lung and the 
chest wall. Dififusion, while more or less a con- 
stant factor in all conditions, played a special part 
in pleural effusion, the sounds becoming s]->read out 
or diluted as they pass from the lung surface in 
contact with the fluid to the point on tlic chest re- 
vealing diminislied vocal resonance. 

Experimental Endocarditis. — Dr. H. K. Det- 
WEiLER and Dr. W. L. Robinson, of Toronto, re- 
])orted that the cultures of streptococcus viridans 
obtained from the blood in cases of chronic endo- 
carditis had been inoculated into a scries of rabbits. 



and endocarditis was jjroduced in a large number 
of cases. The inoculations were all intravenous 
and consisted of enormous quantities of the organ- 
ism suspended in saline. The autopsy findings led 
them to believe that this organism had a special 
affinity for the heart, and especially for the heart 
valves. Evidence was forthcoming to show that 
the streptococcus viridans obtained from the normal 
mouth is equally jjroductive of heart lesions, and 
any grade of endocarditis may be produced by any 
one organism, depending upon the amount injected, 
the number of injections, and the length of time 
between tlie first injection and the death of the 
animal. 

Remissions in Leucemia Successfully Produced 
by Radium. — Dr. Thomas Ordway, of Albany, 
stated that a certain group of leucemia cases were 
resistant to x ray and to benzol. Refractory cases 
might yield to radium therapy and details of a case 
treated by radium were given, including charts 
sho\>?ing analysis of blood changes. Radium was 
applied systematically according to a plotted chart 
corresponding to the surface outline of the spleen. 
The results were a remarkable improvement of the 
blood picture ; reduction of the spleen to normal ; 
and great improvement of the patient's general 
condition. 

Observations on the Starvation Treatment of 
Diabetes.— Dr. C. F. Martin and Dr. E. H. 
Mason, of Montreal, stated that in the course of the 
observation of the metabolism of a number of cases 
of diabetes treated by the starvation method, charts 
were made to illustrate the efifects of such treatment. 
The charts illustrated the speed with which one 
might arrive at the tolerance for various food stuffs 
by this method, and also that hyperglycemia was a 
much better criterion than the glycosuria of the di- 
etetic needs. Starvation, too, affected acidosis in 
different ways, as was shown by the charts. In dia- 
betes it was found that the blood sugar curves, with 
the glucose test, differed constantly from tllose of 
the normal individual. 

Dr. A. Jacobi, of New York, said it seemed to 
him that the starvation treatment of diabetes was 
very satisfactory to the experimental doctor; but 
what happened to the patient? He had seen pa- 
tients with five per cent, or six per cent, of sugar 
go along in satisfactory health for five or ten or 
even twenty years. He had seen starved patients, 
emaciated and suffering with cerebral anremia, com- 
plain bitterly of other symptoms of nerve exhaus- 
tion, and they were now dead. They would not have 
died if they had not been starved. Were not those 
patients with glucose in the urine better off than 
those that died ? He would like to know whether 
more, or less, diabetic patients had died in the past 
few years. 

Dr. C. F. Martin, of Montreal, said that Doctor 
Toslin had answered Doctor Jacobi's question as to 
the present mortality rate of diabetes in the discus- 
sion of acidosis. He was sorry that Doctor Jacobi 
had the idea that he actually starved his patients ; as 
a matter of fact they were not even hungry; thev 
were not fasted to tliat extent. 



January 6, 1917.] 



PROCEEDINGS OF SOCIETIES. 



45 



Preliminary Note on the Germicidal Action of 
Quinine Salts and Allied Compounds. — Dr. S. 
SoLis Cohen and Dr. Jonx A. Kolmer, of Phila- 
delphia, reported the resuks of germicidal tests in 
vitro with sixteen different quinine saks, including 
ethylliydrocuprein, hydroquinine (methylhydrocu- 
prein), and quinine and urea hydrochloride upon 
pneumococci of t)pes I, II and III ; the germicidal 
activity of urea hydrochloride; and a study of the 
parasitropism of quinine on pneumococci by cross 
germicidal tests witli other chemicals and microog- 
ganisms. 

The Effect of Exposure to Cold upon Experi- 
mental Infection of the Respiratory Tract. — Dr. 
James Alex.\nder Miller and Dr. Willis C. 
XoBLE, of New York, stated that at the present time 
there was considerable dilTerence of opinion as to 
whether exposure to cold played any part whatever 
in the causation of disease. Experimental evidence 
was conflicting and as many of the animal experi- 
ments have been conducted with pneumococci, which 
organism did not prochice experimental disease 
with regularity in animals, the results were not con- 
clusive. 

The present experiments were carried out with 
rabbits inoculated with Bacillus bovisepticus, an or- 
ganism which causes the laboratory disease in rab- 
bits known as "snuffles." It was selected for experi- 
ment because it produces in rabbits conditions very 
similar to those in respiratory infections in man and 
because of the relative difficulty of producing pneu- 
mococcus pneumonia in rabbits. The experimental 
animals were kept in a warm temperature for vary- 
ing pyeriods of time and were then inoculated by 
spraying the nose and throat with virulent cultures 
of the "snuffles" bacillus. They were then immedi- 
ately chilled by exposing them to outside cold 
weather. Two series of experiments in two suc- 
cessive winters were carried out. The results in 
each series were given in detail. The totals for the 
two series showed that of thirty-seven experimental 
animals, fifteen, or 40.5 per cent., reacted to the in- 
fection, while an equal number of controls, nine, or 
24.3 per cent., reacted. 

The conclusion seemed justified that exposure to 
cold after previous subjection to warm temperatures 
rendered rabbits somewhat more liable to infection 
with Bacillus bovisepticus. 

Dr. Kenry Pewell. of Denver, said that the 
work reminded him of experiments made by Baker, 
of Ann Arbor ; monkeys were put in ice water and 
then exposed to the breeze ; then back into the water 
and exposed to the breeze again ; but the animals 
thri\'ed. They died in a few days, however, when 
they were confined to an old cellar room where dead 
bodies had been kept. His own experiments, in 
which guinea pigs were sensitized to or protected 
against serum by the mode and time of instillations 
of serum into the nose, solved the secrets of this 
whole problem. Throughout life we are constantly 
receiving antigens which protect us if we are in 
training, and sensitize us if we let down the bars by 
unhygienic indiscretions. 

Dr. S. J. Meltzer, of New York, said that ex- 
periments seeking to show the relations between ex- 
posure to cold and lung affection must all fail for 



the present, because the lungs were always main- 
tained at the same temperature. But the same can- 
not be said of the nose and larynx; exposure to cold 
did cause a reaction in these parts and we begin to 
sneeze or cough. These symptoms were not dis- 
eases, however; they were efforts of the body to 
get rid of undesirable substances. While these ef- 
fects of exposure did not cause disease, they un- 
doubtedly opened the way to disease. The only way 
to prove the matter so far as the lungs or bronchi 
were concerned would recpire the introduction of 
hot or cold air through a tube to the lung or 
bronchus where organisms had been previously 
placed. This would not afford complete evidence, 
however. 

On the Expectorant Action of Ammonium 
Chloride. — Dr. Warren Coleman, of New York, 
staled that ammonium chloride had long been rec- 
ommended as an expectorant. Objections to its use 
had been based on a few experimental observations 
on animals. The objections and factors in this ex- 
perimental work were pointed out. His experiments 
were on human subjects, being observations on the 
expectoration in bronchitis before and after admin- 
istration of ammonium chloride. The sputum was 
carefully collected and preserved and subjected to 
chemical examination, which showed a large in- 
crease of ammonia N in sputum after the exhibition 
of ammonium chloride. Some of the observations 
were upon himself ; when one half grain doses of 
ammonium chloride were taken every two hours 
during the day up to seven p. m., a distinct taste of 
the drug was perceptible in the sputum the next 
morning, but not in the saliva. Another subjective 
observ'ation was that the sense of bronchial rawness 
and tightness in bronchitis was relieved in a half 
hour after taking chloride. The explanation of this 
effect probably lay in the water carriage of the drug 
when excreted by the bronchial mucosa, the mucoiis 
membrane, and secretion being softened thereby. 

Dr. A. Jacobi, of New York, said that some years 
ago, as many years ago as 1857, in lecturing before 
the students at the College of Physicians and Sur- 
geons, he had told them that ammonium chloride 
did not have the expectorant value of the carbonate 
or the acetate. Indeed, when he was a young man 
in Germany, it was the habit to give ammonium 
chloride as a placebo. Since then he had come to 
the conclusion that there was one indication for it: 
it would do something in chronic bronchitis where 
the sputum was sticky and hard to raise. 

Dr. S. J. Meltzer, of New York, said that Doc- 
tor Coleman's interesting experiments did not decide 
the questions surrounding the expectorant action of 
ammonium chloride. First, we should want a defi- 
nition of expectorants ; Doctor Coleman indicated 
that there were two kinds : secretion increases and 
removal helpers. The observation that a given sub- 
stance was absent from a secretion was not evidence 
that the substance had no eft'ect on the secretion ; it 
may have had some effect on something in the blood. 
Physicians should not give up something that good 
clinical observers had found useful on the basis of 
mere experimental evidence. His own observation 
for many years had been that ammonium chloride 



46 



PROCEEDIXGS OF SOCIIITIES. 



[New York 
Mkuical Journa 



was beneficial in a cold. It would not save a pa- 
tient destined to die, but it was a good palliative 
remedy. 

Dr. Joseph Erl.\nger, of St. Louis, said that one 
could not be positive that the ammonium chloride 
found in the sputum was excreted with it. What 
precautions were taken to see that no ammonium 
chloride was retained in the mouth? Was any am- 
monium chloride eliminated in the saliva? 

Dr. L. G. RowNTREE, of Minneapolis, asked: At 
what stage in acute bronchitis did Doctor Coleman 
believe ammonium chloride was indicated? Was 
its action central or peripheral ? 

Dr. Max Einhorn, of New York, said that he 
was delighted that the experiments were on humans 
rather than on rabbits. Animal experiments were 
good, but clinical work on patients was better, and 
personal observations of the eii'ects of drugs on the 
experimenter himself were particularly valuable. 

Dr. Warren Coleman, of New York, said that 
his remarks had to do with ammonium chloride 
only; he hoped to make further studies with other 
drugs. He replied to Doctor Erlanger that careful 
examinations of both sputum and saliva had been 
made by Benedict ; only a very slight ammonia re- 
action was to be fotmd in the saliva. As to the 
stage of bronchitis in which ammonium chloride 
was indicated, benefit might be expected after the 
first few doses given as soon as the first dry, raw- 
ness in the bronchi appeared. The effect of the 
drug was probably due to its elimination by the 
bronchial mucosa, the water carried with it soften- 
ing the secretion. 

Coagulation Time in Lobar Pneumonia. — Dr. 
J. M. Anders and Dr. Geo. H. .Meeker, of Phila- 
delphia, stated that the etiological factors in coagu- 
lation were obscure. That toxins played a part was 
admitted, but the nature of the part played was in 
doubt. It was agreed that in pneumonia, coagula- 
tion was hastened, while in other infections it was 
rather retarded. In the present observations, the 
so called Boggs's test was employed ; the blood was 
obtained by free puncture of finger tip or ear lobe. 
Daily venepuncture was not consider warranted. 
Tables of coagulation time in pneimionia were given. 
It was found that in pneumonia coagulation time 
was slightly shortened, the mean time being nearly 
two minutes. In normal individuals the effect of 
meal time on coagulation was slight but constant ; 
two hours after a meal, coagulation time was slightly 
lengthened. As to the cause of the shortened co- 
agulation time in pneumonia there was no definite 
evidence. Various hypotheses were discussed. It 
occurred to them that the rapid destruction of leu- 
cocytes in the exudate might set free much enzyme 
and so set up the process. It was shown that cal- 
cium was not increased in pneumonia and therefore 
had no effect on the change in coagulation time. 

Dr. S. J. Meltzer, of New York, said that in 
similar experiments he had observed in nonvirulent 
pneumonia no increase of calcium ; but there was an 
increase of this element in experimental virulent 
pneumonia Starch pneumonia was not attended 
with fibrin increase. 

Dr. RuFUS I. Cole, of New York, called attention 



to Dochez's work, in wiiich it was found that in 
blood obtained direct from the vein in pneumonia 
the fibrinogen was increased, but the coagulation 
time was prolonged. 

Dr. Henry Sewell, of Denver, said the iirofcs 
sion did not yet realize the truth of Dochez's obser- 
vation : that there was more fibrinogen, but longer 
coagulation time in pneumonia. 

Dr. Ma.x Einhorn, of New York, asked if the 
retention of NaCl in the blood in pneumonia might 
not play a part in accelerating the coagulation time. 

Dr. J. M. Anders, of Philadelphia, said with ref- 
erence to Dr. Cole's remarks, that he had felt that in 
pneumonia we have a parado.x in the behavior of 
the blood : in the course of the disease there was a 
shortened coagulation time ; but clots found post 
mortem had shown a huffy coat, indicating that their 
formation was slow during life. Venepuncture 
might prevent the body fluids from influencing the 
results : he hoped to do further work on that basis. 

A Study of the Action of Certain Diuretics in 
Chronic Nephritis. — Dr. H. A. Christi.\n, of 
Boston, stated that from former studies it was 
known that certain diuretic drugs shortened the 
lives of animals with acute experimental nephritis ; 
also that in the same disease, diuretics decreased 
renal function. Similar observations were made on 
acute nephritis complicating grippe in man. The 
eft'ects of theocin (as representing diuretics) were 
varying; there might be an increase or decrease of 
diuresis, of salt, or of nitrogen ; but NaCl was more 
often increased than N and tended to parallel water 
excretion. Charts were given, showing results in in- 
dividual cases. The conclusion seemed justified that 
theocin caused an inconstant and not marked effect 
in acute nephritis in man. Charts were also given 
showing the effects of theocin in chronic nephritis. 
Conclusions: i. In chronic nephritis and chronic 
cardiorenal disease, theocin (as example) produced 
diuresis in inverse ratio to renal function. When diu- 
resis was induced, it was followed by reduced renal 
function, suggesting the advisability of the intermit- 
tent use of diuretics. 2. There might be diuresjs 
without increase of nitrogen output ; this made ques- 
tionable the use of diuretics for detoxicating pur- 
poses. In many cases with severe nephritis, diu- 
retics were probably harmful, being followed by no 
diuresis, no increase of urinary ingredients, and by 
diminution of renal function. 

Dr. W. S. Thayer, of Baltimore, said that Doctor 
Christian had undoubtedly contributed an important 
piece of work. The conclusions were in accord with 
clinical experience ; he had noted the beneficial effect 
of diuretics in cardiac disease, and had noted also 
the danger of continuous use of diuretics in severe 
renal disease. 

Dr. J. M. Anders, of Philadelphia, said the paper 
was timely because heretofore we have had no cri- 
teria for the use of diuretics ; the work will afford 
these for practical application. In his own practice 
he had relied on saline diuretics. We should not em- 
ploy diuretics unless the phthalein test showed good 
functional capacity. In order to aid elimination we 
have been used to giving large draughts of water : 
was this taken into consideration in the studies ? 

Dr. L. G. Rowntree, of Minneapolis, said that 
Doctor Christian had attacked the \''erdun of rliu- 



January 6, 1917.3 



LETTERS TO THE EDITORS.—BOOK REVIEWS. 



47 



retics. If he had been asked to pick the best diuretic 
from theoretical considerations, he would have 
chosen theocin. Were there any observations on 
water alone as a diuretic ? 

Dr. Henry A. Christian, of Boston, said that 
Doctor Anders had brought up tlie phthalein test as 
index to the use of diuretics ; but the value of tlie 
test for this purpose will depend upon whether a low 
output is due to chronic passive congestion or to 
tubular insufficiency. As to the influence of water, 
this was not studied ; however, all of the patients 
were on a constant fluid intake. As to the diuretic 
value of water, it acted like other diuretics in short- 
ening the lives of experimental nephritic animals. 
The subject needed more study. 

The Toxic Effects of Urea on Normal Individ- 
uals. — Dr. A. W. Hewlett. Dr. O. O. Gilbert, 
and Dr. A. D. W'ickett, of Ann Arbor, stated that 
in order to study the toxic effects of urea on man, 
about 100 grams of urea were taken by mouth with- 
in a few hours. When the concentration of urea 
in the blood exceeded i6o mgms. per lOO c. c. of 
blood, the subject usually complained of headache, 
dizziness, drowsiness, mental apathy, inability to con- 
centrate the attention, muscular weakness and fa- 
tigue, and slight muscular tremor. These symptoms 
were similar to those described in the asthenic types 
of uremia, in which type the blood urea approached 
and often exceeded the threshold of symptoms ob- 
served in these experiments. It was probable there- 
fore that in this type of uremia many of the symp- 
toms could be attributed to the high concentratimi 
of urea in the body. In these experiments no nau 
sea or loss of appetite occurred at the maximum 
level of urea in the blood, nor was there any marked 
rise of blood pressure. 

Dr. W.\RREN CoLEM.^N, of New York, said that 
an instructive case was that of a girl of thirteen 
years, who came to the hospital in uremic convul- 
sions. Blood taken for therapeutic purposes yield- 
ed of noncoagulable N a total of twenty mg. per 
100 c. c. In later convulsions other observations 
never found the noncoagulable N above thirty mg. 
per 100 c. c. of blood. It was evident that in some 
cases urea was not a factor in the convulsions. 

Dr. Henry A. Christian, of Boston, said that 
Doctor Hewlett's observations were important. They 
coincided with his own observation as to the non- 
effect of diuretics on the removal of nitrogen and 
their failure to influence the symptoms of uremia. It 
was necessary to consider both blood accumulation 
of N and kidney excretion of N in these problems; 
storage was the factor rather than the amount in the 
blood. How long did it take for the level of blood 
urea to return to normal? 

Dr. A. W. Hewlett, of Ann Arbor, said that it 
was necessary to keep in mind that more substances 
were concerned in uremia than urea. Foster had 
demonstrated the presence of a definite toxic sub- 
stance in the blood of eclamptics. 

The time of the return of the urea level of the 
blood to normal was not ascertained, the observa- 
tions were not continued long enough ; the threshold 
of symptom production was passed on the down 
wave in six hours. 

{To be continued.) 



Letters to the Editors 



BEW.\RE OF PICTURE PRIDE, 

New York, December i6, jp/6. 
To the Editors: 

For the privilege of having your photograph, with others, 
placed in the leading club rooms of this city, thus making 
you an "immortal," the sum of twelve dollars and fifty cents 
must be looked upon as small indeed by those responding 
to such solicitation amongst the medical profession. It 
would appear that the higher in the scale of life a man 
may be, the more sensitive his organism becomes, and like- 
wise, the higher the standing in the medical association, 
the easier the mark. However, there would seem to be no 
valid reason why an immortal should feel perturbed, be- 
cause the writer was similarly approached, but declined" 
the honor, or that this fact should in the least degree im- 
pair the distinction conferred upon such an immortal. 

It may not be amiss to remark that conceit is an ex- 
pensive trait, the realization of which explains why the 
writer declined the opportunity above mentioned, and like 
the kite, which in its soaring would tend to break the cord 
that holds it to earth, men in their desire for notoriety are 
at times led into action which breaks rather than cements 
the bond of union which should exist not only between 
members of the medical profession, but between members 
of the great human family everywhere. 

John D. Coghlan, M. D. 



Book Reviews 



[iVe publish full lists of books received, but we acknowl- 
edge no obligation to review them all. Nevertheless, so 
far as space permits, we review those in which we think 
our readers are likely to be interested.] 



Bref och Skrifvelser. Af och till Carl von Linni. Andra 
Afdelingen UTL.JiN SKA Brefvaxlingen. Del. I. An- 
danson-Briinnich. Utgifven och med upplysande Noter 
Forsedd af J. M. Hulth. Upsala : Akademiska Bok- 
handeln ; Berlin : R. Friedlander & Son, 1916. Pp. 429. 
This publication comprises the foreign correspondence 
of Carl von Linne, a series of Scandinavian letters having 
been previously collected by Th. M. Fries. The letters date 
from the epoch making years in Holland, 1736-1739, when 
Linne, at the age of twenty-eight, having come under the 
patronage of the banker Clifford in Amsterdam as the 
latter's house physician and curator of his botanical garden, 
issued not only the Horlus Cliff ortianus and his Flora Lap- 
ponica, the product of his Lapland journey of research, 
which now went to press at the expense of his benefactors 
— among these were Gronovius and Herman Boerhaave — 
but it was at this time that he entered upon the prodigious 
activities that resulted in the publication of his Systcma 
Natures and Genera Plautanim, these winning for him ac- 
quaintance with influential and scientific men, as did also 
his subsequent visit to France and England. Further cor- 
respondence dates from the time that Linne. having re- 
turned to his native land in 1739, established himself in 
the practice of medicine in Stockholm, while continuing 
his researches into the Flora Succica. and rising rapidly 
to high honors, becoming in turn physician to his majesty 
the King, founder and prseses of the Academy of Sciences, 
Professor of Medicine at the University of Upsala. ex- 
changing this soon for the chair of botany, which he held 
until his death in 1776. His writings in the meantime 
brought him into communication with the whole scientific 
world, the more that foreign students flocked to Upsala, 
thither attracted by his lectures, among them many young 
scientists, who later joined the ever widening circle of 
Linne's correspondents, keeping in touch with the viro 
celeberrimo, regis primario medico, botanicorum principi 
perillustri equiti de Stella polari, etc., etc., for of this type 
was invariably the mode of address of the elaborately 
courteous letters. Among the varied contents of the epis- 
tles, which in tone are often effusive to the point of flat- 
tery, are the main topics of common interest, observations 
on plants and specimens, suggestions in the treatment of 
disease, etc.. for the botanists were usually physicians also. 



48 



LOCAL SOCIETIES.-BIRTHS. .UARRL-UjES. AND DEATHS. 



I New Yokk 
Ubdical Journal. 



And Liniie himself was no less ardent a correspondent; 
in a letter to Briinnich in his later years he writes : "Nc 
delasseris oro frequenter ad me scribcre de iis quae vides ; 
hrec me reficiunt, excitant et refocillant suli inRravescenti- 
biis annis ; si umquam queam reciprocis officiis inscrvire 
non intermittain." The letters are almost without excep- 
tion written in Latin. Among the American correspondents 
was the wealthy Lord Baltimore, addressed by Linne as 
Dominus in tola Marilandia, who journeyed to Sweden to 
see the botanist, spent a never to be forgotten day at his 
estate near Upsala and later sent him regal gifts, among 
which was a priceless snuffbox, now in a museum, and 
many treasures in epistolary form remain to give evidence 
of their mutual admiration. But the author and collator 
of the letters comments on the Latin of Lord Baltimore, 
that it was very faulty. This was also the case with one 
or two others who had difficulty in handling the universal 
language then in vogue among scientists. But even more 
discouraging was the tardy delivery of letters, the postal 
facilities being such that weeks and months were needed, 
and in one instance the Italian botanist AUioni acknowl- 
edges receipt of letter and herbarium just come to hand 
that had been sent two years previously. Many of the 
Linnean letters are in the custody of the Linnean Society of 
London. Vol. I contains 267 letters alphabetically arranged 
These letters go far to illuminate in an entertaining way 
a period characterized by profound learning and studious 
pursuits, especially in the field of natural history, that of 
botany being especially popular, and many distinguished 
botanists were physicians as well. 

La Clinica Obstetrica y Ginccologia Del Hospital Alvcar 
en ed Alio, 1915. By Ub.^ldo Fernandez and Toribio J. 

PiCC.ARDO. Pp. 168. 

This as the title implies is the annual report of the gyne- 
cological and obstetrical department of the Alvear Hos- 
pital in Buenos Ayres. From the many excellent photo- 
graphs in the volume this is a thoroughly modern institu- 
tion. _ The clinic is housed in a separate pavilion from the 
hospital proper. The department treated 1068 cases in 
1915 of which 728 w-ere obstetrical and 340 gj-necological. 
The report goes into minute details and gives evidence of 
a vast amount of work in its preparation. 

Proceedings of the American Society for Psychical Re- 
search. Section B of the American Institute for Scien- 
tific Research. Volumes IX, X, XI. The Doris Case of 
Multiple Personality. By Walter Franklin Prince, 
Ph. D. and James H. Hyslop, Ph. D. The Patison Case 
By James H. Hyslop, Ph. D., New York: American 
Society for Psychical Research, 1916. (Price, Volumes 
IX and X, $6 each; Volume XI, $8.) 
The study of multiple personality dates back to 1830 when 
MacNish reported his case of Madame X and this was 
followed during the nineteenth century by Azam, Dufay. 
Bourru, Burot and others. The presumption was that cer- 
tain portions of the personality were capable of breaking 
avvav and leading independent existences, even becoming 
entitities themselves resembling a human personality. This 
led to the formation of a theory of the subconscious. In 
the last decade of the century notable work was done along 
this line by Binet. Flournoy. Janet, Prince, Sidis. and 
White, leading finally to Janet's theory of hysteria. Since 
that time there has been nothing startlingly new developed 
in this field, although there have been some excellent case 
reports, of which the present is probably the most nota- 
ble. Dr. Prince, following in tlie footsteps of his dis- 
tinguished father, has made a thoroughly scientific and 
exhaustive investigation of the case of Doris Fischer who 
show^ed dissociation of her personality into what were ap- 
parently- five parts. The first volume is occupied with a 
description of the periods during which these five personal- 
ities displayed themselves, together with the beginning of 
the period of cure. The second volume continues the im- 
provement to the return of normal consciousness, a record 
of the automatic writing, some statistical and graphic 
studies of the case, and a copious index. Volume three 
contains an interesting theoretical discussion of the case, 
and an examination of the various hypotheses dealing with 
two_ of the personalities. This volume also describes the 
Patison case, a so called instance of obession in which 
an otherwise normal child becomes "possessed" with the 
spirit personalities of famous persons. 



Meetings of Local Medical Societies 

\loN-|)AY, January 8lh—New York Ophthalmological So- 
ciety (annual) ; Society of Medical Jurisprudence. 
New York; Roswell Park Medical Club. Buffalo; 
Association of Alumni of St. Mary's Hospital, Brook- 
lyn ; Williamsburg Medical Society, Brooklyn. 

Tuesday, January Qth. — New York Academy of Medicine 
(Section in Neurology and Psychiatry) ; Medical So- 
ciety of the County of Wyoming; Ontario County 
Medical Society ; ^ledical Society of tlie County of 
Schenectady; Medical Society of the County of Rens- 
selaer; Buffalo Academy of Medicine (Section in 
Medicine) ; Newburgh Bay Medical Society (annual) ; 
New York Obstetrical Society; Onondaga Medical So- 
ciety; Medical Society of the County of Oneida (an- 
nual). 

Wednesday, Janwiry 10th. — New York F'athological Soci- 
et)' (annual) ; New York Surgical Society; Alumni 
Association of Norwegian Hospital, Brooklyn; Schen- 
ectady Academ}- of Medicine; Medical Society of the 
Borough of the Bronx (annual) ; Richmond County 
Medical Society ; Rochester Academy of Medicine 
(annual) : Medical Society of the County of Mont- 
gomery; Medical Society of the County of Dutchess: 
Brooklyn Medical Association (annual). 

Thursday, January nth. — New York Academy of Medi- 
cine (Section in Pediatrics) : Glovcrsville and Johns- 
town Medical Association (annual'* ; Physicians' Oub 
of Middletown ; West Side Clinical Society. New 
York: Brooklyn Pathological Society; Blackwell Med- 
ical Society of Rochester; Jenkins Medical Associa- 
tion, Yonkers ; Society of Sanitary and Moral Pro- 
phylaxis, New York ; Buffalo Ophthalmological Club ; 
Jamestown Medical Society ; Society of Physicians of 
Village of Canandaigua (annual) ; Cayuga County 
Medical Society Medical Society of the County of 
Allegany. 

Friday, January 12th. — New York Academy of Medicine 
(Section in Otology) ; Society of Fxinternes of the 
German Hospital in Brooklyn : Flathush Med'cal S> - 
cietT,-. Brooklyn ; Eastern Medical Society of the City 
of New York; Clinical Society of the German Hos- 
pital and Dispensary; Manhattan Dermatological So- 
cietj'. 

Saturday. January j^lh. — New York Association of the 
Medical Reserve Corps of the United States Army. 



Births, Marriages, and Deaths 



Died. 

Buckingham. — In Boston, Mass.. on Saturday, December 
23rd, Dr. Edward Marshall Buckingham, aged sixty-eight 
years. 

Carter. — In Abbeville, La., on Friday, December 15th. 
Dr. Nelson S. Carter, aged eighty-three years. 

CuMMiNGS. — In Grand Rapids, MicTi., on Wednesday. 
December 20th, Dr. Erasmus H. Cummings, aged eighty- 
one years. 

Faulkner. — In Pittsburgh, Pa., on Wednesaay, Decem- 
ber 20th, Dr. Richard B. Faulkner, aged sixty-three years. 

Gordon. — In Toronto, Ont.. on Saturday, December i6th. 
Dr. Andrew R. Gordon, aged fifty-three years. 

Harrington. — In Grand Junction, Colo., on Friday, De- 
cember 8th, Dr. Robert B. Harrington, aged thirty-seven 
years. 

Harvey. — In Colville, Wash., on Sunday. December 17th. 
Dr. Lee B. Harvey, aged forty-eight years. 

Kutz. — In Weissport, Pa., on Sunday. December 24th. 
Dr, Wilson L. Kutz, aged sixty-three years. 

Lambert.. — In Port Jervis, N. Y.. on Friday, December 
8th, Dr. Emerson B. Lambert, aged sixty-four years. 

Onion. — In Lewiston, III., on Saturday. December i6th. 
Dr. Emery Oliver Onion, aged thirty-nine years. 

Radue. — In Union Hill. N. J., on Tuesday, December 
26th, Dr. William F. Radue, aged fifty-five years. 

\\'heeler. — In Brooklyn. N. Y., on Saturday, December 
30th. Dr. Claude L. Wheeler, aged fifty-two years. 



New York Medical Journal 

INCORPORATING THE 

Philadelphia Medical Journal ^^ Medical News 

A Weekly Review of Medicine, Established 1 843. 



Vol. CV, No. 2. 



NEW YORK, SATURDAY, JANUARY 13, 1917. 



Whole No. 1989. 



Original Communications 



THE RELATION OF CHRONIC INFECTIONS 

OF THE GENITOURINARY TRACT TO 

OBSCURE INTERNAL DISORDERS.* 

By Hugh Hampton Young, M. D., 
Baltimore. 

f*From the James Buchanan Brady Urological Institute, Johns 
Hopkins Hospital.) 

That my subject is one of great importance — espe- 
cially now when the whole question of the bacteri- 
ology of focal infections is receiving so much atten- 
tion in the medical journals, I recognize at once, 
but I also realize how difficult it will be to bring to- 
gether accurate comprehensive data to show the im- 
portant role played in such infections by the genito- 
urinary tract. Bacteriological findings and statistics 
are particularly unsatisfactorj' for two reasons, first, 
because the common presence of the colon bacillus 
in urinarj' infections as a secondary invader often 
obscures other more delicate organisms such as the 
streptococcus, and, secondly, revolutionary advances 
have been made in bacteriology in the last six years 
which depreciate much of the older work. 

In a masterly article on chronic focal infections 
Bilhngs (i), in 191 1, drew the attention of the med- 
ical profession to a long neglected field of medicine. 
After calling attention to the tonsils and throat, 
gums and teeth, bronchiectatic and pulmonic cavi- 
ties, gastrointestinal ulcers, appendicitis, and chole- 
cystitis as foci of infection, he remarked that the 
urinary tract, including the pelvis of the kidney and 
the bladder, are often the sites of infection. "Pyeli- 
tis, even when there is only moderate obstruction of 
the drainage of the kidney pelvis, may produce myo- 
sitis, arthritis, neuritis, etc. The prostate and sem- 
inal vesicles are a common source of infection of 
gonorrheal arthritis and probably of ordinary septic 
infections. The Fallopian tubes and the uterus are 
less common, and the parametrium more common 
focal sources of infection. Local submucous and 
subcutaneous septic foci anywhere may be a source 
of systemic disease." 

Billings further remarked that "the insidious slow 
degenerative process in patients at the meridian of 
life is due to intoxications from focal infections, 
and the result of the removal of those infections has 
been most astounding in many instances." 

In a previous article, published in 1910, Poynton 
and Paine (2) had described their diplococcus of 

*Read by invitation before the New York Academy of Medicine. 



rheumatism which they obtained from the blood, 
pericardial fluid, and tonsil in ten cases. 

Other papers, in 191 2, increased interest in the 
subject, particularly one lay D. J. Davis (3) on the 
bacteriology of chronic infections, and a paper on 
chronic oral infections by T. L. Gilmore (4). The 
year 1913 saw the publication of important studies : 
C. S. Wright (5) ; Bass (6) ; Fuller (7). During 
the same year an important symposium on the sub- 
ject was held in the surgical section of the American 
Medical Association, at which Billings (8) presented 
a paper on focal infection and Young (9) a paper on 
the prostate and seminal vesicles in general toxemia. 
In the medical section, McCrae (10) read a very im- 
portant paper on the remote eU'ects of lesions of the 
prostate and deep urethra. 

During the years 1914 and 191 5, Barney's (11) ar- 
ticle on the seminal vesicles, Brackett's (12) arthri- 
tis and the genitourinary tract, and additional arti- 
cles by Fuller (13), Quinby (14), Squier (15), 
Thomas (16), Belfield (i/), all on the seminal vesi- 
cles and their relations to the general disorders, 
added further interest to the subject and brought to 
the forefront the importance of the genitourinary 
tract. 

This year, 1916, has seen a continuance of the in- 
terest, as shown by the publications of McCrae (18) 
on chronic arthritis, of Anderson (19) on the sem- 
inal vesicle in gonorrheal rheumatism, and of Maier 
(20) on the pelvic organs and systemic disease, a 
very important article from the g)'necological stand- 
point. Lastly Culver (21) has presented by far the 
best bacteriological study of seminal vesiculitis 
which has appeared. 

With such an impressive array of investigators, 
experimental and clinical, it would seem almost use- 
less to attempt to throw new light on a subject con- 
cerning which the profession is already so 
thoroughly aroused. A careful analysis, how- 
ever, shows at once that there are many 
sides to the question of infection in the 
genitourinary tract the importance of which has 
been overlooked, and many remote and "obscure in- 
ternal disorders" the dependence of which on these 
infections is not only not generally appreciated but 
is not even mentioned in the literature of the sub- 
ject. It was with the hope of thus broadening the 
scope of medical interest and pointing out unfilled 
fields for future investigation, that I accepted the 
formidable invitation of vour society. 



Copyright, 1917, by A. E. Elliott Publishing Company. 



50 



YOUNG: GENirOURINARV TRACT AND INTERNAL DISEASE. 



[New York 
Medical Journal. 



In the first place, what are the "obscure internal 
disorders" which are related to chronic focal infec- 
tions? Billings gives this rather terrifying list in 
recent publications, viz., acute rheumatism, arthritis 
deformans, gonorrheal arthritis, malignant endocar- 
ditis, myostitis, myocarditis, pericarditis, septicemia, 
nephritis, various visceral degenerations, thyroiditis, 
pancreatitis, peptic, gastric, and duodenal ulcer, 
cholecystitis, appendicitis, various cardiovascular de- 
generations, arteriosclerosis, and chronic neuritis, 
chorea, erythema nodosum, herpes, spinal myelitis, 
iridocyclitis. 

Wright has added the following: Secondary ane- 
mia, urticaria, furunculosis, eczema, diabetes, pur- 
pura hemorrhagica, asthma, chronic catarrh and 
nervous breakdown, and Maier cites cases of ano- 
rexia, tachycardia, and asthenia, as due to^ chronic 
focal infections. 

McCrae, giving cases which he has seen in our 
clinic, lays stress on the disproportionate general 
symptoms which accompany lesions of the veru- 
montanum, prostate, and seminal vesicles. "In many 
cases," he says, "the predominant feature is anxiety 
for which no cause is found except disturbances 
in the sexual sphere. In several cases with symp- 
toms, especially referred to the heart — palpitation, 
rapidity of rate, attacks in which there is precordial 
distress, tachycardia, pain simulating angina pec- 
toris, have all been seen." One patient came with 
a diagnosis of angina and a gloomy prognosis ; dis- 
ease of the deep urethra and prostate was found, 
local treatment cured him and the "angina" dis- 
appeared. 

In 1906 we (22) called attention to various ob- 
scure referred pains which occurred as a result of 
chronic inflammatory infiltrations in and about the 
prostate, ejaculatory ducts, and seminal vesicles. 
Previous diagnoses of lumbago, renal and intestinal 
colic, neuralgia, neuritis, and sciatica had been made, 
but were dissipated by cure of the prostatic disease. 

The mere recital of this rather formidable list of 
maladies which has been shown to be due to chronic 
focal lesions is enough to show the impossibility of 
treating the subject assigned me in an exhaustive 
manner. 

In order, however, to discuss the subject system- 
atically it seems advisable to take up seriatim the 
various genitourinary regions subject to infection, 
and to point out the anatomical peculiarities which 
might render certain locations natural points for the 
localization and persistence of infectious processes. 

Kidney. Starting with the kidney, a glance at the 
anatomy and pathology would seem to indicate at 
once that many opportunities for absorption from 
localized infectious processes are present. In the 
glomerulus we find at once a distended sac with 
constricted neck and uphill drainage, and likewise 
in the urinar}' tubule imperfect drainage in the nar- 
row ascending tubule should infection occur. In 
parenchymatous and perinephritic infections the 
chances of absorption and resulting general sepsis 
are even greater. 

From the renal pelvis and calices the drainage is 
ordinarily good, and in simple pyelitis we see little 
absorption, but inflammatory infiltrations, anatom- 
ical abnormalities, and calculus interfere with drain- 
age in many cases, and pelvic dilatation, hydroneph- 



rosis, destruction of renal cortex, and perirenal in- 
ilammation follow, producing typical conditions for 
systemic invasion with toxins and bacteria. We 
should therefore expect to find in our clinical mate- 
rial and in the literature an abundance of evidence 
of systemic disease from focal infections in the kid- 
ney and pelvis. But strange to say, such is not the 
case. Rheumatism and arthritis are certainly very 
rare as complications ; our clinical records show 
none, and a hurried survey of our 4,000 autopsy rec- 
ords reveals no case with a combination of arthritis 
and chronic renal suppuration. We do find many 
instances of chronic myocarditis and occasionally of 
endocarditis, and Osier states that chronic suppura- 
tive processes of the kidney are common sources of 
infection in acute endocarditis. 

A careful search of the literature reveals very 
little definite information on the subject. Billings 
says "pyelitis of whatever type, even when there is 
only moderate obstruction of the drainage of the 
kidney pelvis, may produce myositis, arthritis, neu- 
ritis, etc.," but he gives nothing more on the subj|,ct 
and cites no case histories. Likewise David J. Da- 
vis, reporting on the bacteria of focal infections, 
says that his "first work had to do with genito- 
urinary disease, and chiefly infections of the blad- 
der with the colon group," but he cites no cases and 
gives no facts in regard to the relation between 
renal infections and systemic disorders. 

Even the more recent textbooks of pathology, 
bacteriology, and surgery throw no light on the sub- 
ject. The many bacteriological studies which have 
been made of the urine from the bladder in urinary 
infections have invariably shown a large prepond- 
erance of colon bacillus infections in chronic cases. 
In cultures from twelve cases of pyelitis Brown 
found Bacillus coli seven times. Bacillus proteus 
vulgaris four times, Staphylococcus albus once. In 
acute cystitis Suter (23) and Tamaka (24) found 
cocci to be the more common etiological factor, but 
agreed with Brown and others that Bacillus coli was 
the common organism of chronic cystitis. 

All investigators are agreed that streptococci are 
very rarely foimd in chronic urinary infections — 
cystitis and pyelitis — and this may explain why 
arthritis, rheumatism, and endocarditis so rarely ac- 
company renal suppurations. Apparently the latter 
are specifically due to streptococci or gonococci. 
both of which are found with great rarity in focal 
renal infections. In the acute suppurative nephritis 
of Brewer the foci of infection of which are gen- 
erally due to the staphylococcus, endocarditis often 
coexists, but both are acute local manifestations of 
a blood infection and do not properly belong to the 
subject under discussion. 

Dr. Walter James has kindly sent me the statis- 
tics of cultures taken from 800 cases of arthritis by 
Murphy and Kreuscher and presented to this acad- 
emy on October 19th. In this study they found the 
source to be the urethra in seventeen per cent., the 
bladder in four per cent., and the kidney pelvis in 
four per cent. Streptococci predominated and were 
found in thirty-one per cent, of the cases, gonococci 
in fourteen per cent., staphylococci in eight per 
cent., pneumococci in five per cent., and colon ba- 
cilli in only four per cent, of the cases. There was 
a combination of two or more organisms in thirtv- 



January 13, 1917.] 



YOUNG: GENITOURINARY TRACT AND INTERNAL DISEASE. 



51 



eight per cent, of the cases, the varieties found not 
being given. 

We have here again conckisive evidence that arth- 
ritis is a coccus disease ; various kinds of cocci be- 
ing present in fifty-eight per cent, out of the sixty- 
two per cent., in which a single organism was 
found. Their demonstration that the disease is 
periarticular confirms other work in which the joint 
fluid has been usually found sterile. 

Ureters. We have already mentioned the changes 
at the upper end of the ureter which lead to urinary 
obstruction, pyelitis, nephritis, etc. Similar condi- 
tions may exist almost anywhere along the course 
of the ureter with similar results, particularly in 
the pelvic portion where the ureter is often involved 
in diseases of the reproductive organs of the female 
and sometimes in seminal vesiculitis in the male. 
The terminal portion of the ureter is frequently ob- 
structed by calculi, strictures, tmnors, and congen- 
ital defects, and we often find it transformed into 
a dilated flabby tube filled with stagnant infected 
urine, surely most propitious for producing back 
pressure eft'ects and a general to.xemia, but here 
again the literature and clinical material aft'ord little 
help; no citations of definite general systemic infec- 
tions which can be attributed to pyoureters. We 
have niunerous instances, however, of severe im- 
pairment of kidney function due to back pressure 
elTects, as shown by the following cases : 

Case I (3010). C. A. C, aged thirty-two years, came 
complaining of dull pain in the left side of abdomen, night 
sweats, and general weakness of long standing. E.xamina- 
tion showed two ureters on the left side, one of which was 
greatly dilated (about two inches in diameter), as shown 
by the radiogram. The lower end of this ureter was stric- 
tured and the dilated portion above was herniated into the 
bladder in the form of a globular mass, but when the blad- 
der contracted in efforts to void, the tumor would disap- 
pear through the diverticulum like orifice, only to recur on 
deep inspiration. Lov/ered kidney function, pyre.xia, and 
asthenia resulted from the retention of infected urine in 
the ureter and was relieved by a plastic intravesical opera- 
tion. 

Case IT (5168). A. L. B., woman aged thirty-five years, 
complaining of burning on urination of ten years' duration. 
General health remarkably good. Recently pain of slight 
degree in the right iliac region and increased frequency of 
urination. On ureter catheterization, huge pyoureters were 
found on both sides, and the phthalein test showed no ex- 
cretion during the first hour and only a trace during the 
second hour. Both kidneys were badly infected with colon 
bacilli and very little urea was excreted. At operation, 
stricture of the lower end of each ureter was discovered 
and relieved by ureterotomy. The case was remarkable 
on account of the absence of general symptoms, although 
the kidneys had practically been destroyed by back press- 
ure from ureteral obstruction. 

Bladder. It is not to be expected that much ab- 
sorption will occur from ordinary cases of cystitis. 
The stratified mucosa of the bladder is one of the 
least absorbent surfaces in the body, and with good 
drainage and frequent evacuations little trouble is 
caused by severe and long standing cases of vesical 
infection. That remote infections may come from 
localized cystitis is shown by the following case : 

Case III (4920). R. H. D., aged thirty-six years. 
Localized focal cystitis associated with arthritis ; appli- 
cations of ten per cent, silver nitrate through the ureter 
catheter cystoscope ; apparent cure of cystitis and arthritis. 
Admitted March 26, 1916, complaining of "painful swelling 
of joints and pain around the bladder." No history of 
gonorrhea. Present illness began two and a half years ago 
with frequency, burning pain on urination, and swelling of 



wrists and hands. Eighteen months ago another surgeon 
performed suprapubic cystotomy and removed a median 
lobe of the prostate, but without relief of symptoms. Now 
urinated with pain very frequently night and day. Exam- 
ination: Chronic arthrits of shoulders, elbows, wrists, 
hands, spine, and left knee. Prostate and seminal vesicles 
indurated, but secretion obtained l)y massage showed no 
pus or bacteria. Urine cloudy with pus, but no bacteria 
found on several examinations. The cystoscope showed 
on posterior wall near vertex of bladder four small red 
areas, probably three to five mm. in diameter, with evi- 
dence of hemorrhages in mucous membrane at periphery 
of lesion. These areas, which were recognized as localized 
cystitis, were scattered over an area three or four cm. in 
diameter. X ray showed infectious polyarthritis, sinuses 
negative. One diseased tooth found and extracted without 
benefit. 

Treatment : With catheterizing direct cystoscope, applica- 
tion was made with ten per cent, silver nitrate through a 
ureter catheter (with end cut off so as to remove eye) 
directly upon the four small areas of localized cystitis, on 
four different occasions. Patient notic^'d improvement at 
once, and the arthritis soon began to disappear ; in two 
months he was apparently well, and the cystoscope showed 
tlie bladder to be normal. 

Sometimes the mucous membrane is so resistant 
that an infection may persist for months without 
causing inflammation. When obstruction is present, 
however, drainage is interfered with, residual urine 
develops, the bladder becomes trabeculated, pouches 
and diverticula form, and excellent opportunities 
for infection, deep seated inflammation, ulceration, 
septic absorption, and general infection occur. 

Here again the usual absence of the streptococcus 
is probably the reason- we rarely encounter rheu- 
matism or arthritic coinplications. But the bacilli 
of the colon typhoid group which preponderate here 
as the infective agents are far from harmless. 

The course followed by Bacillus coli infections 
of the bladder is seen regularly in enlarged prostate 
cases. After a few catheterizations the bacilli are 
generally found in the urine. For a time they may 
produce no inflammatory reaction, appearing simply 
as a bacilluria, but as a rule a mild acute cystitis 
and urethritis results with varying systemic mani- 
festations — fever, malaise, and occasionally chills 
and moderately severe evidences of toxemia. After 
a short period — three to ten days — a tolerance to 
the chronic infection, which has by this time become 
engrafted, is usually established, and the patient 
may go on catheterizing himself for the rest of his 
days with only occasional attacks of sepsis. If, 
however, regular catheterization is not afiforded and 
considerable residual urine is persistently present, 
pressure efifects with concomitant trabeculations, 
diverticula, dilatation of ureters and renal pelves 
occur, with results of a serious nature upon the 
whole organism. 

Adami has described very lucidly the varied 
phases of "persisting infection" which he prefers to 
the term chronic ; e.xacerbations which occur when a 
smouldering infection bursts forth into a blaze; re- 
mittent types which light up from time to time ; and 
latent infection which persists without causing dis- 
turbance. He uses the term subinfection to apply 
to "the presence of bacteria in the blood which are 
not potent enough to cause gross symptoms of in- 
fection yet which do wear out the cells whose duty 
it is to combat with and kill them." Adami con- 
siders that subinfection with Bacillus coli is respon- 
sible for the production of an important series of 



YOUNG: GENITOURINARY TRACT AND INTERNAL DISEASE. 



[New Yobk 
Medical Jouknal. 



chronic morbid states. Just as these bacilli may get 
into the circulation from the intestinal tract when 
in a condition of stasis from chronic constipation, 
so may the same organisms infect and poison the 
body in chronic urinary obstructions. By repeated 
inoculation of relatively nonvirulent colon bacilli, 
well marked anemia can be experimentally pro- 
duced. I have just seen a case of chronic urinary 
retention with colon bacillus infection accompanied 
by an anemia of almost pernicious type which I be- 
lieve to have resulted from it. 

A more potent effect, however, is probably pro- 
duced upon the kidneys and through them upon the 
heart, bloodvessels, and other vital structures by in- 
fection combined with back pressure. Space does 
not permit me to discuss fully the important remote 
disorders thus produced. The clinical picture is a 
common one, a pale, anemic, asthenic patient, with 
lack of appetite, at times nausea and severe digest- 
ive disturbance, and with evidence of myocarditis, 
arteriosclerosis, hypertension, and chronic renal in- 
sufficiency. The catheter shows considerable res- 
idual tu-ine of poor quality, the phthalein test re- 
veals marked impairment of the kidney function, 
and uremic and cardiac crises during the course of 
palliative treatment emphasize clearly the desperate 
condition of the patient. 

Such cases not infrequently show little or no 
urinary symptoms and go along untreated or mis- 
treated for months or even years, while the insid- 
iously destructive effects of residual urine, back 
pressure, and colon bacillus infection go merrily on, 
unsuspected, while the patient is treated for cardio- 
renal disease, hypertension, indigestion, anemia, 
neurasthenia, or even paresis. 

How many of these unfortunates are brought to 
the clinic, and how surprised are their physicians 
when the catheter withdraws a pint or more of 
residual urine, and the phthalein test shows a mere 
trace of kidney function left! The only complaint 
of one patient with normal urinary intervals in 
whom we found two quarts of residual urine, was 
that his abdomen was constantly growing larger so 
that he had repeatedly to buy new trousers. 

The proof of the urological etiology of these 
grave internal disorders is the marvelous way in 
which they disappear when the back pressure of in- 
fected urine is relieved by systematic catheteriza- 
tion, drainage, or prostatectomy. Several distin- 
guished internists who have directed the medical 
treatment of certain severe cases have been 
astounded to see patients who were apparently in 
extremis gradually become rational as uremia dis- 
appeared and the vascular and myocardial and en- 
docardial conditions improved so astonishingly that 
ultimately a radical perineal prostatectomy was car- 
ried out almost without risk. The remarkable re- 
cuperative power of the kidneys is shown by scores 
of cases in which the phthalein test and blood urea 
indicated only a trace of functional capacity left on 
entrance to the hospital, but which under catheter 
drainage so rapidly improved that often within a 
month a fairly good function was obtained and 
operation successfully performed: 

Case IV. Patient, acced seventy-nine years, with a pre- 
vious history of two apoplectic attacks, came in complain- 
ing of incontinence. He was pale and weak. The pulse 



was intermittent, arteries were markedly atheromatous, the 
heart was dilated, and murmurs were present. The pros- 
tate was considerably enlarged, 1,200 c. c. of residual urine 
present, and only a trace of phthalein appeared iii four 
hours. Under catheter drainage, rest in bed, digitalis, and 
special cardiac diet, the kidney function gradually improved, 
and at the end of six weeks thirty-one per cent, was ex- 
creted in an hour. Perineal prostatectomy was then safely 
performed. 1 saw him the other day; he was eighty-four 
years of age, but apparently enjoyed life and was quite 
well. 

Such cases might be enumerated at length, but 
suffice it to say that not only is it possible to bring 
back well toward normal, by preliminary catheter 
treatment, kidneys which have been greatly impaired, 
but also at the same time to bring about such a great 
improvement in the cardiac condition that where op- 
eration at first seemed unthinkable, it may finally 
be safely performed. 

The urethra and annexa. We come here to an 
anatomical system rich in structures of potential in- 
fection, and with an entirely distinct bacteriolog)'. 
The various glandular structures surrounding and 
draining into the urethra, all with narrow ducts, 
furnish a most fertile field for the development of 
chronic infections. The glands of Littre and of 
Cowper, the prostate, verumontanum, utricle and 
ejaculatory ducts, seminal vesicles, vasal ampulla, 
vas, epididymis, and testicle furnish the most com- 
plex glandular system in the body, and as one or 
all are infected in thousands of cases of gonorrhea, 
we can appreciate the dangerous condition of these 
patients not only to society but also to themselves. 

Gonorrhea is of course the great primar\- 
cause of infection, but space does not permit of fur- 
ther lengthy discussion of this most important 
chronic disease. European statistics attribute to it 
a fearful prevalence and the deep annexa have been 
shown to be involved in from seventy to ninety per 
cent, of the cases. 

As a result of the advent of the newer silver in- 
jections, an aroused medical profession, and in- 
creased knowledge among the laity, gonorrhea is 
less prevalent, more often cured, and deep seated 
chronic infections are now less frequent, in Amer- 
ica at least, than formerly. They are sufficiently 
prevalent, however, to be our greatest infectious 
menace, and the medical profession is even yet 
rather ignorant of or indifferent to the fact that a 
patient should never be declared well simply because 
the discharge has ceased and shreds are no longer 
present in the urine. The examination of the secre- 
tion from prostate and seminal vesicles is so easy 
and so decisive that it should never be neglected be- 
fore discharging an acute or chronic gonorrheal 
case as cured. 

The remote lesions produced by the gonococcus 
are manifold. Almost every tissue and structure of 
the body has yielded cases of gonococcus infection 
(25). In addition to the common lesions produced 
by direct extension — ampullitis, vasitis, epidi- 
dymitis, and orchitis in the male, and vaginitis, ade- 
nitis, endometritis, salpingitis, oophoritis, and peri- 
tonitis in the female — we may have (although 
rarely) cystitis, ureteritis, pyelitis, and nephritis, all 
from direct extension. We have also gonococcal 
septicemia, endocarditis, arthritis, synovitis, myo- 
sitis, pleuritis, meningitis, and localized abscesses in 
almost every part of the body. 



I9I7-1 



rOUNG: GENITOURINARY TRACT AND INTERNAL DISEASE. 



53 



Although fuhiiinating in onset, many of these 
very severe infections, even endocarditis and general 
septicemia, are sometimes not fatal, but the deform- 
ing effects are generally terrible in their results. 
One of the most interesting phases of clironic 
gonorrheal inflammation is the general disappearance 
of the gonococcus and its frequent replacement by 
other bacteria, particularly the streptococcus. This 
has been particularly demonstrated in chronic sem- 
inal vesicuhtis. It has been shown that the gono- 
coccus disappears with increasing rapidity as the 
years go by. Notthaft's figures show the gono- 
coccus in the prostate in seventy-three per cent, of 
cases seen within twelve months after the last infec- 
tion ; in fifty per cent, of twelve to eighteen months' 
cases ; eighteen per cent, of eighteen to twentj'-f our 
months' cases; six per cent, in two to three years' 
cases. No gonococci were found in the prostatic 
secretion after the third year. 

In a bacteriological study of chronic prostatitis 
we (26_) found streptococci in sixteen per cent, 
of the cases, Staphylococcus albus in sixteen 
per cent., no colon bacilli and no gonococci 
found in any case, though fifty per cent, 
came within three years of the gonorrheal 
infection. Our findings have been confirmed by 
a recent exhaustive study by Culver (27) of 
twenty-four cases of chronic vesiculitis with arthri- 
tis ; he found streptococci in six cases, micrococci 
in four cases, and staphylococci in six cases. The 
colon bacillus was present only once, the proteus 
twice, and the gonococcus four times. Skin and 
agglutination reaction and inoculation tests with 
killed organisms were positive in nearly all cases. 
Picker, Voelcker, Barney, and others have found 
cocci in the seminal vesicles at operation. We have 
apparently definite proof, therefore, that the pyo- 
genic cocci and not the gonococcus or colon bacillus 
is responsible for chronic infections of the prostate 
and seminal vesicles, and also for the arthritis and 
rheumatic conditions which so frequently accom- 
pany them. The whole literature on streptococcus 
infection has been in a ver>- unsettled state since 
1910, when Poynton and Paine (28) announced 
that they had discovered an anaerobic diplococcus 
in the blood, pericardial fluid, and tonsils of ten pa- 
tients with rheumatism, and proved the specificity 
of their Micrococcus rheumaticus by inoculations 
into rabbits in which they produced lesions typical of 
rheumatism. Other observers, while failing to con- 
firm exactly these findings, have discovered various 
streptococci and diplococci in rheumatism, and 
Rosenow has produced a nonsuppurative arthritis 
and endocarditis in rabbits with streptococci which 
he obtained from the joints of seven cases of artic- 
ular rheumatism. He has not, however, clarified 
the situation by his discoveries of marvelous muta- 
tions and selective affinity or predilection which he 
ascribed to cocci coming from various lesions. Ap- 
parently most bacteriologists agree tha. "judgment 
must for the present be held in abeyance." 

Holman (29) offers evidence from a long and 
varied experience with diplococci against the occur- 
rence of mutations, and feels that a culture of strep- 
tococci, once carefully purified, remains true to type, 
even for years. He also suspects the reliability of 
animal passages, noting the ease with which other 



varieties of streptococci will invade the tissues of 
the experimental rabbits, especially from the ali- 
mentary canal. 

Rosenow's ideas of transmutation and selective 
tissue affinity are very attractive and have been ac- 
cepted by Billings, Mayo, and others as offering the 
long sought solution of various knotty problems of 
focal and remote infection, and Squier has suggest- 
ed that it is not too much to presume that the gono- 
coccus may mutate and "what is in the beginning a 
Neisserian seminal vesicuhtis is latterly a strepto- 
coccus infective process." 

Clinical cases, in great number, are on record to 
prove the varied lesions of remote and serious char- 
acter which owe their existence to the seminal vesi- 
cles and probably also to the prostate and other an- 
nexa. To Eugene Fuller much credit is attributable 
for his observations, operations, and remarkable 
series of splendid results. Thanks to him, to Squier, 
and others the profession realizes that one of the 
common causes of chronic rheumatism, arthritis, 
myositis, endocarditis, neuritis, and various other re- 
mote lesions mentioned at length early in this paper, 
is focal infection in the seminal vesicle, generally 
curable by operations for drainage or extirpation. 

The marvelous way in which disabled rheumatic 
joints and myocardial conditions disappear, and pa- 
tients wdio have been helpless invalids for years get 
well in a few weeks, is one of the wonders of mod- 
ern surgery. One case may be mentioned here : 

Case V. J. H. W., aged forty-nine years ; severe chronic 
multiple arthritis; myocarditis cured by prostatectomy and 
seminal vesiculectomy. Admitted February 11, 1915, com- 
plaining of artliritis and heart disease. No history of gon- 
orrhea. In 191 1, suffered chronic pain in lumbar region, 
and examination in 1913 showed marked prostatitis and 
seminal vesiculitis, pus, and Staphylococcus aureus present. 
In 1914, manifested multiple arthritis. Diseased teeth were 
extracted, autogenous vaccines given without benefit. Later 
tonsillectomy and operations on nose and sinuses _ without 
result. Examination showed severe multiple arthritis, with 
shoulders, elbows, wrists, spine, hips and right knee in- 
volved. Atrophy of corresponding muscles, marked fixa- 
tion of joints, patient confined to bed. Pulse ranged be- 
tween 100 and no; gallop rhythm. Heart enlarged two 
cm. on right side and 9.5 cm. on left in fifth interspace ; no 
murmurs. Prostate, slightly irregular and indurated, sern- 
inal vesicles moderately enlarged and indurated ; prostatic 
secretion contained pus and staphylococci. All other pos- 
sible foci having been operated upon without relief of 
arthritis, seminal vesiculotomy and prostatotomy were per- 
formed, with immediate benefit. Arthritis disappeared; 
patient, who had been bedridden for many months, was 
soon walking; stiffness o'f joints and rapidity of pulse dis- 
appeared. Six months later, the symptoms were seen 
again; examination by another surgeon showed recurrence 
of seminal vesiculitis. A second operation was performed 
— perineal prostatectomy, and cxcison of seminal vesicles. 
The arthritis again disappeared, and patient reported, fif- 
teen months after operation, that he was entirely well and 
strong — joints and heart normal. 

In numerous other cases simple drainage of the 
seminal vesicles has been sufficient to cure a chronic 
arthritis which had made invalids of such patients 
for years. The role of the prostate in such local 
and remote infections has been too much neglected, 
and little information is to be found in the litera- 
ture. Not infrequently the prostate is seriously in- 
flamed in conjunction with the seminal vesicles, and 
it may be responsible alone for remote rheumatic 
and cardiac lesions. It should unquestionably be 
incised and drained along with the seminal vesicles 
in such cases. Likewise infection often occurs in 



54 



yOUNG: GENITOUKINARY TRACT AND INTERNAL DISEASE. 



[New York 
Meuical Jourx 



liypertrophy ot the prostate, invading, as a rule, 
the normal layer of prostatic tissue bcnind and ex- 
ternal to the hypertrophied lobes. Several of my 
cases have been associated with joint and heart dis- 
orders and have rapidly improved after perineal 
prostatectomy in which this portion of the prostate 
is drained by the preliminary capsular incison. In 
some prostatectomies I have also exposed and 
drained the seminal vesicles, and I believe this 
should be done more frequently, as vesiculitis is not 
seldom present. 

Judging from 'the experiments of Thaon, Posner, 
Kahn, Cornus and Gley, Legueu, and Gaillardot, 
there seems to be little doubt that the prostate has 
an internal secretion. The active principle has not 
been isolated nor are its exact physiological proper- 
ties established, but evidence already accumulated 
points to its being toxic when injected into animals, 
and that it affects the blood pressure and to some 
extent the heart. Certain investigators have even 
noted an anticoagulative action, and this may be re- 
sponsible for some of the troublesome hemorrhages 
that sometimes occur from the prostate. Doctor 
Macht is at present engaged in a research on these 
problems, and we have been using a blood coagu- 
lant, kephalin, particularly after prostatectomy, with 
apparently marked effects in the rapid stoppage of 
hemorrhage. 

The verumontanum, composed as it is of glandu- 
lar and cavernous tissue, and containing the utricle, 
ejaculatory ducts, and a highly complex nerve sup- 
ply, is one of the most common focal causes of re- 
mote disorders. Not only do we have chronic in- 
flammatory conditions accompanied by dispropor- 
tionately severe sexual and urinary symptoms, but 
the most remarkable referred symptoms frequently 
occur. This condition is often inseparable from 
chronic prostatitis and should be considered here 
at the same time. In a study of 358 cases of chronic 
prostatitis we (26) found that referred pains of 
varied character were present in a large proportion 
of the cases. The most common site was the back 
— sixty-four cases; then came the perineum thirty- 
five, suprapubic region twenty-two, hips ten, thighs 
twelve, knee four, leg four, simulating sciatica five, 
kidney region eight, simulating renal colic ten, etc. 
The widespread character is thus evident. The se- 
verity was often great and in other cases the more 
or less constant presence of pain was fearfully 
nerve racking. Those cases with pain in the kidney 
region often simulating renal colic are excellent ex- 
amples of reflexes arising from inflammatory infil- 
tration in and about the prostate, which are ex- 
plainable by Head's researches on the "pain of vis- 
ceral disease," viz., the pain is referred to "the por- 
tion of the body supplied by nerves from the same 
spinal segment instead of to the viscera actually af- 
fected." 

In an excellent paper on the "remote effects of 
lesions of the prostate and deep urethra," McCrae 
(30) cites "several cases in which the symptoms 
have been referred to the heart — palpitation, rapid- 
ity of rate, attacks in which with precordial distress 
there is tachycardia, and attacks simulating angina 
pectoris." McCrae also mentions a patient who 
suflFered with severe attacks of abdominal pain due 
to inflammation of the verumontanum which could 



be reproduced by touching the verumontanum 
through the urethroscope. "There could be no 
doubt of the severity of the attack — the patient 
went almost into collapse." I have seen many 
patients who had been treated for a host of diseases 
— lumbago, sacroiliac disease, renal calculus, appen- 
dicitis, neuralgia, sciatica, and various neuroses and 
psychoses, all due to disease of the verumontanum, 
prostate, or vesicles, the frequency and importance 
of which are little appreciated by the medical pro- 
fession. 

The seminal tract is likewise a frequent focus of 
infection, both for tuberculosis and other suppura- 
tive processes. Drainage and treatment of the vasa 
deferentia and seminal vesicles, advocated by me in 
1 901, have been elaborated and popularized by Bel- 
field in his articles on "pus tubes in the male," and 
Hagner's work in epididymitis has drawn attention 
to the seriousness of these foci of suppuration, both 
locally and remotely, and to the need for prompt op- 
eration in many cases. The demonstration that the 
entire seminal tract may be removed without injury 
of the prostatic urethra, bladder, or testicle (which 
is generally healthy in both tuberculous and other 
inflammations of the epididymis) has brought an- 
other region into the radically curative field of sur- 
gery. 

It seems appropriate to reserve for the last my 
lantern slides^ of anatomical peculiarities which pre- 
dispose to focal infection and systemic absorption, 
the pathological changes which lead to toxemia or 
sepsis, and some surgical measures by which they 
can be eradicated. 

The object of this long paper has been to fulfill 
the requirements of the topic assigned ; to show "the 
relation of chronic infections of the genitourinary 
tract to obscure internal disorders," and to demon- 
strate what the urologist has to oflfer in the cure of 
the local disease and the relief of the obscure dis- 
orders. If I have somewhat accomplished these 
purposes I shall feel well repaid for having inflicted 
upon my readers so long a dissertation. 

REFERENCES 
I. BILLINGS: Arch, of Int. Med., v, g, 1912. 2. POYNTON 
and PAINE: Lancet, ii, 861. 1910. ^. D. I. DAVIS: Arch. Int. 
Med., ix, S06, 1912. 4. T. L. GILMORE: Ibidem. ■;. C. S. 
WRIGHT: Chronic Infection as a Cause of Chronic and Subacute 
Rheumatism, Canada Lancet. April, 1913, p. 566. 6. B.\SS: Acute 
Rheumatic Orch tis, Journal A. M. A.. Ix, 1608, 1913. , 7. 
FULLER: The Cure ThrouRh Genitourinary Surgery of Arthritis 
Deformans and Allied Varieties of Chronic Rheumatism. Med. Rec. 
Ixxxiv, 691, 1913- S. BILLINGS: Chronc Focal Infection as a 
Causative Factor in Chronic .\rthritis. Journal A. M. A.. Ixi, 819. 
I9[3. 9. YdUNG: The Role of the Prostate and Seminal Vesicles 
in General Toxemias, Ibidem, Ixvi, 822, 1913. 10. McCRAE: Re- 
mote Effects of Lesions of the Prostate and Deep Uretlira, Ibidem, 
Ixi, 477, IQI3- II- BARNEY: Recent Studies in the Pathology of 
the Seminal Vesicles, Boston M. and S. Journal, clxxi, 159, 1914. 
12. BRACKETT: Arthritis Associated with Lcs'ons of the Genito- 
urinary Tract, ibidem. 13. FULLER: Med. Rec, Ixxvii, 134. 
1915. 14. QUINBY: Boston M. and S. Journal, xxxiii, ?8. 1914- 
T^. SQUIER: Cleveland Med. Journal, xii, 80, 1908, ifi THOMAS: 
Amer. Journal of Surp., Ix, 3'3, IQU- I7. BELFIELD: Surg. 
Gvncl. and Ohstet.. xxi, 221, 191 ■;. 18. McCRAE: Chronic Arthri- 
tis, Penn. Med. Journal, xix, 501. I9i';-i6- I9. ANDERSON: 
Eo'e of the Seminal Vesicle in Gonorrheal Rheumatism, Tenn. 
Med. Jour., ciii, 506, 1916. 20. MATER: Chronic Focal Infections 
of the Pelvic Organs and Their Relations to Svstemx Disease, 
Amer. Jour. Ohstet.. Ixxiv, 652, 1916. 21. CULVER: Study of the 
Bacteriology of Chronic Prostatitis and Spermatocvst'tis, with Spe- 
cial Reference to the Relat'onshin to Arthritis. /oicnia/ .4. M.A., 1916. 
2^. YOUNG. GER.ACHTY a"'l "STEVENS: Ch-onic Prostatitis././/. 
Hospital Reports, xiii. 23. SUTER: Ztschrft. fiir Urol., i. 127, 1907. 
24. TAMAKA: Ibidem, cxi. 431, 1909. 2i;. VOTING : The Gonncoccus, 
/. ;y Hnspilnl Reports, ix. 19. 2fi. YOTTVG. CPRAGITTY and 
STEVENS; Ibiden', xiii, 278, loofi. 27. CI'LVER : Journal A. 
M. A.. Ixvi, 552. I9ifi. 28. POY'NTON and PAINE, Lancet, xi, 
S61. 1000. 29. ITOLMAN: Jour. Med. Research, xxxiv, 377, I9i«- 
30, McCR.^E: Journal A. M. A . Ixi, 477, 1913. 

lit has been necessary to omit illustrations of the fifty lantern 
slides showing the pathology and surgery of chronic suppurative 
lesions of the urinary tract. 



January 13, 1917.] 



KONKLE: BETE NOIRE OF THERAPEUTICS. 



55 



THE BETE NOIRE OF THERAPEUTICS. 

By W. B. Konkle, M. D., 

Montoursville, Pa. 

The delimitation of our thesis is altogether arbi- 
trarj- — solely a matter of convenience and of se- 
lection. With the same degree of truth and conse- 
quentness its scope might be extended to the entire 
field of medicine — or, farther than tliat, to science 
in general — or, yet farther, to humanity's beliefs 
and practices as a whole. The fallacy of logic de- 
nominated post hoc, ergo propter hoc, is the 
bete noire in question. This has constituted the 
root and source of a vast bulk of popular supersti- 
tion and of many another human error, hoary, and 
venerated. The common prejudice against tliirteen 
at table and Friday undertakings on the one hand, 
and the frequent custom of planting crops and 
slaughtering cattle with reference to the moon's 
phases, on the other hand, are relevant examples. 
Within the stricter conhnes of actual science the 
operation of the same bete noire has been pernicious 
and derogatory, as attested by the manifold doc- 
trines affirmed as f„cts today only to be repudiated 
tomorrow as fancies and follies ; while its sinister 
influence up)on medicine's special movements is evi- 
dent in the sorry exhibition here witnessed of un- 
certainty, mutability, inconstancy. But therapeu- 
tics is the subject of our storj' — it is within this still 
more restricted department that we would trace the 
trail of the bete noire. 

The fallacious principle under consideration, post 
hoc, ergo procter hoc, is none the less baleful be- 
cause it is as a Lucifer fallen from heaven. It is a 
perversion or an abortion of the method of induc- 
tion, thus attaching to the most important and potent 
instrument of progress in knowledge. It represents 
false, inaccurate, inconsequent inductive reasoning, 
and impressively signalizes the risks and dangers of 
advance by the logical route. It is a trite remark, 
but a true one, that anything may be proved by sta- 
tistics; which merely means that induction should 
be carefully guarded. As Aristseus overpowered 
Proteus, so must it be subjected to an alert mastery 
— must be checked and guided, lest, capriciously 
changing form, it lead the explorer far astray. 
Hume contends that in the succession of natural 
phenomena nothing presents to us the idea of caus- 
ality nor of the necessary bond between cause and 
effect. So that it requires nice discernment to dis- 
tinguish consequences from coincidences. Said the 
great Coan himself, "Experience is deceptive and 
judgment difficult." Broussais avers, J'ai pour 
principe de totijours me defter de I'experience des 
esprit s faux. Bouchut declares, Savoir observer 
n'est pas donne a tout le monde. 

In therapeutics our bete noire has been peculiarly 
and abundantly an origin of evil. Indeed, more 
often than truth is reached through g-enuine induc- 
tion does this counterfeit of it lead to error. Oh! 
what a very flood of therapeutic whims and fancies 
sweeps on in perpetual flow ! Embraced only to be 
discarded, the favorites come and go. To mere fads 
and fashions in healing, time and experience are in- 
exorably fatal. But when or ever will this teeming 
progeny of the bete noire be denied begetting? 

The notion, post hoc, ergo propter hoc, in reality 



is entirely without value as a criterion in therapeu- 
tics. Reliance upon it neither establishes nor vin- 
dicates any practice. Application of it results in 
multiform futility and absurdity. Recovery of the 
invalid does not in itself conhrm the efficiency of a 
measure supposedly curative. Here it is negative 
rather than positive proof that counts. The test of 
cure is not in the fact that recovery occurs after the 
administration of a chosen medicine, but in the cir- 
cumstance that without it recovery does not take 
place, or is deferred. Upon this point Bouchut 
says, Toittes les pratiques ridicules qui se sont 
glissees dans la science n'y ont penctre qii'a I'aide 
de ces mots; Cela reussit, I'experience I'a demontre. 
And again, Si I'on tient coinplc des gucrisons, tous 
Ics mcdecins ' ont ramene des malades d la sante. 
But the coming of any means surely therapeutic or 
prophylactic has the ring and swing of triumph — is 
as the march of a conqueror, or as the onsurging of 
the imperious, resistless tide. 

The injurious consequences of the therapeutic 
errors engendered by our bete noire are various and 
serious. Simplicity is sacrificed to complexity. In 
the temple of healing the vague, intricate, involved 
features of Hindu architecture replace the plain de- 
sign, the clear cut lines, the stately symmetry of 
Greek art. Multiplicity precludes unity. The 
devils that possess the therapeutic body are not six 
nor a dozen; they are legion. Instability under- 
mines permanency. Let Bouchut, who has written 
so lucidly and forcibly of the matter, again be 
quoted: // n'y a pasde mcdecin aujoitrd'liiii capa- 
ble d'accepter les trois quarts des opinions de Galien 
ou de 7.opyre, sur la maticre medicale. 

Another dire consequence of the procreative ac- 
tivity of the bete noire is that in running to the false 
we frequently desert the true — relinquish the worthy 
in welcoming the worthless. Not only do fads and 
fashions not constitute nor promote progress in cure, 
but they are positively detrimental to it, because 
they detract attention from, and occasion abandon- 
ment of real progressive measures and methods. 
Iodine for erysipelas and opium for peritonitis are 
instances in point. These remedies, assuredly valu- 
able in the cases cited, have after a period of eclipse 
come into their own again. After partial neglect 
and retirement during a generation their worth is 
being reasserted. With the opium treatment of 
peritonitis the name of Alonzo Clark is linked ; and 
thereby hangs a lesson. It is always unwise and 
rash to ignore a statement deliberately and insist- 
ently set forth by a man like Alonzo Clark — to as- 
sume hastily and offhand that he does not know 
what he is talking about. At any rate, a safe rule 
with reference to the whole subject is the one for- 
mulated in this admonition of Saul of Tarsus : 
"Prove all things ; hold fast that which is good." 

Still another deleterious result of the formative 
and directing influence of our bete noire within the 
therapeutic field is the effect of the same upon the 
tone and ability of the doctor himself. To be mis- 
led is to be duped ; to be duped is to be belittled ; to 
be belittled is to be enfeebled. To see clearly and 
to decide precisely are the indispensable attributes 
of power in medicine. The bete noire beguiles, 
hoodwinks, deludes. It promises substance, and 



56 



KONKLE: BETE NOIRE OF THERAPEUTICS. 



[New York 
Medical Journal. 



yields phantoms. It offers faith and then betrays, 
it gives assurance of victory, and straightway acconi- 
phshes defeat. Of course, the very condition of op- 
erating in the log with will-o'-the-wisps for guid- 
ing lights is conducive to a peculiar kind of personal 
enthusiasm or fanaticism which wins homage and 
patronage from certain classes of the laity. Ig- 
norance and conceit are a wedded pair between 
whom divorce will never come. Not rarely is mad- 
ness mistaken for inspiration. Ever is the fool an 
object of awe. So in medicine shallow egoti.sm 
has its own strength of a sort. Even though there 
is not much of him, the doctor who believes in him- 
self will be believed in by others. Self infatuation 
is the common starting point of the acclaimed won- 
der worker. But such lure has no appeal for the 
doctor at once honest and able. He would know 
things as they are, albeit such seeming retrench- 
ment of the precincts of knowledge may discredit 
him in some quarters. Exact apprehension and 
comprehension of his power and usefulness will de- 
velop into modesty and humility; and this may 
mean the loss of prestige with people who lack per- 
spicacity. No matter ; he will, nevertheless, resolve 
to know what he knows — to know what he is doing, 
and what he is not doing; what he can do, and 
what he can not do. He will insist upon determin- 
ing accurately how far he may be a puissant ally of 
Nature, and the line beyond which he becomes an 
audacious and dangerous supplanter. 

Of the veritable agents of cure some act directly 
and immediately. These may be arranged in two 
groups — specifics and remedies. A specific largely 
or completely controls disease. A remedy favor- 
ably affects disease. Specifics are few, and reme- 
dies not numerous. But there are other instruments 
which indirectly promote healing — those which dur- 
ing the course of disease regulate the various or- 
ganic functions. These form a larger class. These 
are the doctor's tools. Yet the careful doctor 
should not attempt to employ all of even these. 
With due regard to situation, occasion, circum- 
stance, he should tactfully select. Then by sedu- 
lous study and practice, by trial and retrial, in the 
use of any given implement of them he should make 
himself proficient, skillful, adroit, until the man and 
the tool are one, like Ingomar and his sword. And 
of a well approved tool thus made his very own let 
no siren song charm him into forgetfulness nor 
neglect. 

The proper attitude and procedure relative to the 
question of treatment of disease are as difficult as 
they are vital. Reviewing the mazy problems of 
therapeutics. Zimmermann declares once and again 
in purport that brain vigor to the measure of actual 
genius is required in their best solution. Yes ; the 
healing art calls for genius — genius which can dis- 
cern between the real and the seeming, between fact 
and sophistry — genius which is the gift of recog- 
nizing sterling progress. The ideal doctor is a man 
of free, far vision, and keen, discriminating judg- 
ment. As a therapeutist his merit will be liable to 
a dual test — a positive and a negative one. He will 
have to decide both what he should do, and what 
he may not do. What he should do, of course, will 
include the employment of known and proved spe- 
cifics and remedies. But these are a meagre set. His 



larger duty will be faithfully, tactfully, deftly to 
handle his tools. Of these he will have a sufficiency 
in number and in variety. Any one of them that 
does what he would have it do, will be as good as 
any other that no more than does the same thing. 
Let him not, like a fickle suitor, lightly discard the 
old love for the new. If he adopts this course he 
will have ample work before him, although, as he 
ought, he refuses to follow Celsus to the extreme 
of his contention, melius est anceps remedium qnam 
nullum. Let physicians thus "keep the noiseless 
tenor of their way," heeding not the loud heralding 
of pretended marvels. They need have no fear of 
missing a real discovery. "For as the lightning 
conieth out of the east, and shineth even unto the 
west," so is the coming of a true remedy. 

In the management of sickness, negative merit 
ranks high. It lacks brilliancy, has about it a pre- 
dominant Fabian quality; but it is solid and unex- 
ceptionable. It is a laudable ambition to attain 
signal rightdoing ; yet not to be despised is the trib- 
ute, he has done no wrong. In the department of 
therapeutics overdoing is wrongdoing; activity here 
to the extent of harm is the reproach of medicine. 
Would the doctor escape such guilt, let him beware 
of the hete noire. 

All along the therapeutist may test the efficiency 
of his personal work by comparison with the results 
of general practice. This he should conscientiously 
and assiduously do. Pausing thus to check, to orient 
himself, to take his bearings, not only absolutely 
but also relatively, if he finds that his average suc- 
cess is equal to the average success recorded as the 
outcome of enlightened effort in the field at large, 
then he should be satisfied ; if his surpasses the com- 
mon ratio, he may congratulate himself. Having 
proved that he is abreast or in advance of the pro- 
fessional body in attainment and accomplishment, 
he need not apologize for measures or methods. 
With his mortality rates speaking for him, he will 
not have to plead his own case. Gauging with 
such a standard his operations and endeavors, he 
will dare to be independent and original — to ignore 
fashion — to defy the toils of the bete noire. He 
will not be "tossed to and fro, and carried abotit 
with evcrv w-ind of doctrine." He will not heed- 
lessly follow the thoughtless throng to the worship 
of false gods of healing — impotent, ephemeral gods, 
which in number and variety outclass the gods of 
old Rome. But he will be a good, true, strong doc- 
tor. His work may not be dramatic nor spectacu- 
lar; finer, nobler still, it will be the expression of 
power and virtue. And he will be content, know- 
ing that worth is better than show, and feeling that 
rather than a mere refined and cultured counter- 
part of the African fetish doctor or the Indian med- 
icine man, he would prefer to be forever a Tele- 
machos exploring earth and sea under the jegis of 
Pallas Athene, or a Numa in devoted discipleship 
sitting at the feet of divine Egeria within her grotto 
at the base of the Caelian Hill. 



Cheyne-Stokes Breathing in Heart Disease. — 
D. Gerhard recommends inhalation of oxygen for 
from five to twelve minutes, which is usually fol- 
lowed bv a period of normal respiration. 



January U. >9i7] 



GRAD: BORDERLINE ABDOMINAL CASES. 



57 



BORDERLINE CASES OF THE LOWER 
ABDOMEN.* 

By Herman Grab, M. D., F. A. C. S., 
New York, 

Attending Surgeon, Woman's Hospital. 

In considering this subject I have reference en- 
tirely to the female abdomen. The subject divides 
itself into two groups, the acute and the chronic. 
In the acute cases the first pathological entity that 
arrests attention and needs to be differentiated in 
the borderline cases of the lower abdomen, is that 
of the disease of the appendix vermiformis. It is the 
atypical case of appendicular disease, where many 
of the objective signs and subjective symptoms are 
lacking with perhaps noncorroborative laboratory 
findings, with vague and indefinite previous history, 
as gathered from the patient and relatives, that we 
must be careful not to overlook. It is in these cases 
that our examination must be exhaustive, and we 
must not lightly dismiss the idea of the existence 
of disease because the symptoms are atypical. Ap- 
pendicitis is a very frequent disease, and in affec- 
tions of the lower abdomen the possibility of this 
pathological entity should not be lightly dismissed 
from the differential diagnosis. I know of no short 
cut road to the diagnosis of these borderline cases. 
The best mode of procedure to arrive at a diagnosis 
is to take into serious consideration every sign and 
symptom, spend sufficient time in their analysis, 
and weigh carefully their significance and their rela- 
tive merits- This procedure will serve us well, and 
the time spent will be amply rewarded. 

For example, muscular rigidity is a fairly reliable 
sign in appendicitis, and as a rule the rigidity of 
the right rectus is in proportion to the degree of 
peritoneal irritation, but in borderline cases the ab- 
sence of rigidity should not lead us into the mistake 
by dismissing from our mind the possibility of ap- 
pendicitis. This will hold true also of the labora- 
tory findings. A high leucocyte count and a high 
differential count ser\e as corroborative evidence, 
but a low count does not necessarily exclude the 
possibihty of appendicular affections. The very 
fact that the appendix is so often the seat of dis- 
ease justifies us in not excluding this affection from 
our diagnosis when we are dealing with trouble in 
the lower abdomen. This is rightly so, and yet this 
very fact is often the cause of error. A case in 
point is a recent experience of my own. 

Case I. The patient, sixt\--5ix years old. of some social 
prominence, the mother of a large and influential family, was 
taken ill quite suddenly with trouble in the lower abdomen. 
The diagnosis of appendicitis was established by three 
careful and conscientious practitioners of medicine, and I 
was asked to operate for appendicitis. At the consultation, 
the signs and symptoms presented by the old lady failed 
to dovetail into each other. For example, peritonitis was 
present. There was a temperature of 104° F., a !eucoc}rte 
count of 16,000, with a differential count of eighty-six per 
cent., polymorphonuclear, but on careful palpation there 
was only a relative rigidity of the recti and an inflamma- 
tory mass about appendix was wholly absent. Bimanually 
a very hard and enlarged uterus was found, and although 
she was eight years past her climacteric, a profuse vaginal 
discharge was discernible. The enlarged organ was ten- 
der, and very gentle palpation brought out the fact that 
the tenderness was confined to the lower uterine segment. 

•Read at a meeting of the Yorkville Medical Society, October 
16, 1916. 



These findings threw an entirely different light on the 
case. Twenty-seven years previously the patient was ad- 
vised to have an operation for Hbroid of tlie uterus. When 
i opened the abdomen a calcareous degenerating gangre- 
nous fibroid with an active peritonitis was found and the 
appendi.x was entirely normal. Recovery followed a 
stormy convalescence. Here we had a borderline case 
with atypical symptoms of appendicitis. A careful analy- 
sis of tlie symptoms saved us from an error in diagnosis. 
In chronic appendicular disease we also have bor- 
derline cases. There are a large number of chronic 
sufferers who have gastric and intestinal symptoms 
that have their origin in a reflex neurosis as a result 
of morphological changes in the appendix. Many 
cases of indigestion, constipation, malnutrition, 
flatulence, and general debility, with perverted se- 
cretory function of the alimentary tract, are cases 
where the focal point of origin of abnormal reflexes 
is the appendix. Experience has shown that the 
great sympathetic ner\'Ous system of the abdomen, 
the abdominal brain, so to say, is a mighty factor in 
the mechanism of normal secretion, excretion, as- 
similation, and metabolic changes that occur in the 
abdominal viscera. Abnormal nervous impulses 
arising at some focal point in the sympathetic nerv- 
ous system will cause disturbance in the nervous 
mechanism which will affect reflexly organs 
and viscera at a point distant from the 
seat of disease. Thus, in chronic appendi- 
citis we may have marked gastric symp- 
toms, depending on a hyperniotility or atony 
of the muscular mechanism, or hypersecretion or 
perversion of the secretary function. The same 
will hold true of the liver, kidney, and pancre- 
atic function. These cases are borderline cases. 
These patients go from place to place seeking relief. 
The gastrologists, the neurologists, the electrothera- 
peutists are all consulted in turn, and if no relief 
comes, they drift into the hands of the various so 
called healers. After years of progressively steady 
pathological changes in the appendix, involution is 
complete, the nervous irritation subsides, and the 
patient gets well. The healer who happens to be 
the last one to have had the case in hand gets the 
credit of cure. While all this is true about the ap- 
pendix, we are forced" to admit that many of these 
borderline patients fall into the surgeon's hands to 
have their appendix removed, when in reality they 
should have been in the hands of a neurologist, 
stomatologist, or electrotherapeutist. The inter- 
pretation of the ailments of this class of cases is a 
difficult task, and in justice to the patient and our- 
selves we must make our examination a most 
searching one and bring our best diagnostic acu- 
men to bear. An accurate diagnosis results in 
proper therapeusis which brings relief of symp- 
toms, if not a cure. Errors in diagnosis drive these 
cases away from legitimate medical practice and into 
the arms of the so called "healers," of whom there 
are thousands. 

In the lower abdomen of the female there is a 
variety of possible pathological entities in the so 
called borderline cases, and these pathological enti- 
ties have their seat in the generative organs. The 
tissue changes occurring may be divided into four 
classes: i. Those due to inflammatory reaction; 
2, those due to pregnancy; 3, those due to neo- 
plasms ; 4, those due to traumatism. Under these 



'.8. 



GR.ID: BORDERLINE ABDOMINAL CASES. 



[Ni'.w York 
;dkai. Joi.B.N 



four main groups we can classify every case in the 
lower abdomen, arising in the generative organs. 
In approaching these cases for the purpose of diag- 
nosis, we may profitably ask ourselves, to which of 
these four classes the case under consideration be- 
longs. If this is impossible, on account of the mea- 
gre or conflicting history, then there is nothing to 
do but to ferret out just what etiological factors are 
at work in this particular case. The cases most 
frequently encountered are of inflammatory dis- 
ease of the generative organs. They are of two 
types, the gonorrheal and the pyogenic. These two 
types of infection frequently coexist or the pyogenic 
follows the gonorrheal. Each type of infection has 
its own particular life history. The gonorrheal in- 
fection spreads by continuity of tissue, while 
the other type spreads by lymphatic arid blood 
streams. In the gonorrheal type of infection of 
uterine annexa, we have very palpable external evi- 
dence of the existence of the disease. We frequent- 
ly have an associated urethritis, vaginitis, infec- 
tion of the vulvovaginal or Skeene's glands. The 
presence of such external evidence is, of course, 
a great help in arriving at a diagnosis. It must be 
remembered, however, that gonorrheal infection of 
the external genitalia remains dormant for many 
years, and while it is possible to demonstrate gono- 
cocci in the secretions of the infected glands, their 
presence does not necessarily mean that the dis- 
turbance in the abdomen is the result of the gonor- 
rheal infection. It is quite safe to surmise, how- 
ever, that the abdominal condition is one belonging 
to the class of inflammatory cases when the ex- 
ternal organs are infected. Gonorrheal infection 
of the female genital organs has an interesting 
life history. The virulence of the infection, the 
degree of tissue changes, the acuteness of the onset, 
the chronicity of the inflammatory process are so 
variable in this disease that seldom are two cases 
of gonorrheal infection aHke. In the majority 
of cases gonorrhea in the female is so mild and so 
insidious as to fail to attract attention. The suf- 
fering the infection entails is of the mildest kind 
and the symptoms are practically nil. Contrast this 
with the "fulminating cases of gonorrheal infection. 
Scarcely is the incui)ation period passed when the 
infected tissues throb and burn, the sufifering is in- 
tense, the temperature rises, the systemic reaction is 
marked, and even in a few days the entire gen- 
erative tract, from the vulva to the ovarian and 
pelvic peritoneum, is aflame with the infection, nor 
does the urinary tract escape. In former years, be- 
fore the fulminating cases of gonorrheal infection 
were well understood, many an abdomen was 
opened during the acute stage, and what wtis found 
to account for the intense sufifering of the patient? 
A very angry looking tube and an active peritoneal 
reaction. Operative interference invited fatal peri- 
tonitis, or at best the removal of such tubes resulted 
in a stormy convalescence with more or less break- 
ing down of the abdominal incision, a long and tedi- 
ous recovery, and a postoperative hernia into the 
bargain. We have learned to know better. These 
cases do better without operative interference in the 
acute stage, and under appropriate medical care, the 
acute symptoms subside, and operation becomes a 



safe procedure during the chronic stages. These viru- 
lent cases of gonorrheal infection of the uterus and 
annexa are to be dilterentiated from acute pelvic 
disease of a type where immediate operative inter- 
ference is called for during the acute stage, namely, 
cases of long standing, annexal disease with acute 
exacerbations. These cases with acute "comebacks" 
are safe operative risks; nothing is gained by wait- 
ing. These are the cases where with ablation of 
parts and thorough drainage above and below, we 
can get brilliant results. We can take a woman 
with this type of pelvic disease, who has been bed- 
ridden for months and years, and who is sick unto 
death, and by operative procedure make her once 
more a useful member of society. How can we 
differentiate these two classes of patients in the bor- 
derline cases? The diiiferentiation at times is beset 
with difficulties. However, by taking a careful 
histor)', by having in mind the life history, by trac- 
ing back the histories, year by year, to the time of 
marriage or an early miscarriage, we can come to 
the conclusion whether the case is a primary infection 
or a chronic infection with an acute exacerbation. In 
the former it is best to delay operation during the 
acute stages ; in the chronic cases operation is safe 
The latter cases have multiple foci of pus in the 
pelvis which call for evacuation and drainage as 
well as ablation of tumified infected tissue, which 
can never regenerate and become functionally inte- 
gral. There is still another type of acute affection 
of the lower abdomen belonging to the inflamma- 
tory' class which often calls for differentiation, 
namely, acute salpingo-oophoritis and- metritis with 
pelvic peritonitis of puerperal origin and following 
septic abortions. The prognosis is bad, and 
operative interference has a high mortality. These 
cases have fever often for a long time, have very 
little tendency to subside, and are apt to be compli- 
cated by phlebitis, by metastatic abscesses, and vari- 
ous other sequellje. The history of these cases read- 
ily dififerentiates them from the other. The abdo- 
men becomes distended early in the disease, the 
recti are rigid, and the vaginal examination is quite 
characteristic. The vaginal fornices, the cul-de-sac 
of Douglas, become more boardlike and unyielding 
in a most characteristic manner, and the more 
chronic the case becomes, the more boardlike is the 
feel of the pelvic floor in a vaginal examination. 

There are diseases encountered in the lower abdo- 
men which have as their causes conditions connected 
with pregnancy, and in some of these cases the dif- 
ferentiation between these and those arising from 
other causes is not as easy as it seems. For exam- 
ple, the dififerentiation between a ruptured ectopic 
gestation sac and that of inflammatory reaction of 
the uterine annexa is quite difficult. This was il- 
lustrated in a recent case, and an error in diagnosis 
was avoided by a preliminary puncture of the cul- 
de-sac of Douglas. 

Ca-SE II. The patient, a woman of twenty-seven years, 
was taken ill with chills and fever and some pathological 
condition in the lower abdomen. A temperature of 103° F. 
and a corresponding rise of pulse was present. Peritoneal 
irritation was elicited on e.xamination. Bimanually a mass 
was discovered in the pelvis. The menstrual history was 
vague; there had been irregularity in the menses on pre- 
vious occasions. The last pregnancy had occurred six 



GRAD: BORDERLIKE ABDOMINAL CASES. 



59 



years before when the patient was only twenty-one years 
old. Tile diagnosis of pelvic abscess was made. Leucocy- 
tosis was increased. There were 16,000 whites and eighty 
per cent, polymorphonuclears. A posterior section was de- 
cided on and this was performed. Much to our surprise, 
we found a ruptured ectopic gestation sac. A large mass 
which could not be removed trom below was palpable, so 
it was decided to do a section. On opening the abdomen 
the large gestation sac in the right tube was ablated and 
the pelvis drained above and below. 

Here was a borderline case where the historj' and 
physical findings all pointed to an inflammatorj- 
case, and while the inflammatory reaction was pres- 
ent, the important factor was the ruptured ectopic 
sac. Cases where symptoms of ectopic gestation 
and appendicitis exist calling for differentiation 
have come to many a diagnostician, and to differ- 
entiate the conditions is at times a difficult task. 
The tenderness at McBurney's point may be veni- 
marked, the rigidity of the right rectus quite pro- 
nounced, the temperature rise, the pulse rate, the 
blood findings may all harmonize with the condi- 
tions that come with an attack of appendicitis, and 
yet the affection may be in the right uterine tube. 

Such a case has also fallen to my lot and the error 
of diagnosis led to an operation for appendicitis. 
When the abdomen was opened the findings were 
those of a ruptured ectopic sac. As I sat at the bed- 
side of this particular patient the question of ectopic 
gestation arose between the attending physician and 
myself. We discussed the condition of the patient, 
and obtaining no confirmatory evidence so far as 
the history of menstruation was concerned, the 
diagnosis of ectopic gestation was abandoned and 
that of appendicitis adopted. A McBumey incision 
was made and on opening the abdomen the pres- 
ence of free blood led us to the proper diagnosis. 
The posterior sheet of the right rectus was split up, 
the rectus retracted, and in this way access was ob- 
tained to the pelvis for operation and removal of 
the right tube. 

Here was a case where the jxjssibility of ectopic 
gestation was clearly held before our minds, and 
yet we dismissed it and favored a diagnosis of ap- 
pendicitis. 

There are other conditions which arise in con- 
nection with pregnancy that may call for differen- 
tiation between that and other affections. Preg- 
nancy, for example, in abnormal or rudimentary 
uterine structures, interstitial pregnancies, or preg- 
nancies in the horns of abnormal uteri. In these 
cases pain is a prominent symptom, and the differ- 
entiation between pregnancies in abnormal uteri and 
pregnancies in the normal organ is at times attended 
with difficulty, nor can a diagnosis of these cases 
be cleared up without a section. The differentia- 
tion between a ruptured ectopic sac and an inter- 
stitial gestation may obviously be impossible. There 
is. however, this to be said. In interstitial gestation 
the rtipture occurs as a rule at a later date of preg- 
nancy than in ectopic gestation, so that when rupture 
does occur the shock is greater and the loss of 
blood is more marked than in gestation in the tube. 
Nevertheless we should be very bold to try to dif- 
ferentiate between these two conditions as we 
stand at the bedside of our patient. 

While the diagnosis of neoplasms of the gener- 
ative organs is readily made, nevertheless there 
are borderline cases where the differentiation has to 



be made between neoplasm and other affections in 
the lower abdomen. Fibroid tumor of the uterus, 
for example, is readily diagnosed, but when these 
neoplasms undergo pathological changes of various 
i^inds of degeneration, the differential diagnosis be- 
comes difficult. Furtliermore, the differential diag- 
nosis is difficult when the neoplasm, for example, 
one of the ovary, suddenly becomes twisted or its 
blood supply impeded. Twisting of the ped- 
icle of an ovarian cyst, for example, may usher in a 
form of acute symptoms such as to defy the best 
diagnostic ability. The symptoms may be acute, 
may simulate those of a ruptured ectopic sac or of 
an acute suppurative process, or even those of a 
fulminating case of appendicitis. The peritoneal 
irritation is marked, prostration of the patient is ex- 
treme, and in some cases the shock is intense. 
Usually, however, the discovery of a neoplastic mass 
in the abdomen or pelvis points the finger and leads 
us to the proper diagnosis. 

In a recent experience the history of a patient 
was so clear and so unmistakably that of a ruptured 
ectopic sac that no less than four diagnosticians 
confirmed the diagnosis of a ruptured ectopic gesta- 
tion sac. When the abdomen was opened, a gan- 
grenous neoplasm of the left annexa revealed itself. 
The pedicle was twisted several times in such fash- 
ion as completely to block circulation in the tumor. 
Furthermore, twenty months previously, the patient 
was delivered of a baby under normal conditions 
and with a normal puerperium. It is not an un- 
common experience to diagnose fibroids of the 
uterus, and such a diagnosis is justifiable in those 
cases by the symptoms, and yet when the abdomen 
is opened, to the chagrin of the operator and the di- 
agnostician, no fibroids are found, but an agglutinated 
mass of diseased uterus and annexa. The tubes 
and the ovaries are massed together by inflamma- 
tory organized tissue. Palpation gives the feel of 
multiple fibroids. The mass as a rule is insensitive, 
and an error of diagnosis is made because of lack of 
.symptoms which would lead us to suspect inflam- 
matory disease instead of a neoplasm. In the class 
of cases, where traumatism is a factor in the affec- 
tions of the lower abdomen, the history will help in 
ilie differential diagnosis. 

Spontaneous rupture of a gravid uterus, for ex- 
ample, may have to be differentiated in borderline 
cases of the lower abdomen, but here the history 
will help us. Rupture of a neoplasm such as an 
ovarian cyst, which comes by direct or indirect vio- 
lence, may sometimes call for differentiation, and it 
might be difficult for the diagnostician to arrive at 
the proper diagnosis. These cases are, however, 
comparatively rare, and if an error in diagnosis does 
occur, the diagnostician cannot be blamed too se- 
verely. There is one other condition in the lower 
abdomen that I wish to call attention to ; it may be 
of considerable concern to the diagnostician. The 
patients complain of severe and sudden attacks of 
pain in the lower abdomen, with symptoms of peri- 
toneal irritation. I have reference to cases where 
the pain is due to rupture of Graafian follicles in 
abnormal ovarian structures. As a rule, the pain is 
sudden, comes on from ten to twelve days after 
menstruation, is attended by peritoneal irritation, 
lacks fever, and the diagnosis is sometimes difficult. 



6o 



RIDDELL: A CAUSE OF DISABILITY. 



[New V^ork 
Medical Journal. 



The question is often asked if the attack is not one 
of appendicitis or some other acute infective pro- 
cess of the lower abdomen. With careful question- 
ing of the patient and gentle palpation appendicitis 
can be ruled out, and other infectious (liseases be 
set aside. The symptoms promptly subside and in 
from twenty-four to thirty-six hours the patient is 
well again. I have had occasion to see such cases 
in consultation and by being on the lookout for 
them, especially in young women, I have often been 
fortunate in making the proper diagnosis. 

Space will not permit even mention of the vari- 
ous diseases of the intestinal tract which may call 
for difi'erention from borderline cases of the lower 
abdomen. 

40 East Fortv-first Street. 



WHAT IS THE "CAUSE" OF DISABILITY? 
A Medicolegal Question, 

By William Renwick Riddell, LL.D., Etc., 
Toronto, Ont. 

In the Supreme Court of Ontario, a medicolegal 
case has recently been decided which will be of in- 
terest to many medical men. 

Doctor Mitchell took out an accident insurance 
policy in the Fidelity and Casualty Company of 
New York ; a few days thereafter, he was thrown 
from his berth in a Pullman car and sprained his 
wrist. The injury did not improve as expected ow- 
ing to tuberculous infection ; and it appeared to be 
permanent. The policy called for $150 a week for 
total disability, "however long continued, if resulting 
from accident directly, independently, and exclu- 
sively of all other causes" ; the company held that 
the accident was not the only cause and refused to 
pay. Doctor Mitchell sued and succeeded at the 
trial. The matter came to be decided in the Ap- 
pellate Division of the Supreme Court, of which I 
have the honor to be a member. 

I add here so much of my judgment as is not of 
interest to lawyers only : 

"Riddell, J. : — This apf>eal involves the interpreta- 
tion of a contract of very common occurrence. Were 
it a case of less importance, I should be content to 
adopt without further comment the conclusions of 
the learned trial judge, and so dismiss this appeal. 

But the advance of knowledge raises and will con- 
tinue to raise novel contentions : and what is a com- 
monplace at one time becomes a matter of great con- 
troversy at another. Until very recently, the main 
ground of dispute of liability here would not have 
been thought of: or, if thought of, would have re- 
ceived scant consideration — but tempora mutanttir et 
ftos mil tarn iir in illis. 

The plaintiff, a doctor of medicine, a specialist in 
diseases of the eye, ear, nose, and throat, took out 
an accident policy with the defendants, an accident 
insurance company. In most accident insurance pol- 
icies, the beneficiary is entitled to payment only for 
a limited time (usually one year or less), but this 
company finds its account in making its policies per- 
petual, that is, for the life of the patron who may 
be injured. No doubt, this forms a strong induce- 
ment to those desiring accident insurance, to prefer 
this company. 



In the application, the duties of his occupation are 
described as "special work on eye, ear, nose, and 
throat," and the insurance was against "bodily injury 
sustained . . . through accidental means . . . and 
resulting directly, independently, and exclusively of 
all other causes in an immediate, continuous, and 
total disability that prevents the insured from per- 
forming any and ever)' kind of duty pertaining to 
his occupation." 

The plaintiff was thrown from an upper berth in 
a sleeping car and thereby sprained his wrist 
severely — it is not contended by the defendants that 
this was not an injury within the meaning of the 
policy — and, had the injur)' healed within a short 
time, no doubt the company would have paid the 
$150 per week without demur. 

But the injury did not heal, it is not yet healed, 
and it is doubtful whether it will ever be much im- 
proved — the company tind themselves charged with 
an obligation to pay $150 per week for years, per- 
haps until the deatli of the plaintiff; and hence they 
dispute liability. 

Several medical men of eminence were examined 
at the trial : without at all reflecting on any other, 
it seems to me that the evidence of Doctor Anderson 
gives the most satisfactory explanation. He says 
that some time ago, probably some ten or fifteen 
years before the accident, there had been a tuber- 
culous condition of part of the pleura, probably 
the apex of the left lung: any existing tuberculous 
mass had become encysted so as to leave no apparent 
disease — the patient would be quite well, wholly un- 
conscious of any trouble, danger, or disease ; and 
there would be no danger of another outbreak pro- 
ceeding from the original disease. 

But an accident happens, tissues are injured, a 
lessened resistance to the "germs" occurs, these, 
otherwise innocuous, find a nidus into which to in- 
trude and in which to become active. 

I can see no difference between this case and the 
case of an injury causing a break in the skin and 
thereby • allowing some of the germs which are 
(practically) always and everywhere floating 
around, to enter and set up a diseased condition. 
How is a "lessened resistance" of tissues, without 
a breach of continuity of the skin allowing germs 
which may be in the blood to enter and set up or 
continue an inflammator)' condition, different from 
a lesion of the skin allowing similar germs which 
may be in the air to enter with the same result? 

Until a comparatively recent day, no one knew 
anything about the tubercle bacillus, and such affec- 
tions as are now known (so far as such matters are 
known) to be due to the invasion of a bacillus were 
supposed to be due to exposure to the air. Would 
any one in that state of theory — knowledge if you 
will — say that the air was a contributing cause of 
the disability? And is the meaning of words to be 
changed by the change of medical theory? 

We must interpret this document on common 
sense principles ; no one could, when obtaining acci- 
dent insurance, imagine that he was guaranteeing 
the company against the presence, accidental and 
temporary or otherwise, of tubercle bacillus or any 
other bacillus or spirillum in his system. We must 
interpret the language of this contract in its ordi- 



■9'7.] 



BEATES: NARCOANESTHESIA. 



6i 



nary and popular meaning — the use of language 
preceded scientific investigation. 

That this disability has as a cause the accident, 
cannot be disputed. In a well known Scottish case 
a miner was, by reason of an accident to a pimip, 
compelled to stand for some time in cold water, ex- 
fKJsed to a current of cold air. This reduced his 
vitality and permitted the pnemnococci which are 
(practically) everjwhere, to overcome the resistance 
of the tissues; pneumonia set in and the man died. 
The arbitrator held that the pneumonia \vas caused 
by the occurrence; and, of the seven judges, six 
agreed with him — one only thinking tliat there must 
be some direct lesion. This case was approved in a 
case in the House of Lords. A miner was exposed 
to a cold current of air which "brought on pneu- 
monia," and it was held that the death was the re- 
sult of the exposure. 

I do not know of any difference between the case 
of a tubercle bacillus infection and tliat of a pneu- 
mococcus infection — it is said you cannot have tu- 
berculosis without the former or pneumonia with- 
out the latter. And I can see no diflference in law 
between an accident weakening the power of resist- 
ance of the tissues and allowing the pneumococcus 
to enter and an accident of another kind weakening 
the power of resistance of the tissues and allowing 
the tubercle bacillus to enter — the infection of either 
kind could not fairly be called a cause within the 
meaning of this policy. 

It is to be noticed that in both the pneumonia 
cases, the pneumococci did not enter by any external 
lesion, but attacked the tissues in the same way as 
the bacillus in the case now imder consideration. 

The case of Briutons Limited v. Turvey contains 
much of value. A workman engaged in sorting 
wool contracted anthrax, which caused his death. 
"According to the medical evidence and theory," an 
anthrax bacillus passed into his eye, thereby infect- 
ing him with that terrible disease, and causing his 
death. The County Court Judge held that the en- 
try- of the bacillus was an accident ; his decision was 
affirmed by the Court of Appeal and the House of 
Lords. Lord Halsburj- gives examples of what he 
would call accidents : "A workman . . . spills 
some corrosive acid on his hands ; the injury caused 
thereby sets up erysipelas — a definite disease: some 
trifling injury by a needle sets up tetanus." No one 
in the present state of medical science doubts that 
en,-sipelas and tetanus are germ diseases like tuber- 
culosis, pneumonia, and malaria. 

In answer to the argument or suggestion that the 
condition of the plaintiflf's bodily system was a con- 
tributing cause, I asked, "Suppose the plaintifif were 
'a bleeder' — of the hemorrhagic diathesis, as the 
technical expression runs — so that a trifling lesion 
would produce (in the sense of being followed by) 
excessive hemorrhage, long continued, almost impos- 
sible to check, could it be argued that the diathesis 
was a contributing cause to the continued disabil- 
ity ?" Surelv such conditions of the body are condi- 
tions only (in the logical sense of the word) and not 
causes. 

The appeal should, in my opinion, be dismissed 
with costs." 

All the four judges of the highest court in the 



Province agreed that, while medically the infection 
was a cause of the disability, it should not be con- 
sidered such in interpreting such a contract. 

The case is interesting (if for no other reason) 
as showing that even courts of law, conservative as 
they are and must be, cannot avoid taking cog- 
nizance of the advance of medical science. 

OsGOODE Hall, Toronto. 



NARCOANESTHESIA. 

By Henry Beates, Jr., M.D., 
Philadelphia. 

The primary object of anesthesia, it is superfluous 
to remark, is to render patients unconscious of pain. 
From the present day viewpoint, it resolves itself 
into local anesthesia, in which consciousness remains 
unaft'ected, and general anesthesia, during which 
complete unconsciousness prevails. Too commonly 
has it been a conventional practice of operators, 
without attempt at intelligent differentiation, to re- 
sort to one anesthetic, ether, for all operations, and 
on the part of a few, occasionally, to chloroform. 
Because of certain injurious properties and effects, 
which experience has proved both ether and chloro- 
form to possess, attempts have been made to secure 
an anesthetic which is free from these disadvan- 
tages. Hence we have ethyl chloride, ethyl bro- 
mide, pental and nitrous oxide, and a resort to com- 
binations, of which the best known is the old A. C. 
E. mixture. 

The assertion that all anesthetics are more or less 
dangerous cannot be denied. Ignoring the argu- 
ments pro and con, chloroform, for illustration, is 
known occasionally to result in sudden death ; some- 
times by unheralded and abrupt cessation of the 
heart action which efforts fail to reestablish and, 
again, by unannounced, as it were, paralysis of res- 
piration, which, as in the heart paralysis, finds the 
functional processes involved incapable of being re- 
established. 

Ether exerts a profound toxic effect upon the red 
blood corpuscles, which the pallor, well known to 
the ether anesthetist and surgeon frequently demon- 
strates. In addition, the action of ether upon the 
cortex, which is commonly witnessed in the strug- 
gles that are encountered, even when administered 
most skillfully, constitutes an objectionable effect. 
The frequency with which impressions remain in 
this type of patient, that sometimes threaten mental 
integrity itself, are matters of such common knowl- 
edge that it almost requires an apology for refer- 
ring thereto. 

There are many operations in which it is desirable 
that the patient, when emerging from the anesthetic, 
should not be subjected to the agony and distress 
which excessive or even mild vomiting occasions, to 
say nothing of the pronounced shock. Needless to 
remark, another very important matter is the disar- 
rangement of structures, that retching and vomiting 
frequently threatens, that have been surgically 
placed in normal relationships, as in (inguinal) her- 
nia, iridectomy, and cataract. 

Reaction and recovery from serious surgical pro- 
cedure, it must be borne in mind, are more or less 



62 



BE.l TES: S ARCOANESTHESIA. 



I New York 
:dical Journai 



hindered by shock, as it is termed. Investigation 
has demonstrated that ether and chloroform anes- 
thesia is followed by albuminuria in about one third 
of the cases and in a considerable nmnber changes 
in the renal structure result, giving rise to casts that 
indicate parenchymatous lesions of a serious nature. 
Tile resort to spinal anesthesia, whereby the field of 
operation is rendered insensible to pain, although 
consciousness remains, has contributed much knowl- 
edge concerning shock, and has proved that where 
the mental makeup is such that the emotional side 
is not sufficiently influenced by knowledge of pro- 
cedure, shock, which was formerly considered to be 
due to extensive operative manipulation, is largely 
mental and the result of anxiety, apjjrehension. fear, 
yes, and even terror, that for days frequently domi- 
nates the mind of the patient who is compelled to 
undergo a major operation. In a word, anxiety 
contributes to shock almost as much as, if not more 
than operative procedure, and if it is possible to 
eliminate this, the duty of the surgeon is apparent. 
Spinal anesthesia, then, has shown beyond question 
that major operations can be performed in those not 
of an hysterical mental temperament, without shock, 
although consciousness remains. 

These and many other objections serve sufficiently 
to demonstrate the point to be made, to wit, 
that anesthesia should be affected by means that 
will secure unconsciousness and perfect freedom 
from pain, and, at the same time, exert a minimum 
of injurious eiTects. Here it may be remarked that, 
while unconsciousness to pain may be apparent, un- 
der such anesthesia as ether, for illustration, the 
nenous system itself, in contradistinction to the 
mind, suffers from the consciousness of pain almost 
as severely as though the patient was aware of the 
suffering which the operation would occasion. Thus 
it is evident that shock is of dual nature, in an etio- 
logical sense, and can be, as will be demonstrated, 
largely eliminated in so far as the psychical factors 
are concerned. 

What is known as narcoanesthesia has been grad- 
ually evolved by the study and investigations of 
various operators, having in view the practicability of 
overcoming many of the objections briefly mentioned. 
The construction of narcoanesthesia embodies 
a knowledge of the physiological effects of certain 
medicaments which act synergistically. Thus, what 
one lacks in advantages is made up by others that 
complementally supply the deficiencies. The fol- 
lowing plan has been adopted in a variety of op- 
erations now sufficiently large to enable a logical 
conclusion to be reached and submitted for consid- 
eration. 

About two and a half or three hours before the 
time set for operation, the patient receives a hypo- 
dermic injection of 1/50 of a grain of scopolamine 
hydrobromide and one sixth of a grain of morphine. 
One half hour later, a second injection is adminis- 
tered and an hour later a third, which may or may 
not contain morphine, as the susceptibility of the 
patient is more or less apparent. At the time of 
the third injection an enema of two fluid ounces each 
of whiskey and spiritus setheris compositus is given. 
By the time the hour for the operation has arrived, 
the patient is, as a rule, in a condition of complete 
narcoanesthesia. The face is more or less flushed. 



(Jccasionally there is moderate pallor. The respira- 
tions resemble those of profound sleep and, because 
oi the morphine and the susceptibility of the patient 
to its action, there may be a retardation of the respi- 
ratory rate to as low as ten or eight to the minute. 
There has been no material disturbance of the renal 
functions observed in any case ; hence, experience 
proves that even with the coexistence of renal de- 
generative lesions narcoanesthesia is safe. 

Operations upon the biliary tract, hernise, appen- 
dicectomies, pelvic operations of major type, such 
as hysterectomy, plastic work in the pelvic canal, 
operations upon the kidneys and rectum, constitute 
a group that may be most admirably subjected to 
narcoanesthesia and performed with that leisure that 
stands for the highest skill and greatest achievement 
of thorough surgery. 

A practical point here to be emphasized is 
the fact that senile subjects seventy and eighty 
years of age are most readily anesthetized in 
this manner, and it is not uncommon for tw'O injec- 
tions of 1/50 of a grain of scopolamine hydrobro- 
mide and one sixth of a grain of morphine to 
be found sufficient. Under the relatively pro- 
found narcoanesthesia which this apparently small 
(juantitv of the drug produces, radical and extensive 
operations for mammary carcinoma have been in 
every sense successfully performed. It sometimes 
is necessary, and this seems to be determined by in- 
dividual characteristics, to administer as high as five 
doses of the scopolamine hydrobromide and three, 
and even four, of the morphine. This, however, is 
exceptional and has been done by carefully watching 
the results and giving ample time to secure them. 
Thus a somewhat wide range of dose is showai. 

In operations upon the eye, such as iridectomy, 
where for obvious reasons it is desirable to avoid 
postanesthetic vomiting, a few surgeons who have 
resorted to this method of inducing anesthesia re- 
port satisfactory results. 

In operating in the abdominal cavity, it occasion- 
ally happens that there is a lack of relaxation of the 
external, internal, and transversalis muscles, which 
makes it a little more difficult than it otherwise 
would be to reach the field of operation, when deep- 
ly seated, and again because of this rigidity, which 
is only relative, however, a tendency of the intes- 
tines to protrude may prove annoying. In these 
cases a few whiifs of ether promptly overcome the 
difficulty and enables one experienced in narcoanes- 
thesia to secure ideal results for ease of procedure, 
and at the same time to avoid the depressing effects 
of the ether, as well as the subsequent nausea and 
vomiting. 

The patients sleep from three to seven hours after 
the operation and awaken, some without any dis- 
comfort whatever, the majority of them with a sliglit 
dryness of the throat and very exceptionally, slight 
vomiting. This latter postoperative symptom has 
only occurred twice in a series of more than two 
hundred cases, and was then only slight. 

For operations upon the nose and throat, the de- 
gree of narcoanesthesia necessary to control the re- 
flexes is so profound that, with the advantages of 
lessened secretion, the disadvantage of the necessity 
of having the patient watched for several hours 
.'ifter operation renders it an undesirable method to 



BEA TES : NARCOANESTHESIA . 



63 



rely upon alone. Recently therefore a mixed 
method, so to speak, has been tried. This con- 
sists in the single injection of the scopolamine 
and morphine, which, as a rule, renders the patient 
so inditterent to environment and surroundings that 
the ether can be comfortably administered and the 
operation completed with decidedly lessened nausea, 
vomiting, and shock. 

.\nother use, which saves the patient much post- 
operative discomfort and pain, is the resort to one 
or two doses when removing large packs and drains 
from the operative field, for illustration, in the 
drainage of a nephritic or perinephritic abscess, 
where large quantities of gauze are to be removed : 
or again in a series of drains necessary in delayed 
appendicectomy, in which we have enteroperitoneal 
adhesions and localized collections of pus, when re- 
moving the gauze and conducting postoperative 
treatment, an injection renders the procedure per- 
fectly comfortable. For prompt relief of the suf- 
fering incident to simple and compound fractures, 
and for securing conditions most favorable for re- 
duction and dressing, narcoanesthesia oflfers superior 
advantages. 

Twice it has occurred after operation, for unex- 
plained reasons, that there have been sudden symp- 
toms of profound morphine toxemia ; the respira- 
tions, reduced to four or less to the minute, and 
cyanosis in a moderate degree indicated the neces- 
sity for prompt measures to avert the threatening 
danger. Both instances necessitated the maintenance 
of artificial respiration and of such measures as are 
ordinarily necessary in acute morphine poisoning. 
The administration of caffeine or coft'ee by enema, 
the hypodermic injection of strychnine, and the in- 
travenous administration of normal saline solution, 
plus time, enabled us to bridge over the impending 
crisis, if we may call it such, and the patients con- 
valesced as though the accident had not occurred. 
In one of these instances it is doubtful whether or 
not a mistake had been made in the quantity of mor- 
phine advised, for obvious reasons, to be given 
alone ; two injections did not have the somnolent 
effect which they usually have, and an additional 
dose of morphine was given to secure this. The 
other was a late manifestation of susceptibility to 
the remedy which seems to have been most unex- 
pectedly precipitated. In some instances, after the 
full physiological eftects of the remedies employed 
in inducing narcoanesthesia had been secured, there 
was still reflex consciousness, as it were ; the patient 
opening the eyes, and, in one instance, raising the 
head and appearing to look about. At the time, it 
may be remarked there was no consciousness what- 
ever, as questioning the patient, upon recovering 
normal conditions, proved. When this condition ob- 
tains, the administration of one twentieth of a grain 
of apomorphine hydrochloride, overcomes the dififi- 
culty in a few minutes. Experience enables us to 
judge whether or not this medicament is necessary. 
Frequently this synergistic drug will advantageously 
replace ether, used as above described, for securing 
finishing touches, so to speak. 

The most conspicuous feature of this method of 
inducing surgical anesthesia is the testimony, with- 
out exception, of every patient that has been oper- 
ated upon that he would no longer, if it were neces- 



sary, hesitate to have an operation performed. To 
paraphrase one of them : "'The nurse told me that 
you desired me to have a hypodermic injection. 
This was given. I became sleepy and scarcely knew 
that another injection had been administered. When 
I awoke it was night and it was with difficulty that 
I could be made to realize tliat the operation had 
been performed." Many so testifying had previous- 
ly experienced operation under ether and approached 
the operation to be performed under narcoanesthe- 
sia with horror. There was no shock ; the patient 
was comfortable, free from the annoyances of the 
stench and taste of ether and the nausea, vomiting, 
sweating, and prostration which are too commonly 
witnessed after the old routine method of the al- 
most universally used anesthetic, ether. 

One extremely important precaution, which must 
never be omitted when inducing narcoanesthesia, is, 
that an intelligent and experienced attendant must 
not leave the patient from the time of the first injec- 
tion until consciousness or the reflexes which govern 
respiration have become reestablished. As in all 
anesthetics, there is danger of the epiglottis, tongue, 
or both, "being swallowed" and actual strangulation 
occurring. The air must be known to be passing 
in and out through the larynx. In other words, 
respiration must be unimpeded. It is the failure to 
observe this point that has resulted in some fatalities 
having been reported. The attendant, not being suf- 
ficiently, enlightened to recognize that the air was 
not passing into the lungs, and mistaking the con- 
vulsive respiratory movements of the thorax for res- 
piration, left the patient for a few minutes and re- 
turned to find the body warm, but dead. 

An objection that may be advanced against narco- 
anesthesia is that it requires special watching, and. 
therefore, necessarily engages from one to three 
hours of the time of an attendant qualified to guard 
against possible accident. If this is done, from the 
patients' point of view, the horror of surgery and 
its conseqtient shock will be averted ; and, from the 
doctors' viewpoint, an hour or two more of time 
may be consumed in conducting comfortably and 
safely any operation in the field above outlined. Dr. 
Wayne Babcock suggests the placing of a little wisp 
of cotton to the nostril. It serves as an indicator 
of the ingress and egress of breath, thus preventing 
mistaking the convulsive movements of strangula- 
tion for those of respiration. This simple device 
will avoid a very serious mistake on the part of the 
attendant having the care of a patient emerging from 
narcoanesthesia. 

260 South Sixteenth Street. 



Treatment of Osteomalacia. — Lawrence Litch- 
field {Pennsylvania Medical Journal, December, 
1916) outlines, as the rational procedure in a case 
of osteomalacia, an attempt to secure the best possi- 
ble hygienic environments, a generous diet, rich in 
calcium and phosphorus, the avoidance or termina- 
tion of lactation, the avoidance of pregnancy, adren- 
aline therapy and, if no improvement is noted, ster- 
ilization of the patient by the x ray. If this does 
not suffice, oophorectomy, followed by a return to 
the administration of phosphorus and the hvpoder- 
mic use of adrenaline. 



64 



IIEACOX: PHYSICAL EXAMINATION Of PRISONERS. 



[New York 
Meuicai, Journal. 



THE PHYSICAL EXAMINATION OF PRIS- 
ONERS ON ADMISSION TO PRISON. 

By Fr.\nk L. Heacox, M. D., 

Auburn, N. Y., 

Prison Physician, Auburn State Prison. 
INTRODUCTION. 

At this time, when prison problems are much in 
the pubHc mind, and are being discussed in terms 
of mental efficiency or feeble mindedness ; when 
Binet-Simon tests, point scale examinations, and in- 
telligence quotients seem to be signs of modern 
prison progress, and the sine qua non of juvenile 
delinquent reformation, a consideration of the 
physical fitness of the adult delinquent may seem 
like a reversion to the archaic. We present these 
statistics, however, as a reminder that this aspect of 
the prison problem, a knowledge of the physical 
condition of inmates, is as highly important as the 
determination of their mentality. Even a normal 
mind requires a healthy body to attain its highest 
efficiency. How necessary, then, in studying the 
individual delinquent, that we should endeavor to 
obtain the physical health survey as well as the 
intelligence quotient. 

While many investigators of prison problems have 
been dazzled by the opening up of a bright vista, in 
our recently acquired knowledge of methods for 
sorting out the feeble minded, the prison physician 
cannot lose sight of the other, the physical side of 
the Droblem, which offers considerable incentive 
from the fact that, while feeble mindedness cannot 
be cured, physical health may be restored. 

Object. The object of these examinations, aside 
from the outlining of individual treatment, has been 
twofold. 

1st. To determine, as accurately as possible for 
statistical purposes, the actual physical condition of 
the convicted men at the time of their admission to 
prison. 

2nd. To obtain an idea of the amount of the med- 
ical and surgical treatment that would be required 
to restore these men to the most efficient healthful 
conditions. 

Scope. It is not a complete medical survey of 
the prison population, but is limited to those ad- 
mitted during one single year, and does not include 
those who are already present. Nor does it repre- 
sent the total amount of medical and surgical work 
that is required of the medical staff, since it does 
not comprise the illnesses, injuries, or pathological 
conditions that arise after these men have been ad- 
mitted. Indeed, it would be almost impossible to 
make a complete medical and surgical survey of a 
population that is constantly fluctuating, as at this 
institution, where the number arriving during the 
year exceeded one thousand, and the number depart- 
ing approximated nearly that figure. 

Basis. The basis of this compilation is the rec- 
ords obtained in the routine entrance physical ex- 
aminations of all inmates admitted to Auburn Prison 
during the fiscal year of October i, 1914, to Sep- 
tember 30, 191 5. This includes, not only the men 
admitted directly from the courts, but also those 
transferred from other prisons and reformatories 



as well as those returned for violation of parole or 
previous escape. During the year there were 1,025 
admissions, as follows : 

From State Courts 364 36 per cent. 

Prom Sing Sing Prison 593 58 per cent. 

From Clinton Prison 33 3.5 per cent. 

From violation or parole 30 3 per cent. 

From escape 2 

From Elmira Reformatory i 

From Dannemora State Hospital i 

From Great Meadow Prison i 

Total 1025 

Time of examinations. These examinations are 
made within a day or two after admission, often on 
the same day, though on the occasion of a large 
draft from another prison, which may consist of as 
many as fifty or sixty men, a week or ten days may 
elapse before the completion of the examinations. 

Method. The routine examination is comprehen- 
sive and as complete as the usual insurance exami- 
nation given at a physician's office. The outline of 
the examination is as follows: 

1. General inspection. 

2. Stigmata of degeneracy. ■» 

3. Alimentary system. 

4. Respiratory system. 

5. Circulatory system. 

6. Genitourinary system. 

7. Cutaneous system. 

8. Glandular system. 

9. Nervous system. 

A. General. 

B. Special senses. 

1. Eyes. 

2. Ears. 

10. Articular and muscular. 

11. Deformities. 

The patient is stripped, first to the waist, then 
later completely, so that direct inspection and ex- 
amination may be made of the whole body. Uran- 
alysis, hemoglobin estimations, examination of blood 
and pus stains, blood counts, and other tests that 
can be rapidly performed are made at once, as indi- 
cated, to complete the initial examination. Simple 
interrogation alone is never depended upon for any 
part of the examination, but is accompanied by in- 
spection and other forms of inquiry as may seem 
necessary, to determine any pathological condition. 
Of course, no assertion is made of absolute accuracy 
of diagnoses, since many of those admitted require 
further observation to determine their exact condi- 
tion, so that the tabulations represent the conditions 
jjresented to the examiner on the first examination. 
This series of examinations has been made by one 
and the same examiner. 

Place. The routine examinations have all been 
made in the privacy of the physician's office, no one 
else being present except the physician's clerical or 
laboratory assistant. 

E.Yaminer. The examiner is the prison physician 
who has been making similar examinations for 
nearly ten years. 

Character of subjects. Those examined are all 
male adults, ranging in age from eighteen to over 
eighty years, sentenced for a wide variety of crimes : 
comprising all classes, from the accidental first term 
criminal to the recidivist of deliberate choice; rep- 
resenting nearly all occupations, races, and religions, 
and grading mentally from the medium grade imbe- 
cile to those capable of conducting a business or 
practising a profession. 



I 



January ij, igi?.] 



HEACOX: PHYSICAL EXAMINATION OF PRISONERS. 



65 



Method of classification. As a result of the ex- 
aminations, the subjects have been graded into three 
groups, according to the state of heahh, good, fair, 
or poor. Such classifications are not made from- 
the medical standpoint purely, but represent working 
ability as related to the institution, but not neces- 
sarily corresponding to their previous mode of liv- 
ing or occupation before admission to prison. Such 
classification is admittedly arbitrary', but useful as 
well as necessary. 



Total number admitted 1025 

Those in good health Soo 

Those in fair health 147 

Those in poor health 70 

1017 



78 per cent. 
14 per cent. 
8 per cent. 



Tabulation. We have adopted the method of enu- 
merating the pathological conditions discovered, in 
the order of frequency, under each physiological 
system, and in the following tables these defects are 
found arranged in such manner, while the number 
of subjects showing each condition is tabulated in 
the columns under their classification of health, 
good, fair, or poor, with a column added for the 
totals. The data obtained under No. i of the out- 
line, General Inspection, related largely to general 
appearance and degree of bodily nourishment and 
did not readily lend themselves to tabular form. 
Regarding No. 2, Stigmata of Degeneracy, it seemed 
to the examiner wiser to withhold these data until 
they can be studied in relation to mentality as well 
as physical condition. 

ALIMENTARY SYSTEM. 

Good. Fair. Pooi 



Total. Percent 
5S0 0.570 

270 0.263 

222 0.218 

89 0.087 



1.006 

►.030 



Carious teeth 451 

Constipation 204 

Indigestion 165 

Hemorrhoids 67 

Enlarged spleen 52 

[nguinal hernia 23 

Scrotal hernia 7 

Ventral hernia 2 

Pyorrhoea alveolaris 20 

Contracted liver 16 

Fistula in ano 4 

Syphilitic mucous patches o 

Rectal prolapse 2 

Subacute appendicitis o 

Chronic appendicitis o 

Syphilitic condylomata o 

Ulcer of mouth i 

Ischiorectal abscess o 

Oxyuris vermicu'aris o 

Tuberculous enteritis o 

Recovering from recent abdom- 
inal operation o 

Total 1022 



Operations Needed. 

Hernia 50 

Keraorrhoids 89 

Fistula 6 

Prolapsus z 

Abscess I 



Total 



RESPIRATORY SYSTEM. 



Good. Fair. Poor. Total. Percent 



Hypertrophic rhinitis 197 

Deviated septum 174 

Chronic pharyngitis 151 

Enlarged tonsils . . . ._ I34 

Pulmonary tuberculosis: 

Active o 

Suspects 62 

Atrophic rhinitis 69 

Ulceration of nasal septum 44 

Spur on nasal sepura 45 

Bronchitis 26 

Laryngitis 10 

Perforation of nasal septum 10 

Nasal polypus 7 

Asthma 3 

Coryza 3 

Acute tonsillitis .... 2 



257 
229 

207 



KESPIRATORY SYSTEM (Continued). 

Good. Fair. Poor. Total. Percent. 



Anosmia 2 i o 3 0.002 

Chronic pleurisy o 2 o 2 o.ooi 

PleurisV with effusion o i i 0.000 

Aphonia 2 o o 2 0.00 1 

Nasal synechia o 2 o 2 0.001 

Adenoids i o o i 0.000 

Perforation of soft palate 010 i 0.000 

Total 942 235 122 1299 

Operations Needed. 

Tonsillectomy 100 

Na?^al resection: 

Turbinate or septum 250 

Removal of spur 54 

Removal of senechia 2 

Removal of polypus 8 

Removal of adenoids i ■" 

Asp. ration of pleural effusion i 

Total 416 

CIRCULATORY SYSTEM. 



signs 



He 

Arteriosclerosis 

Myocarditis 

Aortic stenos's 

Mitral regurgitation 

Cardiac hypertrophy, without other 
cird.ac sign.s 

Cardiac arrhythmia, without other 
card.ac s gns 

Pulmonic stenosis 

Aortic regurgitation 

Cardiac dilatat.on 

Tricuspid regurgitation ........ 

Tricuspid and mitral regurgitatioii 

Aortic stenosis and regurg tation 

Pulmonic stenosis and mitral re- 
gurgitation 

Mitral stenosis 



Good. Fair. Poor. Total. Percent 

. 31 II 7 49 0.048 

- 34 9 4 47 0.046 

. 13 20 14 47 0.046 



Total 



43 



GENITOURINARY SYSTEM. 
Good. Fair. Poo 

Varicocele 25 g o 

Acute gonorrhea o o 9 

Chronic gonorrhea (gleet) o ig 4 

Ph'mosis 13 

Orchitis 6 

Testicle incompletely descended 5 

Enlarged prostate 5 

Hard ' 



Total. Percent 



>.oi3 
3. 008 
).oo5 
1.005 



Incomplete circumcis'on 2 

Chancroidal ulcers o 

Atrophied testicle i 

Herpes 2 

Chronic nephritis i 

Hydrocele o 

Diabetes mellitus . o 

Syphilitic ulcer on scrotum o 

Hydrocele of spermatic cord.... i 

Cancer of penis o 

Retracted frenum 1 

Supernumerary opening of urethra i 

Total 63 

Operalions Net 



Circumcision 

Enlarged prostate 
Hydrocele ........ 

Cancer of penis . , 
Retracted frenum 



Total 45 



CUTANEOUS SYSTEM. 

Good. Fair. 

Acne vulgaris 29 3 

Syphilitic skin eruption 18 - 3 

Eczema 10 2 

Pediculi pubis 8 o 

Varicose veins, lower extremit'es 6 o 

Scabies 4 3 

Lipoma i i 

Alopecia areata 2 i 

Urticaria i 2 

Ringworm 2 i 

Tinea versicolor 2 o 

Sebaceous cyst i i 

Psorias's ._ I o 

Furunculosis 2 o 

Edema, lower extremities i o 

Eruptions, undiagnosed i o 

Wounds, unhealed 2 o 

Acne rosacea i o 

Condylomata o o 

Varicose ulcer o o 

Axillary abscess o o 

Total 92 17 



Total. Percent. 



66 



UEACOX: PHYSICAL EXAMIXATION OF PRISONERS. 



rUTANKOUS SYSTEM (Continued). 
Operations Needed. 

Lipoma , 

Sebaceous cyst , 

Axillary abscess' !!!.'!!! i 



Total 



GLANDULAR SYSTEM. 
Good. Fair. 
259 52 



Enlarged cervical 

Enlarged epitrochlear .... 

Enlarged ingu.nal 135 

Enlarged thyroid 18 

Enlarged supraclavicular 5 

Enlarged submental o 

Enlarged axillary .• o 



Total. 


Pe 


rcent. 


338 




0.332 


199 







19.'! 


174 







171 


22 







021 


7 







006 


I 







000 


I 







000 



Total. Percent. 



"Tofal 571 116 55 

Operations Needed. 
Cervical adenectomy 

NERVOUS SYSTEM— GENERAL. 

Good. Fair. Poor. 

Epilepsy g 4 3 

Chronic alcoholism 7 1 i 

Nervous symptoms following head 

p.^"j"^y 5 3 o 

Chorea 4 i 2 

Exophthalmic goitre 3 2 i 

Speech defects . . 4 i o 

Neurasthenia 3 3 

Hysteria 4 o o 

Symptoms of drug withdrawal... 3 i 

Traumatic neuritis 2 i o 

Cerebrospinal syphilis i o 2 

Facial neuralgia 3 o o 

Facial paralysis 2 i i 

Insomn.a 2 i 

Mental depression o 3 

Nystagmus i o o 

Depressed fracture of skull (no 

symptoms) i o i 

Locomotor ataxia i 

Hysterical paralysis, arm and leg 001 

Progressive muscular atrophy. . . o 2 

Total 54 ig 18 

Operations Needed.^ 



NERVOUS SYSTEM: SPECIAL SENSES; 
Good. Fair. Poor, 
Defective vision (by tests for 
visual acuity, not includ ng con- 
ditions enumerated below .... 235 54 20 

Strabismus 3S 5 : 

Chronic conjunctivitis 23 5 3 

Acute conjunctivitis 14 o 

Follicular conjunctivitis 2 i 1 

Corneal scar 8 2 o 

Optic atrophy, one eye 2 4 t 

Optic atrophy, both eyes o i 

Chalazion 4 i o 

Blepharitis 1 3 o 

Pterygium 2 o i 

Trachoma o 2 i 

Ptosis ^2 I o 

Traumatic blindness, one eye . * o 2 

Traumatic cataract both eyes o i o 

Meibomian cyst i o o 

Syphilitic iritis 1 o 

Interstitial keratitis o i o 



EYES. 
Total. ] 



Total 332 



S3 



Operations Needed. 

Strabismus .' 25 

Chalazion '5 

Pterygium 3 

Trachoma 3 

Meibomian cyst i 



Total 

NERVOUS SYSTEM: SPECIAL SENSES; EARS. 
Good. Fair. 

Otitis media, chronic 34 10 

Impacted cerumen 56 7 

Retracted membrane 5 i 

Perforated membrane, with no 

discharge 6 o 

Deafness, marked in both ears.. 6 o 

Deafness, marked in one ear..,. i o 



37 



Total. 


Percent. 


47 
70 
7 


0.046 
0.068 
0.006 


6 
6 


0.005 
0.00.'; 
0.000 



Total 



oS 



Operation Needed. 
Mastoid 25 

ARTICULAR AND MUSCULAR. 

Good. Fair. Poor. Total. Percent. 
Chronic articular and muscular 

rheumatism 113 27 19 i59 0.156 

.... 16 6 o 22 0.021 



Rheumatism, lumbago 



riatic 



0.004 



*In the cases of head injuries 
operation, at time of admission, 
observation might show that in : 



no indications were found for 
and more comTilete study and 
operation would be of benefit. 



ARTICULAR AND MUSCULAR 



Syphilitic joint pains . 

Traumatic joint stiffness: 



Elbow 
Hip . 
W rist 



Knee 5 

Finger 5 

Shoulder 3 

Chronic luxation: 

Shoulder 1 

Thumb o 

Rupture of biceps o 

Tuberculous kneejoint o 

Syph.litic periostitis i 

Muscular atrophy, arm o 

Paralysis — ■ partial, 
from hemiplegia . . 



[New York 


Medical Journal. 


jr. Total. 


Percent. 


22 


0.021 


8 


0.007 


9 


0.008 


8 


0.007 


7 


0.006 


7 


o.oo6 


6 


0.005 


5 


0.004 




0.000 




0.000 




0.000 




0.000 




0.000 




0.000 



Total 194 so 

Operations Needed. 
)erculous kneejoint , 



265 



Total 



DEFORMITIES. 

Good. Fair 



Curvature of spine 

Kyphosis 

Scoliosis 

Hipjoint disease . 



Bow 



One leg shortened (result of frac- 
ture) » 

Deformities due to aniputattons: 

1 finger 

2 fingers 

4 fingers 



toes 



Ankylosis of elbow joint i o 

Resection of elbow joint o 

Ha-nmer toes o o 

Rheumatoid arthritis, upper ex- 

tremiiies o 

Total 36 ic 

Operation Needed. 

Hammer toes 



Poor. Total. Percent. 



SUMMARY OF DEFECTS FOUND. 



Good. Fair. Poor. Total. Percent. 



Alii 



nentary system 1022 

Respiratory sysrtem 942 

Circulatory system 98 

Genitourinary system 63 

Cutaneousi system 92 

Glandu ar system 571 

Nervous system: 

General 54 

332 

108 



222 


130 


1374 


2^s 


122 


1299 


«3 


43 


224 


38 


«4 


125 



Ears 

Articular and muscular . . 
Deformities 36 



444 

•37 

265 

58 



Total 3512 891 488 4891 

Summary of Number of Operations Needed. 

Alimentary system 

Respiratory system 

Genitourinary system , 

Cutaneous system 

Glandular system 

Nervous system — -general 

Nervous system — special senses, eyes 

Nervous system — special senses, ears 

Articular and muscular systems 

Deformities 



Total 734 

The foregoing lists, it will be observed, do not in- 
clude dental work, of which there is a vast amount 
indicated, as over half of the total number of men 
admitted had carious teeth ; nor do they include re- 
fraction and fitting of glasses for at least 200 pris- 
oners. 

CONCLUSIONS. 

1. The solution of the medical problem of the 
prison lies, to a great extent, in the recognition and 
treatment of pathological conditions at the time of 
admission of each inmate. 

2. The medical staff of the prison, consisting of 
only two physicians, is much too small to take care 
of this immense amount of work. As a matter of 



January ij. '9'r] 



KLHIX .IXD RUBUXSTONE: VISCERAL AMEBIASIS. 



67 



fact, a staff of two is inadequate to perform a ma- 
jor operation. 

3. There should be provided an adequate general 
medical and surgical staff, as well as specialists in 
the various branches 

4. This work could best be accomplished through 
a central clearing house to which all prisoners should 
tirst be committed for individual examination, study, 
diagnosis, and treatment, before being assigned to 
anv particular institution. 



\TSCERAL AAIEBIASIS* 

With Report of an Unusual Case. 

By Alexander Klein, j\I. D., 
Philadelphia, 

.\ttending Physician, Mount Sinai Hospital; 

.\ND A. I. Rubenstone, M. D., 
Philadelphia, 

Pathologist, Mount Sinai Hospital. 

In the literature comparatively few instances are 
recorded of lesions in which amoebae were demon- 
strated that were not associated with or occurred as 
sequelae of dysentery. Undoubtedly some lesions 
of amebic origin are not discovered because of lack 
of routine microscopical examination of fresh speci- 
mens of pus in the absence of dysenteric history. 
This may account for the dearth in reported cases 
of lesions in other organs of the body. Several au- 
thors have reported finding amoebae in the blood. 
That visceral amebiasis may be present without a 
previous history' of dysentery is now conceded by 
many investigators. Craig cites as an example Bux- 
ton's case of a woman with amebic abscess of the 
liver, at the Philadelphia General Hospital, in which 
no trace of previous intestinal disease was demon- 
strated at autops}'. Flexner, Kartulis, and Doflein 
report lesions adjacent to the oral cavity in which 
apparently pathogenic amoebae were demonstrated. 
Artault describes finding amoebae in a lung abscess. 
Lynch reports a case of submaxillarv- tumor in which 
he found amoeba?. Some observers found amoebae in 
association with malignant growths notably that re- 
ferred to by Schaudinn in peritoneal carcinoma with 
ascites reported by von Layden. Ijima records 
peritonitis with endothelioma in which he observed 
an ameba, but his statements concerning these para- 
sites have not been confirmed. Smith and Weid- 
man report amoebae found in various tissues of a 
stillborn child; also in a syphilitic infant dying of 
pneumonia. The case we take the liberty of re- 
porting is as follows : 

Case. J. Z., Russian, forty-nine years old, cigar maker, 
married, who was admitted to the Mount Sinai Hospital. 
October 31, 1915, complaining of gnawing, dull pain in the 
right buttock, and occasionally pain in the right knee. His 
family history was negative. Past medical history: 
Measles during infancy, and gonorrhea at twenty-two years 
of age. Denied inte^t'nal trouble at any time during his 
life. Had lived in Southern Russia until fourteen years 
ago, when he came to New York, and six years ago moved 
to Philadelphia, where he resided since, having never so- 
journed elsewhere. Smoked moderately, did not consume 
alcoholic beverages. Present illness began about three 
months ago, with dull aching sensation deep in his right 
buttock. He spent several w-eeks in a local hospital without 
relief and finally went home. Gradually locomotion be- 

•Read and specimens presented before the Philadelphia Patho- 
log cal Society, May 11, 1916. 



came more ditHcult until he was unable to walk without 
assistance. 

Physical examination : Patient presented an anxious e.x- 
pression, pinched features, sunken cheeks showing signs 
of emaciation. Mucosa markedly anemic, skin moist and 
warm. Fingers and toes clubbed. No edema. A large 
movable, slightly resistant mass was outlined over the right 
liuttock, giving it an appearance of extreme fullness. 
Slight fluctuation elicited. Local examination : Reflexes 
normal, head, eyes, ears, nose, and neck presented nothing 
of interest. Most of the teeth were missing, those present 
in bad condition. P3'orrhcEa alveolaris and gingivitis 
marked. Chest: ."Ml bony prominences marked, left supra- 
clavicular and infraclavicular fossre deep. Slight scoliosis 
of the spine to the right. Expansion poor, respiration 
abdominal in type. Right lung: Sliowed slightly dimi- 
nished tactile and vocal fremitus at the base and dry rales 
at upper lobes ; also harsh respiratory murmur. Left lung ; 
Dullness and harsh respiratory murmur over the upper lobe 
anteriorly ; lower lobe showed a pleuritic friction rub and 
a few moist and dry rales. Heart : Feeble sounds, rapid 
and irregular. .Abdomen negative. Upon admission tem- 
perature was 99° F., and fluctuated between 99° and 100° 
throughout the entire course of illness, until his terminal 
infection increased it to 103° six days before death. Res- 
pirations were 24 and pulse 82. Systolic blood pressure 
varied throughout the illness between 125 and no mm. 
Hg. Urine showed no abnormalities in quantity or quality 
throughout the illness, except for traces of al-bumin during 
the last few days. Blood : Hemaglobin, seventy per cent. ; 
red blood cells, 3,610,00a; white cells, 13,200; polymorpho- 
nuclears, eighty-live per cent. ; small mononuclears, twelve 
per cent. ; transitional, one per cent ; eosinophiles, two per 
cent. Widal, malaria, and Wassermann tests negative on 
repeated examination. The sputum was thin, scanty, and 
mucopurulent, many Gram positive and negative organisms, 
especially Micrococcus catarrhalis, some long chain strepto- 
cocci and leptothri.x. Tubercle bacilli were not demon- 
strable. Fresh specimens were frequently examined and 
no amebas were found. Examination of the pyorrheal 
pockets disclosed myriads of amceba; and a few Triclio- 
monades hominis, associated with the usual bacterial flora 
accompanying them. X ray findings, by Dr. George Rosen- 
baum : Chest: Left side threw a shadow resembling fluid, 
probably due to a thickened pleura. Right side showed 
some nodules near the apex. Pelvis : Above and to the 
inner side of the pelvis, from the acetabulum to the right 
sacroiliac synchondrosis was a mass of fluid consistence. 
It also showed much iliac bone absorption in this region. 

A needle was inserted deeply into the mass in the right 
buttock, and si.x ounces of fluid were easily withdrawn. 
This fluid was yellowish brown in color, moderately viscid, 
very turbid, and was immediately removed to the laboratory 
for examination. Fresh preparations under cover glass 
showed with a one sixth inch objective: Some polymor- 
phonuclear and mononuclear leucocytes, much cellular 
debris, and fragmented blood cells, as well as larger cells, 
many of them in motion. These cells ranged from twenty 
to fifty microns in diameter and showed typical ameboid 
movement, which in some was very active. They consisted 
of a clear ectosarc, glassy in appearance, and a granular 
endosarc in which could be seen small grayish particles and 
occasionally fragments of, or whole red blood cells, as 
well as one or more vacuoles. The pseudopodia were blunt 
and broad and somewhat elongated, and very few cells ex- 
hibited more than one projection at a time. Motility was- 
marked in a great many and sluggishness in a few. A 
few of these organisms were smaller in size, probably not 
more than ten to twenty microns in diameter, consisting 
of much granular material, few vacuoles, and giving the 
typical appearance of encysted forms. A nucleus was not 
observed in the majority of parasites studied, but in a few 
a very small peripherally situated body in the endosarc, 
oval in shape, was observed. We could not establish to 
our satisfaction that this body was a nucleus or some in- 
gesta of the parasite. On staining dry smears with Hast- 
ing's and Gietnsa's stains as well as the ordinary dyes, the 
same general characteristics were observed, but no distinct 
nuclear chromatin could be demonstrated. Puncture of the 
left chest wall was performed, and upon deep insertion of 
the needle, five ounces of fluid were aspirated. This fluid 
was decidedly more brown in color than that removed 
from the buttock. Examination revealed it to be of the 
same character and the findings were identical, only that it 



68 



KLEIN AND RUBENSTONE: VISCERAL AMEBIASIS. 



(New York 
'edical Journa 



contained more epithelial elements and red blood cells. 
Arncebx were present and presented the same characteristics 
as in the other fluid. Some of the fluid obtained from both 
abscesses was injected per rectum into guineapigs (unfor- 
tunately no kittens) and also sprinkled over the food. 
Some animals were also inoculated in the inguinal region 
with this fluid. The animals manifested no illness and 
were soon well. Cultures of the liuid on serum and blood 
media both aerobically and anaerobically were sterile. In 
an attempt to obtain, if possible, complement fixation with 
this pus, some of it was repeatedly washed with sterile 
physiological saline solution, and finally the sediment, after 
several hour's sliaking, was used in diluted form as antigen. 
The single unit hemolytic system was used, and half the 
anticomplementary dose of the antigen employed. No fixa- 
tion occurred with the patient's serum up to 0.2 c. c. Al- 
though the patient presented neither symptoms nor history 
of inteslinal disturbance, his rectum was carefully ex- 
amined with negative results. Repeated examinations, both 
by passing a rectal tube and examining the particles that 
came away, and also the fresh stool after a saline purge, 
failed to disclose amoebae. 

The patient received, beside general care and 
treatment, emetine, both hypodermically and by 
mouth and by injection into the two cavities. By 
November i8th, after several tappings during which 
a total of thirteen ounces of fluid were removed 
from the chest and eleven from the buttock, 
the patient was improved, having lost most 
of his pain in the buttock and no longer 
complaining of pain in the chest. Physical 
findings were of the same character. On No- 
vember 24th the patient again began to complain 
of pain in the chest, and there was increasing tender- 
ness in his right buttock. The patient consented to 
operation on the buttock only, which was performed 
by Dr. N. Ginsburg, who found a cavity below the 
gluteal muscles involving part of the iliac bone pos- 
teriorly which was necrosed. The cavity contained 
necrotic tissue, a few blood clots, and about ten 
oimces of fluid of the same character as described. 
Following the operation the patient was somewhat 
relieved, but weaker, the pain in the chest continued, 
and the dyspnea grew worse. On December 24th 
the temperature suddenly rose to 103° F. ; he com- 
plained of severe pain in the chest, dyspnea became 
very marked, accompanied by sweats and prostration. 
Heart sounds were muffled, and there was frequent 
asystole. Upon physical examination pericarditis 
with eiTusion was diagnosed, he refused surgical in- 
tervention, became rapidly worse, and death ensued 
on December 31st, after an attack of pulmonary 
edema. 

Permission was granted for partial autopsy and 
the following was found. The pericardium was dis- 
tended, containing 125 c. c. of yellowish gray thin 
pus ; visceral and parietal layers were deeply inject- 
ed, and a fine fibrinopurulent membrane covered it. 
This fluid was made up of polymorphonuclear pus 
and long chain streptococci ; culture showed hemo- 
lytic streptococci. The heart showed cloudy swell- 
ing, the right lung and the pleura were free, there 
was some congestion at the base, and several healed 
fibrous nodules at the apex. The left pleura was 
greatly thickened and adherent, especially at the 
upper half, where at some points it was three mm. 
thick. Upon incision of the lung, there was found 
a cavity which extended through the lower portion 
of the upper, and the upper portion of the middle 
lobe, about ten by six cm., not connected with the 
larger bronchi. It was filled with a reddish brown 



fluid, and contained shreds of necrotic tissue; the 
wall was ragged with many shaggy projections of 
shreds of connective tissue and necrotic lung ex- 
tending into the cavity. The cavity showed no con- 
nection with either the pleura or pericardium, nor 
with any other of the adjoining structures. Sur- 
rounding the cavity the lung was markedly edemat- 
ous and grayish, with many small pin point necrotic 
foci. Stained sections of the lung immediately sur- 
rounding the cavity revealed epithelial cells which 
showed great swelling and granular degeneration, 
and many deep seated pigmentary infiltrations. The 
capillaries were injected. Closer to the abscess cav- 
ity were noted diffuse necrotic areas, and at points 
infiltration with mononuclear leucocytes. 

The intestines were carefully examined and no 
signs of present or of past inflammation were de- 
tected. The liver was slightly congested and 
somewhat enlarged. The spleen and pancreas 
were normal. The kidneys showed slight conges- 
tion. Exploration of the operative site in the but- 
tock revealed a cavity about the size of a fist, in- 
volving the iliac bone near the synchondrosis, at 
which point the bone was ragged, and there 
was an opening five by six cm., forming a hole in 
the ilium. The cavity had no connection with the 
psoas or peritoneum. It contained a grunious fluid 
with several small blood clots and necrotic bone tis- 
sue. Sections of the wall revealed great infiltra- 
tion with polymorphonuclear and mononuclear and 
red blood cells, with many necrotic areas, as well as 
a few of the parasites previously described. 

CONCLUSIONS. 

The parasites found in the abscesses of this pa- 
tient seemed in nearly all characteristics to conform 
to the species definitely established by Schaudinn, 
in 1903, as Amoeba dysenterica histolytica. This 
amoeba had been thoroughly investigated by Kartu- 
lis, Councilmann and Lafleur, Strong, and others. 
Schaudinn's work has been amply confirmed by such 
investigators as Craig and Hartmann. In the Euro- 
pean district from which our patient originally came 
it was thoroughly studied by Hlava, and in this 
country it has been found in many States, including 
New York and Pennsylvania. In the absence of 
any other etiological factor we must conclude that 
these amoeba were the causative agents in the pro- 
duction of these lesions, and the unique situation of 
these lesions leads us to think tliat the distribution 
was most probably hematogenous. We can only 
speculate as to the original focus of the infection, 
remembering the condition of the patient's mouth. 

We are indebted to Dr. R. C. Rosenberger and Dr. 
Allen J. Smith for their kindly interest in the case 
and for confirming the parasitic nature of the cells. 
bibi.1(m;i;aphy. 

I. ARTAULT: Arch, de parasit, i, p. 275, 1898. 2. DOFLEIN: 
Lchrhtich der Proto::oen Kunde. 3. FLEXNER: Bui. Johns Hop- 
kins Hospital. 25. iSy2. 4. DOFLEIN: D'C Prolo:ocn als. Para- 
siteit und Krankheitserriger, 1901, p. 30. 5. J. IJIMA; Ref. Cen- 
trab. f. Bakt, xxv, 1899, p. 885. 6. HLAVA: Centr. fer Bakt.. 
1 887, p. 537. 7. SCHAITDINN: Katscrl. Gesntidhc'tsamte. xix, 
547, 1903. 8. CRAIG: Parasitic Amcha of Man. loii. Ibidem: 
Arch. Int. M.:d.. 1914. P- 737- 9. STRONG: Osier's Mod. Med.. 
i. 1907. 10. COUNCILMANN and LAFLEUR: Johns Hopkins 
Hosp. Reports, 1891, p. 395. 11. LYNCH: Journal A. M. A.. 
November 28, 191 5- 12. SMITH and WEIDMAN: Univ. Penna. 
Med. Bulletin. September. 1910. Ibidem: Amer. Journal Trotical 
Diseases, October, 1914. 

321 South Eleventh Street. 
1704 East Moyamen.sing Avenue. 



January 13, 



KAEMPFER: FOREIGN BODY IN AORTA. 



69 



A FOREIGN BODY IN THE AORTA, 

By Louis G. Kaempfee, B. S., M. D., 
New York, 

Adjunct Laryngologist, Mount Sinai Hospital. 

The sudden onset of cough in a person previously 
well, especially if it occurs while he is eating, is a 
fact of such significance that no alert physician can 
be excused for overlooking it or underestimating its 
gravity. If the cough persists, either with or with- 
out dyspnea or cyanosis, and at first, at any rate, 
without fever or expectoration, it points in such an 
unmistakable way to the diagnosis of a foreign 
body, usually in the trachea but sometimes in the 
esophagfus, as to be almost pathognomonic. 

The patient often does not remember whether or 
not there was anything in his mouth at the time that 
the coughing spell began, and a child — most of these 
patients are children — is either too young to tell, or 
fear of punishment causey suppression of the in- 
formation. It is the duty, then, of the medical at- 
tendant to give due consideration to this possibility 
when confronted by such a problem. By submitting 
such a patient to prompt endoscopic examination a 
life may be saved. 

In the laryngological service at the Mount Sinai 
Hospital, where the material is extraordinarily rich 
in this special field, it is not uncommon to see these 
cases. Patients who absolutely deny that a foreign 
body could have been swallowed or inhaled, when 
it has been removed and shown to them, will recall 
some incident, unimportant at the time, which would 
have made the diagnosis unequivocal. It is to show 
the folly and danger of relying upon the patient's 
word in this class of case that the following is re- 
ported : 

Case. George S.. eight months old, a healthy, normal, 
breast fed baby, was brought to the Mount Sinai dispensary 
(pediatric department). The mother stated that the baby 
had never been ill before and had suddenly begun to cough. 
There were no other symptoms. The child never had a 
rise in temperature. He was treated for the cough for 
four weeks without its getting either very much better or 
very much worse. Apparently no stress was laid upon the 
manner of the onset of the cough. Suddenly, the child 
became acutely ill and vomited a quantity of clotted blood. 
There were no food particles. About an hour later, the 
child was brought to the hospital. The mother absolutely 
denied the possibility of the child having swallowed any- 
thing. 

An abstract of the examination made at the time of ad- 
mission : \\'ell nourished, pale baby ; crj-ing and acutely 
ill ; no meningeal signs. Breath sounds over the entire 
chest exaggerated ; few moist rales heard ; no alteration 
of the percussion note. Heart sounds feeble and not 
clearly heard ; pulses rapid and of poor quality. Extremi- 
ties cyanotic and cold. Abdominal examination negative. 

The child was fluoroscoped and a collar button 
was seen behind the upper part of the sternum. It 
had a spherical head which pointed downward and 
a little to the left. The broad base was uppermost. 
About an hour later, the writer esophagoscoped the 
patient. It was done without anesthesia, as owing 
to the child's perilous condition haste was a desider- 
atum. 

Direct laryngeal examination showed an entirelv 
normal iar\-nx. The tube was introduced into the 
esophagus without difficulty, the child being on its 
back with the head supported over the edge of the 



table and the neck in partial extension. The child's 
body was held by two assistants, one holding the 
arms and torso, the other the legs. 

At its entrance the mucous membrane of the 
esophagus appeared normal. j\ short distance down 
the picture changed. The tube entered an area 
deep red in color in the midst of which a portion 
of the edge of the base of the collar button was 
visible. It was grasped with the foreign body for- 
ceps and gentle traction was made in an attempt to 
dislodge it. The button did not move. It appeared 
to be fimily held by the surrounding tissues. Dur- 
ing this time the child's condition, though very poor, 
was as good as it had been at the beginning of the 
operation. Stronger traction was now made, where- 
upon breathing stopped immediately. The tube was 
at once withdrawn and artificial respiration was em- 
ployed. .-Vfter a few minutes, breathing was re- 
stored. The baby was cyanotic and the pulse was 
scarcely perceptible. The heart beats were poor in 
quality and 240 a minute. Further attempts to re- 
move the button were deferred until the following 
day. 

During the night, about nine hours after the op- 
eration, the child became suddenly dyspneic and 
died. Death was in all probability due to pressure 
upon the pneumogastric, as in cases of retroeso- 
phageal abscess. 

The • following day, about twelve hours after 
death, the body was esophagoscoped by Doctor 
Yankauer, who removed a quantity of clots and 
found that the button had ulcerated through the 
wall of the esophagus and into the aortic arch. The 
head of the button acted as a plug to close the 
dehiscence. The hemorrhage evidently took place 
at the moment of penetration. 

The conclusion to be drawn from this case is ob- 
vious. Had the presence of a foreign body been 
considered earlier, and the child fluoroscoped, the 
diagnosis would have been made before the patient 
was moribund and its life would have been saved. 
This brings us again to the sudden onset of the 
cough in the absence of other symptoms. Had that 
fact been given due weight by the physician who 
first saw the child, the fatal outcome undoubtedly 
would have been avoided. 

616 Madtson Avenue. 



Filtered X Rays in Treatment of Fibrous 
Bands and Adhesions. — A. Winkelried Williams 
(Brit. Med. Jour., December 2, 1916) states that 
the value of x rays in the treatment of keloid and 
hypertrophic scars of the skin suggested their ixse 
for the relief of fibrous bands and adhesions result- 
ing from bullet wounds. Filtered rays from a hard 
tube were applied to such bands in several cases 
with most excellent results, producing prompt soft- 
ening of the scar tissue, increase in range of motion, 
and removal of the symptoms which had resulted 
from the compression of nerves and vessels in scars. 
In one of the cases the rays produced favorable re- 
sults at first, but the cessation of their use was fol- 
lowed bv a return of hardening and contraction of 
the scar tissue so that surgical interference was re- 
quired. 



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CLXXVII. — How do you treat delirium tremens? {Closed.) 

CLXXVIll. — How do you treat acne vulgaris? {Answers due not later than January 15, 1917.) 
CLXXIX. — How do you treat eczema in children? {Answers due not later than February 15, 1917.) 
The award will be based solely on the value of the information contained in the answer. No im- 
portance \vill be attached to literary style. Answers should preferably contain not more than six hun- 
dred words, and should be written on one side of the paper only. All papers submitted become the 
property of the Journal, and should bear the full name and address of the author for publication. 
The prize will not he awarded to the same person more than once within a year. 

The prise of $25 for the best anszi'cr to Question CLXXVI has been awarded 
to Dr. Robert T. Morris, of Xezc York city, ic'hose paper appeared on page 24. 



PRIZE QUESTION NO. CLXXVI. 

THE TREATMENT OF COLLES'S 

FRACTURE. 

{Concluded from page 28.) 

Dr. Louis Neiivelt, of Nczo York, remarks: 

Ih the treatment of all fractures of the wrist, 
radiography should be a part of the routine both 
for diagnosis and treatment. Taken before the re- 
duction of the fracture, skiagrams aid in the 
diagnosis by giving pictures of the conditions and 
relations of the broken ends of the bones much more 
accurately than can possibly be obtained by palpa- 
tion. As a result, greater accuracy is obtained in 
the treatment. Many a sprain is in this way found 
to be in reality a fracture. Fluoroscopy alone is 
misleading. The arm should be photographed 
stereoscopically, or skiagrams should be taken in 
two directions, anteroposteriorly and laterally. 

After immobilization, we can tell whether the 
correct position of the fragments has been secured 
without removing the dressing, and the patient is 
spared unnecessary and painful manipulation and 
etherization. A picture showing intractable frag- 
ments may decide in favor of an operation. 

By availing himself of good x ray plates, the 
physician frees himself from possible futtire mal- 
practice suits, which too frequently follow. In 
fact, the courts have recently decided that any one 
treating fracture cases without the use of the x ray 
is culpable. 

Reduction of the fracture should be accom- 
plished as soon as possible, preferably under anes- 
thesia, either partial or complete, as considerable 
force is necessary to effect reduction, especially in 
the impacted cases. To reduce a Colles's fracture, 
the operator clasps the patient's hand in his own, 
palm to palm, and with the other hand he grasps 
the wrist at the site of fracture. An assistant 
should make counterextension from the fixed elbow, 
while the operator makes forcible traction on the 
hand, at the same time inclining it to the vilnar side 
and making pressure on the fragments. The reduc- 
tion can be felt as the deformity becomes corrected. 
The head of the ulna will return to its normal posi- 
tion and again become prominent on the back of 
the hand. When the reduction is complete, allow 
the hand to rest without support to determine 
whether the deformity recurs; if there is no recur- 
rence, the wrist may be immobilized. 



Plaster of Paris molded splints (anterior and 
posterior) are the most desirable for the purpose 
of immobilization. Ready made or wooden splints 
should not be used, as they cause widening of the 
wrist. Three to four inch wide bandages are used. 
The posterior splint should extend from the heads 
of the metacarpal bones to a little above the middle 
of the forearm. Measure the above mentioned dis- 
tance on the bandage, running it back and forth 
making eight to ten layers, and firmly incorporate 
the bandage by pressure. Cut out a piece of the 
dorsal splint where the ulna touches it, to prevent 
undue pressure. In the same way make an anterior 
splint, again measuring the distance between the 
head of the metacarpal bones and a point a little 
beyond the middle of the forearm. The splints 
should be padded with a layer of sheet wadding, 
with retention pads at the seat of fracture if neces- 
sary. 

The hand and forearm should be kept in the posi- 
tion of semipronation, with the hand adducted. 
While the plaster is still soft, apply a firm bandage, 
riie fingers and thumb should be left free and 
movable, and the arm is supported in a sling, so 
adjusted as to receive the whole weight of the arm. 
The ends of the sling should cross in front of the 
neck. The hand should be free from the upward 
pressttre of the sling. The patient should be seen 
again within the first twenty-four hours, to correct 
any swelling that may be caused by a too tight 
bandage. Every three days the pads and bandage 
are removed and the arm carefully inspected, to 
avoid circular constriction. The pads are so placed 
as to maintain the fragments in their proper align- 
ment. The patient should be warned that pain and 
swelling during any part of the treatment are a 
signal for a consultation with the physician. 

At the end of the first week, discard the anterior 
splint and secure the posterior splint with three zinc 
oxide adhesive plaster straps, one at each end of 
the splint and one at the seat of fracture. Apply 
a pad over the fragments to the anterior surface, 
secured with a roller bandage. 

Gentle massage and active and passive motion of 
the fingers, hand, wrist, and forearm are given dur- 
ing the second week. In the third week, the dorsal 
splint may be shortened, and the amount of active 
and passive inotion increased. During the third or 
fourth week, the splint may be removed, and the 
wrist supported by a zinc oxide adhesive plaster 
dressing applied as follows : Apply two or three 



Januao- 13, 1917.] 



OUR READERS' PRIZE DISCUSSIONS. 



layers of a gauze strip about four inches wide (^dou- 
ble), and then live or six layers of the zinc oxide 
plaster of the same width aromid the wrist, and 
support with a sling. This dressing can be worn 
for one or two weeks, after which all dressings arc 
removed, except a simple bandage. The forearm 
should always rest in a sling on the ulnar side of 
the hand, unsupported, and slightly adducted. 

If after two or three weeks there is malunion, 
the bones should be refractured to correct the de- 
formity. If even this procedure is of no avail, 
operative interference becomes necessary as a last 
resort." 

Dr. Max Soletsky, of New York, states: 

The lower end of the radius is, after the ribs, the 
most frequently fractured bone in the body. Colles's 
fracture is a fracture of the lower end of the radius, 
from one third to three quarters of an inch above 
the articular surface. It is usually produced by a 
fall on the palm of the hand and causes a displace- 
ment of the lower fragment posteriorly, the styloid 
process of the radius rising to a higher level, with 
the addition sometimes of a fracture of the styloid 
process of the ulna. 

It is treated by first reducing the fracture accord- 
ing to the following method (see Treatment of 
Colles's Fracture, by Doctor Hoag, in New York 
Medical Journal, November 13, 1915) : The in- 
jured wrist is held dorsum upwards, the surgeon's 
thumbs on the dorsum of the lower fragment, the 
index fingers in front of the lower fragment, and 
the other fingers in the patient's palm. The pa- 
tient's wrist is held stiffly and the forearm is hyper- 
flexed at the point of fracture in order to break up 
impaction, then, traction being made by the fingers 
in the patient's palm, the forearm at the point of 
fracture is hyperextended (dorsally flexed) and the 
lower fragment pushed into place, the overlapping 
thumbs preventing overcorrection. The fracture is 
reduced preferably under general anesthesia. The 
styloids are then measured in order to make sure of 
reduction, and the forearm and hand, extended and 
in ulnar deviation, are put up in moulded plaster of 
Paris splints. The splints are made in the follow- 
ing manner: Two pieces of canton flannel three 
inches wide (for the adult) and reaching from the 
metacarpophalangeal articulations to within two 
inches of the elbow are covered about one quarter 
of an inch thick with layers of bandage impreg- 
nated with plaster of Paris previously wet with 
water. The splints are then applied one anteriorly 
and the other posteriorly and bandaged on with a 
gauze bandage to allow the water to evaporate 
quickly. The hand and forearm are held in the 
correct position, in extension (dorsal flexion) and 
ulnar deviation, until the plaster of Paris has hard- 
ened, and then the forearm is placed in a sling. 
The fingers are left free and are to be manipulated, 
otherwise they become stiflf. An x ray picture 
should be taken to ascertain the position of the frag- 
ments. 

Hot air baking daily witli the splints on may be 
begun during the second week. During the third 
week it may be combined with massage, gentle at 
first, gradually increasing in amount and force. 



The splints are left on for the baking and removed 
one at a time for massage. First the posterior 
splint is removed, leaving the anterior one in place, 
ihen the posterior one is replaced after massage, 
ihe forearm with both splints in position turned, the 
anterior splint is removed and replaced after the 
massage is completed. Baking and massage are 
done ever}' other day. During the fourth week the 
posterior splint is discarded, the anterior one alone 
being replaced. At this time active and passive 
motion is begun. After the fourth week even the 
anterior splint is discarded and the patient is ad- 
vised to do light work for a time, gradually doing 
more as the wrist grows stronger. The patient con- 
tinues to obtain baking and massage until complete 
function is restored. This generallv takes from six 
to eight weeks. 

Dr. Vern W . Emhree, of Sioux City, la., asserts: 

In the treatment of Colles's fracture I first ex- 
amine the injury under the x ray, taking a trans- 
verse and an anteroposterior view ; then under 
surgical anesthesia, by crepitation and abnormal 
mobility, I confirm my x ray interpretation. While 
the patient is still under complete surgical anes- 
thesia, I make hyperextension to loosen the frag- 
ments and the dorsal periosteum ; secondly I make 
longitudinal traction to separate the fragments, and 
lastly I make forced flexion to get them into posi- 
tion. I next place the hand in extreme adduction. 
Then I proceed to cleanse the forearm, wrist, and 
hand \vith soap and water if the injury is quite 
sensitive, otherwise I do this before starting the 
anesthesia. After drying thoroughly I wrap a thin 
layer of absorbent cotton or roller flannel around 
the forearm, wrist, and a portion of the hand, be- 
ing very careful to have the thickness uniform 
throughout. Then I place the plaster of Paris 
bandage in lukewarm water, and remove when the 
bubbles cease to rise, and apply quickly with a 
uniform thickness from just below the elbow to a 
point on the hand opposite the base of the ex- 
tended thumb. In this way there is no immobili- 
zation of the fingers. Ihe hand is placed in ex- 
treme adduction. I use a quick setting bandage 
and in a few minutes the cast is hard and firm. 
I now make an anteroposterior and tranverse x ray 
picture to be sure the bone is properly approxi- 
mated. I place the arm in a broad muslin sling, 
after having wrapped a gauze bandage around the 
plaster cast. 

If there is considerable bruising of the tissues 
with swelling at the time of setting the fracture, 
the cast after twenty-four to thirty-six hours may 
become somewhat loose; if so I cut the cast prefer- 
ably on its anterior surface throughout its length 
and trim off a portion of one or both edges, then 
I draw the two free edges together and hold in 
place by applying a two and a half inch gauze band- 
age. Likewise if the injury has been so recent that 
when set the maximum of swelling has not taken 
place, or if the cast should become uncomfortable, 
I cut it longitudinally and by forcibly spreading I 
can relieve the pressure and not endanger any seg- 
ments of the fractured radius. 

:\t the end of ten days after setting the bone I 



72 



ABSTRACTS AND REVIEWS. 



(New York 
Medical Journa 



remove the cast, and besides cleansing the forearm, 
hand, and wrist with alcohol, I also move the wrist. 
At the end of a week I again remove the cast and 
do not replace it. After cleansing the parts thor- 
oughly 1 examine the wrist to take note of its 
function. 

Dr. Frederick G. Miller, of Nezv York states: 

The most essential step in the treatment of 
CoUes's fracture is the complete reduction of the 
deformity. Failure to do so is bound to be fol- 
lowed by permanent deformity, stiffness of the 
wrist and fingers, and often a useless hand. 

Reduction is accomplished by traction and over- 
extension of the wrist in order to separate the 
fragments, and release them from the possibly torn 
periosteum. Then by forced fiexion and manipu- 
lation the fragments are brought into normal appo- 
sition. 

The forearm and hand are held in supination 
and well padded splints applied. It depends upon 
the condition of the deformity before and after 
reduction whether an anterior or posterior or both 
fomis of splints are used. 

I prefer using an anterior or palmar splint ex- 
tending from the elbow to the wrist joint, and a 
posterior or dorsal from the elbow to the fingers' 
tips. These are held in place with adhesive strips 
or turns of a bandage. Sometimes it may be neces- 
sary to place extra padding on the extensor sur- 
face of the wrist over the upper end of the lower 
fragment, and on the flexor surface over the lower 
end of the upper fragment, held in {X)sition by ad- 
hesive strips ; this I do when I feel there may be 
a chance of the fragments slipping out of place. 

The forearm is placed midway between supina- 
tion and pronation, and suspended in a sling. 
Always try to keep the thumb and fingers as free 
from bandaging as possible, and commence passive 
motion on the third day. Also remove the splints 
on the third day, sponge the skin with twenty-five 
per cent, alcohol, drj', dust with talcum powder, and 
reapply the splints. Repeat this every second day for 
the first two weeks and every third or fourth day 
for the following ten days. Begin passive motion 
of the wrist at the end of second week. On about 
the twenty-fourth day union is quite firm, and I re- 
move all splints and encourage the full use of the 
hand and wrist. 

Dr. W. C. Caitble, of Brooklyn, ivrites: 

Make a careful diagnosis of the injur)' by ex- 
amination, preferably under anesthesia, and by 
comparison with the other arm. 

Reduce the fracture by traction and by manipu- 
lation of the parts to insure a breaking up of the 
impaction, which is necessary to avoid defonnity. 

With the arm midway between pronation and 
supination, to secure the best relations between 
ulna and radius, make strong traction on the hand, 
and by manipulation being assured of reduction, 
apply gauze pads anteriorly and posteriorly, se- 
curing them by adhesive tape not too tightly drawn. 
The anterior pad should be the heaviest to protect 
the ulna from deformity. Next apply two light, 
well padded splints, using care to trim out the an- 
terior one to prevent pressure on the thenar 



eminence of the thumb, and secure them by a snug 
fitting roller bandage. Place the arm in a position 
between pronation and supination in a sling, avoid- 
ing pressure on the hand. If possible get an x ray 
picture to see the results secured. 

In one week begin gentle massage and passive 
motion of the fingers. At the end of the second 
week dispense with the posterior splint and shorten 
the anterior one. Now use gentle massage and 
passive motion of the hand and wrist if union is 
firm. After three weeks one can usually dispense 
with the splints and dress with pasteboard or 
leather strips and a roller bandage. After all 
dressings are left off a leather wrist support, at 
least three inches wide, may be worn with comfort. 



Abstracts and Reviews 



efficiency and inefficiency: a 
proble:\i in medicine.* 

By Pearce Bailey, M. D., 
New York. 

Dr. Pearce Bailey said that at the risk of saying 
something that everyone knew, he wished to hazard 
a definition of efficiency as production which se- 
cured a full output in the shortest time with the 
least effort and which reduced waste to a minimum. 
In America it had attained its ideal almost exclu- 
sively in industry, where it had reached a high de- 
gree of perfection ; it produced and conserved. Em- 
ployers of labor were finding it more and more ad- 
vantageous to see to it that those who worked for 
them were well, prosperous, happy, and, of course, 
temperate. But industrial efficiency considered 
only its own end. It had no concern with general 
public welfare and considered the employee only 
in so far as he was a working unit. 

Real efficiency embraced much more, for it was 
not limited to the perfection of certain specialized 
groups of carefully selected individuals, but con- 
cerned the welfare of the whole heterogeneous peo- 
ple. Its aim, and indeed its obligation, was to do 
for the entire community what industrial organiza- 
tions did for themselves and their chosen associ- 
ates. Its task required a more careful planning 
than those of industry, because, while industry 
picked its own men and could in no way be held 
responsible for them, a nation was bound to make 
provision not only for the capable, but, just as in- 
evitably, to ensure some opportunity for those who 
could not fully provide for themselves. The fore- 
sight with which a nation accepted this problem and 
protected all of its varying classes and put oppor- 
tunity in their way determined whether or not that 
nation was really efficient. It was inseparable from 
practical government and economics, but it was also 
a problem for medicine, if that term were used to 
include all the sciences which had to do with man 
as a working machine, a machine of varying con- 
struction and liable to be put out of repair. Medi- 
cine must come more and more to the front as a 
helper and guide in meeting this great modem prob- 
lem. 

•Summary of a lecture delivered at the Academy of Medicine, 
New York, January 4, 1917. 



ABSTRACTS AND REVIEWS. 



7i 



A hint as to how the plan might be worked out 
could be had from the experience of industry where 
one of the medical sciences, psychology, had come 
forward recently to meet certain industrial difficul- 
ties, especially that of the detennination of voca- 
tional htness of candidates for employment, for 
time lost in getting men who did not suit was very 
costly. The basis of the tests used were those in- 
vented by Binet and Simon. Other tests were used 
to determine higher grades of mental capacity in 
persons for whom the Binet tests were too elemen- 
tary. These vocational tests had hardly been used 
long enough to justify a final opinion of their full 
usefulness, but the results of them had attained a 
reasonably high percentage of agreement with the 
employers' opinions of the candidates examined. 
The mental examination of proposed employees had 
only recently been added in certain industries to the 
physical examinations, and together they formed a 
stiff barrier of exclusion which made it inevitable 
that large percentages of those seeking employment 
were rejected at the outset and were thus thrown 
back on the community. 

A street railway company in New York in the 
past twenty-nine months, out of 82,031 candidates 
for employment examined only physically, rejected 
13.173. or 16.5 per cent., the chief causes being her- 
nia, varicocele, varicose veins, flat feet, heart and 
lung conditions. All candidates for work in a large 
hfe insurance company in this city, except for such 
positions as those of cleaners, printers, laborers, 
waitresses, kitchen help, elevator men, engineers, 
foremen, and porters, had to attain seventy-five per 
cent, in mental testing before being passed on for 
physical examination. Of 1,443 candidates mentally 
tested, 604 passed; that is, more than half failed. 
The number examined physically in one year was 
1,125: of these 841 were approved medically, 108 
were postponed, and 148 were rejected. 

What was to become of the large number of per- 
sons deemed incompetent for first class service ? 
They must not only smother their first disappoint- 
ment, but must make a new adjustment by finding 
employments which made less exacting demands on 
physical and mental capacity. These employments 
not being forthcoming, or not paying well enough 
for support, many of these individuals became alco- 
holic, insane, or criminals, and ended up by being 
supported by the State. Industry could not be 
blamed for these results. It was less a question of 
responsibility than common sense which dictated 
that society make some provision beforehand. It 
would be easy to prevent many of these failures 
which showed a glaring defect in American methods 
of education. The many people who grasped at 
what they could never attain, or at what they would 
be certain to fail, would liave been far better oiif 
if they at the outset had correlated their aims with 
their capacities. 

Some idea of the terrible sacrifice of human use- 
fulness and the burden in money put on the State 
by those of its people who did not produce was fur- 
nished by the records of charity and correctional 
institutions and commissions. In the State of New 
York, with a population of nine and one half mil- 
lions, there were nearly three hundred thousand 



persons who were registered every year as unable 
to take care of themselves, either by reason of phys- 
ical disability, mental defects, or criminality. For 
every one of these there probably were in addition 
three or four who had escaped registration. Ac- 
companying the money loss to the State entailed by 
these failures there came a deterioration in charac- 
ter which mortgaged future values. The workman 
who lost his job because he was not good enough 
for it, the boy who went to college and had to leave 
it, the young man pushed into some industrial en- 
terprise at which he failed had not only lost time 
and money, but also had impaired his chances of 
succeeding' at something else. Even if failure was 
not absolute, by keeping on at something at which 
he could never really succeed, he never got in har- 
mony with his work and missed the elation which 
adapted labor brought ; he was assailed by two sul- 
len enemies of efficiency, namely, discouragement 
and discontent, for he realized that he did not ob- 
tain for himself and from others the respect neces- 
sary for his happiness and believed that he might 
have done better things under different conditions. 
Work was more than production ; it was the means 
of self expression, the great adjuster between the in- 
dividual and society. 

It would seem then that the time had come to 
study more intensively the human element in labor, 
and to recognize at the outset that all men did not 
belong to Class A. All branches of human en- 
deavor proved this to be true. It was time that na- 
tional policies should recognize that hopes of econ- 
omy, of effectiveness, and of national peace de- 
pended on the success with which it was able to pro- 
vide suitable employment for men of all grades of 
capacity, and the first great task was to analyze and 
sort them. In spite of the fact that all men were 
not equal and that none could be free, the agreeable 
delusion of equality and liberty was still the cher- 
ished ideal of America. The fact that this belief in 
the right of every person to dispose of himself as 
he pleased resulted in substandard men, in the in- 
evitable waste and deterioration in inebriety, in al- 
coholism, in pauperism, crime and insanity, seemed 
to escape observation. 

It seemed now one of the greatest obligations of 
medicine to reconstruct public opinion in these mat- 
ters and to show that the efforts of lawmakers in 
the way of decreasing the opportunities for tempta- 
tion, as in prohibition and in punishing seasoned 
offenders, did not meet the full issues and could 
never attain the maximum good for mankind. It 
was for medicine to show that efficiency in human 
affairs, just as surely as in industry, depended on 
developing and improving the material, and that a 
primary condition of this was to know the material. 

One of the first points to be made clear to the 
minds of the public was that physical disease offered 
fewer obstacles to national efficiency than did de- 
fects or disorders of mentality. It was not intended 
to slight the importance of physical examinations, 
especially when made in youth for the purpose of 
controlling disease tendencies at their beginning, nor 
to minimize the social significance of tuberculosis 
and especially of syphilis, which was so prone to 
disable the nervous system. But the physical dis- 



74 



ABSTRACTS AND REVIEWS. 



(New Vc 

Medical Jau 



eases were neither so widespread nor so disastrous 
to character as mental impairments. 

Of the various methods which would be called 
into use in planning for mental preparedness, ap- 
plied psychology should perhaps be mentioned first. 
It dealt with the purely intellectual aspects of per- 
sonality as opposed to the emotional ones ; its 
methods were reasonably speedy and furnished sur- 
veys of material without prohibitive expense. It 
had shown in the past few years the high percentage 
of feeblemindedness in the schools and had pointed 
out the necessity of graded classes. It showed the 
wide distribution of mental inefficiency in clerical 
operatives and in the experiments of Professor 
'I'ernan, of Leland L'niversity, it showed in a 
general way how mental ability was distributed 
in those early age periods at which all reconstruc- 
tion, to be effective, must be begun. In these ex- 
periments the general intelligence of i,ooo unse- 
lected school children was analyzed; sixty per cent, 
had average intelligence, fifteen per cent, were 
above the average, and fifteen per cent, were dul- 
lards, or dull normals ; six per cent, to seven per 
cent, comprised the actually feebleminded. The 
large bulk of sixty per cent, was composed of those 
who did fairly well under simple requirements, but 
their usefulness to themselves and others when out 
in the world would largely depend on the way they 
were guided and helped. These tests did not indi- 
cate the social usefulness of the individuals ; this 
was not to be determined by tests of intelligence as 
this might be gained by other qualities, such as 
moral traits, personal appearance, influence and op- 
portunity, and the emotional attitude of the indi- 
vidual toward himself and to the world. Herein 
lay the chief practical criticism of Professor Ter- 
nan's experiments. In addition, some possessing 
superior intelligence were handicapped by such 
qualities as moodiness, feelings of injustice, ideas 
of reference, and dreamy idealism, all of which 
were obstacles and sometimes absolute bars to suc- 
cess in life, but none of them were to be detected 
by the ordinary methods of normal psychology. 
When it came to an estimate of the personal equa- 
tion, psychiatry could furnish a far more accurate 
estimate ; it determined the actual value of qualities ; 
it singled out the defects in character, and it esti- 
mated the chances of permanency of energy ex- 
panded in any direction ; it lay bare not only the 
mind but the heart. 

The practical task which psychiatry had before 
it concerned the determination of vocational fitness, 
which was still a vexed question. But this had 
already been undertaken in the Boston Psychopathic 
Hospital in an efifort to establish a rational attitude 
toward delinquents. Doctor Glueck had established 
at Sing Sing a clinic where the records showed that 
fifty per cent, of the inmates there were so handi- 
capped mentally and physically that under given 
conditions they would always commit crimes. 

Whoever invented the term education had an idea 
of it which had to a certain extent been lost to 
view. Etymologically, education meant to draw out, 
to develop something the individual had in him ; but 
the present educational methods seemed based 



rather on the idea ul pulling something in, more 
or less irrespective of what was being put in. The 
present methods neglected the personality of the in- 
dividuals educated, while the plain fact was tliat 
education was only of use in so far as the total per- 
sonality was of a character to make use of it. The 
real purpose of education was the upbuilding of 
character, the transmutation year by year of the 
feral propensities with which a child came into the 
world into cooperated and directed forces. Without 
this transmutation of the infantile primitive im- 
pulses into an adult coordinated selfcontrol, the in- 
dividual remained against or outside social order. 
And psychiatry, from dealing with those who for 
some reason had lost, or had never obtained a grasp 
on reality and who were out of sorts with society, 
was in a position to identify the way this had hap- 
pened and to suggest the remedies most likely to 
prevent its happening. 

An example of the opposite of what education 
was intended to inculcate was furnished by the dis- 
ease dementia prsecox, which was in reality a deteri- 
oration of character. As this disease progressed 
those qualities which made for success were 
diopped off one by one. The patient, instead of 
being self restrained, became impulsive; he had sud- 
den outbursts of temper; he refused and resisted 
whatever was offered to him; he was apathetic and 
fearful ; he was suspicious and attacked those about 
him. There was a resumption of the affectations, 
grimaces, and mannerisms which should not persist 
after early childhood. All his behavior was the di- 
rect opposite of what it was the real purpose of edu- 
cation to foster. Education should view with con- 
cern the persistence of any of these characteristics 
beyond the time of their normal disappearance, and 
the presence of several of them in an individual 
made it important to check their further develop- 
ment. Sometimes an alienist was put to it to dis- 
tinguish between a badly brought up child and a 
case of dementia praecox. 

Education should have for its purpose the detec- 
tion of all persons so inclined and should institute 
special methods for tlieir training. It was in con- 
nection herewith that a military service was of so 
much benefit to a country. There was little general 
interest in the psychological way of looking at these 
things To bridge over this general lack of public 
interest an institution was suggested where adoles- 
cents should be examined for the purpose of deter- 
minino- individual efficiency. It would have the 
advatitai^e ot self support and there physical and 
mental examinations would be made which would 
embrace the life history of the individual. Complete 
records would be kept and at the end of one, or 
three, or five years these records would be com- 
pared with how the individual turned out. 

What was needed now was a general dissemina- 
tion of these views among the public at large and 
among educators, a great psychological representa- 
tion in educational matters, and a close coopera- 
tion between alienists and psychologists and the 
other groups, economists, sociologists, and states- 
men, who were working toward the same end, 
though on different lines. 



Dietetics, Alimentation, and Metabolism 

Food and Food Preparation, in Health and Disease 



FOOD AND EFFICIENCY. 

By Martha Tracy, M. D., 

Philadelphia. 

Professor of Physiological Chemistry, Woman's Medical College, 
Pennsylvania. 

( Concluded from page 124J.) 

VIII — PRACTICAL DIETETICS. 

'i'he knowledge thus far gained by physiologists 
as to the daily food requirement of man in terms 
of proteins, carbohydrates, fats, salts, and vitamines, 
is of little value to the practical dietist or to 
the public, unless the facts can be translated into 
units of everyday experience, meat, potato, bread, 
butter, etc. It is no uncommon occurrence to meet 
people of superior intelligence, who may be familiar 
with the chemical nomenclature, entirely unaware 
of the true nutritional value of foods as offered in 
the market or at the table, because uninformed as 
to the presence in such foods of the essential con- 
stituents. The tuieducated public is completely and 
pitifully ignorant in this regard. 

That the average individual is appreciative of in- 
formation along these lines is indicated by the in- 
telligent interest shown by the employees of the 
New York Board of Health, in the data as to the 
fuel value of the foods offered, which is furnished 
on the bill of fare in the restaurant organized for 
their benefit under the direction of Dr. Charles F. 
Bolduan. 

Professor Lusk's suggestion that the manufac- 
turers of canned foodstuffs might well be compelled 
by law to include on the labels information as to 
the quantity of protein and total calorific value of 
the food contained therein, is deserving of serious 
consideration. Such a procedure would be of enor- 
mous value in educating the general public. 

Elaborate and accurate analysis of common foods 
are now available in tabulated form for those who 
ha\e time and opportunity for their use, and con- 
stitute the essential sources of reference on this 
subject. Among the most important are the follow- 
ing: The Chemical Composition of American Food 
Materials, Atwater and Bryant ; Bulletin No. 28, 
U. S. Department of Agriculture ; Food Values, 
Edwin A. Locke. D. Appleton & Co. ; Analysis and 
Cost of Ready to Serve Foods, F. C. Gephart, In- 
troduction by Graham Lusk, Press of American 
Medical Association, 1915. 

Such tables are, however, somewhat unwieldy 
for everyday use by the housewife, and the com- 
plexity of the matter presented is usually sufficient 
to discourage a beginner. The following compara- 
tively brief tables, the data for which are taken 
chiefly from Locke's book, seem to me to place the 
facts essential for the home caterer in a relatively 
simple and accessible form. 

Bearing in mind the two main requirements for 
the the daily diet, namely, that it shall contain ap- 
proximately 65 grams of protein with 2,500 total 



calories, or 75 grams of protein with 3,000 total 
calories, these tables have been made to include 
only data as to the weight of protein and the total 
fuel value of the foodstuff. Since multitudes of 
figures are in themselves a bewilderment to one 
unaccustomed to their use, it is believed advisable 
to eliminate as many unessential figures as possible. 

In tables as brief as these, undoubtedly there 
will frequently be noted the omission of a veg- 
etable or a dessert, or other food article which is 
desired for a particular menu, but by reference to 
the Locke or Gephart tables such an article can be 
looked up as occasion demands and added in its 
proper place according to the amount of protein 
and total fuel value. Thus, according to the fam- 
ily tastes, the tables may be enlarged from time to 
time. 

In order to bring together portions which are 
comparatively uniform as regards protein or fuel 
content, the portion as described by Locke is in 
some instances modified by a qualifying word, 
large or small, and the analytical figures changed 
by a correspon,ding definite percentage increase or 
decrease. Wherever this has been done the sign 
(t) is placed before the name of the article. Thus 
the quantities suggested for a portion are approx- 
imate only, but, it is believed, are sufficiently uni- 
form to constitute a basis for every day planning 
of the household meals. A little larger portion on 
one day will undoubtedly be balanced by a smaller 
portion on another day, and great accuracy is not 
necessary. A weekly ration of 17,500 calories is 
without doubt quite as satisfactory as a daily ra- 
tion of 2,500 calories for seven days. 

In using these tables the following simple rules 
will readily lead to the combinations of food mate- 
rials which will supply the nutritive requirements 
arid add the desirable variety to the daily menus. 

1. For the heaviest meal of the day — dinner — 
select one article from each of Tables I, II, and III. 

2. For luncheon, or supper, select one article 
from each of Tables II, III, and IV. 

3. For breakfast select one article from each of 
Tables III, IV, and V. 

4. Add together the protein values and deter- 
mine what addition of protein is needed to com- 
plete the daily requirement. 

5. Add together the total calorific values, and to 
this total add 600 calories, which will be inci- 
dentally taken during the day in accessories, as 
sugar, cream, butter, sauces, etc. (Table IX). De- 
termine what fuel value must be added to bring the 
total for the day up to the requirement. 

6. Supplement the protein and fuel as may be 
indicated by the necessary additions, according to 
taste, and to any meal desired, of articles from one 
or more of Tables IV to VIII. 

7. Do not let the daily protein run above 75 
grams for any length of time. The total fuel value 



DIETETICS, ALIMENTATION AND METABOLISM. 



of the food may run above 2,500 or 3,000 calories 
without harm, especially in cold weather, unless 
one tends to become excessively fat. 

8. Remember that the total fuel value of the ra- 
tion must be increased if very active or severe 
muscular work is to be done, and see to it that such 
active worker receives double or triple portions of 
the food articles provided. 

9. After the occasional feast day, which will do 
no harm to a vigorous digestive tract, eat a little 
less for a day or two until the weekly balance is 
struck. 

By such use of the tables a general appreciation 
of the nutritive value of the common foodstufifs 
will be acquired in a remarkably short time, and 
the housewife in planning the meals for the day, 
or the individual selecting his or her own food in 
a restaurant, will by second nature, or with an 
educated common sense, find no difficulty in meet- 
ing the nutritive requirements without special 
thought as to protein or calories. 



Meats, Poultry, Fish. 
High Protein Foods 
be served at a i 



TABLE I 

t — modificatio 
Only one article 
eal, and preferably only once 



of Locke's "portion." 

this table should 
day. 



Food Article „ 

SECTION A Portion 

tBeef, roast i small slice . . . 

Beef, steak i slice 

tChicken, fricassee . . . large helping . . . 
tLamb, roast iVi slices 

I.amb, chops I average chop . 

tMutton, roast 3 slices 

tHam, boiled large slice 

tTurkey, roast small slice 

tSalmon large helping ... 

tMackerel double helping , 

SECTION B 

Beef, scraped (round) 4 in. pat V average 

tChicken, roast small helping f 21 grms 

Mutton, chops I chop 

Mutton, boiled i slice , 

tPork, roast small slice | 

tPork, chops I large chop j 

Veal, roast I slice 

tBIuefish small helping [ 

Codfish average helping 1 

Halibut average helping 

Spanish mackerel average helping I 

tClams (long) lo clams 

iCrab, hard shell i large crab J 



Rough 



Rough 
average 
265 cal. 



Rough 
'■ average 
)o cal. 



TABLE IL 



th 



Green Vegetables. — Low fue 
iluable for salts, vitamines, 
s table should be included i 



nd protein value (exception, com). 



and bulk. At least 
, the day's ration. 

Protein 
Grams 



article from 



Total 
Calories 

Rough 
average 

55 cals. 



Food Article Portion 

Squash 2 heap, tablesps. 

Spinach 2 heap, tablesps. 

Tomatoes, raw 1 average size . 

Tomatoes, cooked j heap, tablesps. 

Asparagus, canned ...average helping 

Beets 2 heap, tablesps. 

String beans n heap, tablesps. 

Carrots 3 heap, tablesps. 

Cabbage 3 heap, tablesps 0.6 1 

Cauliflower 2 heap, tablesps. 

Turnips 2 heap, tablesps 0.4 [ 

Corn, green boiled ...i car 3.5 J 

Any of the above articles used as salad with mayonnaise dressing 
will be increased in fuel value by 187 calories. 

Cream sauce added in serving any of the above articles will in- 
crease the fuel value by gi calories. 

TABLE III. 

"Starchy" vegetable foods. High fuel value (carbohydrate). 
Low Protein. — Only one article from this table should be used 
meal. 



Rough 
average 



Rough 
average 
7 cals. 
140 cals. 



at a 

Fooi 
Potatoes- 
Baked 
Boiled 



Portion 



Protein 



Article 

-white ^ 

I medium size j 

■. I medium size j R^ugh 

*incd 4 heap, tablesps ( average 

bed 3 hc.np. tablesps f , , „„. 



tM 
Potatoes — sweet boiled. 1 small 

tRice. boiled I'A heap, tablesp: 

Macaroni, boiled 3 heap tablesps... 



Rough 
Average 
140 cals. 



prefe 



TABLE IV. 
is containing moderate protein of animal origin. 
1 articles from this table may be used at the same 
ably not with articles from Table I. 



Portion 



Food Article 
section a 

Egg, boiled 1 egg 

Egg, raw I egg 

Milk, skimmed i glass 

Butter milk (from 

churn) I glass 

American cheese i cu. in 

Cream cheese i cu. in 

Chicken sandwich . . . i sandwich . . 

Ham, fried average portion 

Sardines, canned .... 3 fish 

Oysters, raw 9 oysters 

Whole milk 

Omelette, 3 eggs li omelette ... 

3 tablesp. milk f- average 

1 heap, teasp. butter. I 7^2 grms. 

Meat stew average helping 

Custard pudding 2 heap, tablesps. 

Sausage, country 

Bacon 

Ham 



Rough 



Cream toast 



targe sausage . . 

sandwich 

slices with 5 
tablesps. sauce 

tablesp 



Rough 

^ average 

80 cals. 



Rough 
average 
1 50 cals. 



Rough 
"• average 

300 cals. 



tCustard pie i4 

Mince pie % 

Section B. — Foods containing moderate protein of vegetable 
origin. Two articles from this table may be used at the same meal. 



ration up to the 



'ithout articles 
requirement. 



from Table I to 



the protein 



lo"^.":^- ■:::::.[ ^t 



Food Article Portion 

Baked beans, canned .3 heap, tablesps. 

Lima beans 2 heap, tablesps. 

Green peas 4 heap, tablesps. 

tPeanuls 20 nuts 

fBrazil nuts 7 large nuts 

tPecans 

Walnuts 

Cocoa 

I heap, teasp. ca 

1 heap, teasp. s 

^ cup milk .... 

I tablesp. cream 



Breadstuffs and Cereals— High fuel 
low protein. 

Section A — Breadstuffs. Useful additii 
and three times the Dortion given. 

Food Article Portion 

Corn bread Slice jx2x^4 in. .. 

White bread, baker's. . Slice sVi^i^V^ in. 

White bread, homemadeSlice 3x4x1/2 in. . . 



!,■ 



Rough 
rage 

40 cals. 



J j 



Rough 
average 
300 cals. 



(carbohydrate) with 



ns to every meal in twice 



oil 



oil 



Biscuit, homemade . 

Graham bread Slice 3^x2jiSxj4 

W'hole wheat bread . . . .\verage slice . . 

tGraham crackers .... 3 crackers 

tSaltines S crackers 

tButter crackers 6 crackers 

Section .B — Cereals. Only one article 
used at a meal. 

Food Article Portion 

tOatmeal, boiled 3 heap, tablesps 1 

Shredded wheat i biscuit i 

Indian meal mush .... 3 heap, tablesps [ 

Hominy, boiled 2 heap, tablesps J 

Sugar and cream on cereal will add 2 



I 3-0 



Rough 



Rough 
average 
>o cals. 



from this table should be 



Rough 



Rough 
average 
100 cals. 



Nutritious Soups — ?Iigh fuel valu 
,o\v protein. Useful to increase the 
ne of these is selected a fruit des5 



Food Article 
Mock turtle soup ....4 
Chicken soup, homemade3 
Bean soup, homemade. 4 
Cream soups: 

Asparagus 4 

Celery 4 

Com 4 

Potato 4 



; due to carbohydrate and fat. 

fuel value of any meal. When 

Qrt is desirable. 

Protein Total 

^^ Grams » Calories. 

1 Rough 
,- average 
J 55 cals. 



nato 



Pea 

Note — Clear soups 



Rough 
average 



stimulants to flow of digestive juices. 



of low fuel value, and useful 



DIETETICS. ALIMENTATION AND METABOLISM. 



77 



TABLE VII. 
Desserts — Protein negligible to moderate, 
hydrate). Useful food articles to 
up to the requirements. 

Food Article Portion 

Tapioca pudding 3 heap, tablesps. 

Ice cream 2 heap, tablesps. 

Doughnuts I doughnut .... 

Frmt cake Slice ^iVtxiiix'A 

Sugar cookies 3 cookies 

Apple pie yi pie 

Squash pie ^ pie 

Bread pudding 2 heap, tablesps. 

Indian meal pudding . . 2 heap, tablesps. 

Orange ice 2 heap, tablesps. 

Gingerbread Slice 2x3x1 in. 

Chocolate layer cake. . . i average slice . 



Fuel value high (carbo- 
br.ng the fuel value of day's ration 



b-: 



Rough 

erage 

65 cals. 



Rough 
average 



TABLE VIII. 
Fruit — Fuel value high to moderate (carbohydrate), protein neg- 
ligible. Useful additions to any and every meal on account of or- 
ganic acids, salts, and vitamines. 



Food Article Portion 

Banana 1 average size . . 

Grapefruit 'A large size . . . 

Apple, baked i large apple . 

tApple sauce ^ heap, tablesps. 

Cranberries, stewed . . . 2 heap, tablesps. 

Rhubarb, stewed J heap, tablesps. 

Apple, raw 1 average size . 

Canteloupe 'A average size 

Orange i average size . 

fPeach 2 average size . . 

Pear i average size . . 

Blackberries 3 heap, tablesps. 

Strawberries 4 heap. Ublesps. 

Raspberries 3 heap, tablesps. 

Pineapple 2 slices 



Pro 


FEIN 




Tot.\l 


Grams 




Calories 


2 


5 
3 


1 


Rough 




2. 
27 
4 


1- 


average 
■35 cals. 





4 




Rough 


j 


5 

2 


" 


average 
85 cals. 





7 


J 










Rough 




8 
4 


) 


average 
45 cals. 



TABLE IX. 

Accessories — Moderate to high fuel value (carbohydrate or fat), 

negligible protein. Commonly used additions to every meal, and can 
usually be expected to add 600 calories or more to the day's ration 
without particular calculation. C — Carbohydrate. F — Fat. 

Protein Total 
Food .-Article Portion Grams Calories 

C-Sugar, loaf i cube_ 29 

Loaf I domino 25 

Granulated i heap, teaspoon. ... 41 

C.-Honey 1 Ublesp loi 

C. -Maple syrup i tablesp 88 

C.-F. -Cream sauce ....3 tablesps 91 

F.-Olive Oil > tablesp 121 

F.-Mayonnaise dressmgi tablesp 187 

F.-Cream, average .... 1 tablesp 54 

Heavy I tablesp 72 

Whipped I heap, tablesp 81 

F.-Butter i average ball 119 

There are a number of considerations whicli re- 
quire some further dis^ssion. Note particularly 
that the foods of animal origin are conspicuous as 
the chief protein containing foods. Next to these 
in protein content are the leguminous vegetables, 
peas and beans, and the nuts. Cereals contain 
small but useful quantities of protein, but in the 
so called coarse vegetables and the fruits, this food 
element is usually present in such minute amounts 
as to be practically negligible. 

The animal foods owe their high fuel value, as 
is shown in the tables to the presence of fat. Some 
vegetable foods also contain fat in abundance, as 
olive oil and nuts. The vegetable foods for the 
most part, however, owe the high fuel value, noted 
in potatoes, rice, and other cereals, macaroni, 
bread, and sweets, to the presence of the carbohy- 
drates, sugar, and starch which is changed to sugar 
in digestion. 

You may ask, if I like meat and eggs and milk 
better than vegetables and bread, and the protein 
in these foods can be used for fuel, why should I 
not eat more meat and burn it instead of carbo- 
hydrates? The answer to this lies in the fact 
that, as already shown, protein contains nitrogen 
and phosphorus and sulphur. The body needs 
these, as we have noted, in small amounts for tis- 



sue building purposes, but the nitrogen, phos- 
phorus, and sulphur tal^en in excess of the tissue 
building needs, yield verj' little energy on oxida- 
tion. Unly the carbon and hydrogen parts of the 
protein are useful as fuel, so that the first work 
of the body upon the excess of protein is to break 
off the nitrogen, phosphorus, and sulphur, and ox- 
idize these elements to a condition in which they 
can be passed to the kidney for excretion. The 
kidneys then will have to do a great deal of un- 
necessary work to get rid of these waste products 
and may undergo a chronic inflammation due to the 
abnormal strain. 

Certain persons, furthermore, are particularly 
susceptible to the toxic effect of the nitrogenous 
waste products, such as the so called purin sub- 
stances of which uric acid is an example, and which 
are derived chiefly from the meat foods. Retention 
of excess of uric acid in the body accompanies 
symptoms which we designate as "gouty," and in- 
dividuals liable to the development of these con- 
ditions may find it necessary to cut down the pro- 
tein of the food to considerably less than seventy- 
five grams a day, and to eliminate entirely the meat 
foods, which are conspicuous "purin formers." 

Certain diseases of the skin, also, eczema and 
psoriasis, characterized by scaly eruptions, have 
been shown to be related to excess of protein in 
the diet. We must bear in mind, in addition, the 
important consideration that animal foods are rela- 
tively expensive, and while a certain proportion of 
animal protein is extremely desirable, it is poor 
pocketbook economy, as well as poor physiological 
economy, to eat too largely of these substances. 
Carbohydrates and fats are just as satisfactory fuel 
and their use is not open to the above objections. 
But some one may say, I do not like meat at all 
and prefer to eat only vegetables ; why cannot I 
take all the protein I need in vegetable form? It 
must, however, be remembered that vegetable pro- 
teins are less like the proteins of our tissues than 
are proteins of animal origin. Many of them are 
deficient in certain of the essential building stones, 
the aminoacids, and consequently we must take 
more of them to supply adequately our needs in 
this respect. The large amount of vegetable foijd 
that would be necessar}' to furnish enough protein 
would contain too much carbohydrate. These 
foods are bulky and the appetite is lost before the 
needed amount is consumed, the digestion of so 
much is difficult, and there is danger of bacterial 
fermentation ancl uncomfortable gas fonnation in 
the intestinal tract. A strict vegetarian runs one 
of two risks : he is in danger of disturbing diges- 
tion by excessive bulk of vegetable food, this be- 
ing unavoidable if he is to secure sufficient proteiii ; 
or he is in danger of not supplying adequate protein 
to keep the body tissues properly repaired. Th( 
experience of many physicians indicates that those 
persons who maintain a strict vegetable diet are 
less resistant to infections, and are less well able 
to endure the eft'ect of an anesthetic if a surgical 
operation becomes necessary than are those whose 
tissues are well reinforced by adequate protein 
from animal sources. Eggs and milk can, if de- 
sired, take the place of meat, and in using the food 
tables here given in such cases two articles or more 



/S 



DIETETICS, AIJMEXTATIOX .IXD METABOLISM. 



(New York 
Medical Journal. 



from Tabic I\' may replace one article from Table 
1 in the dinner menu. Eggs and dairy products are 
obviously not of vegetable origin, and an individual 
who adds these to the dietary is not a vegetarian, 
though often popularly so called. 

Cooking is of considerable importance in bring- 
ing foodstuffs into an edible and appetizing condi- 
tion, and in rendering the nutritive substances more 
accessible to the digestive juices. Bacteria and 
parasites are usually killed by cooking also. There 
may, however, be considerable loss of food material 
in the cooking process, and this should be more 
generally appreciated and guarded against. It has 
been shown, ^ for example, that as much as thirty- 
seven per cent, of the fat, and sixty-seven per cent, 
of the inorganic salts will be found in the water in 
which meat has been boiled; and that when meat 
is roasted as much as fifty-seven per cent, of the 
fat and fifty-seven per cent, of the salts may be 
foimd in the drippings. The use of the broth and 
the drippings in soup or gravy will save these ma- 
terials. Potatoes may lose thirty-eight per cent, of 
the inorganic salts, and carrots may lose forty per 
cent, of the nitrogenous matter and twenty-six per 
cent, of the sugar, on boiling. ^As the vegetables 
are important sources of inorganic salts, calcium, 
and iron, and phosphorus, the possibility of this 
loss should be borne in mind and the vegetable 
broths used in soup when possible. Potatoes when 
baked do not lose their nutritive value in this way. 

The dififerences in digestive capacity of normal 
individuals constitute still another factor to be 
reckoned with in selecting the daily ration, and the 
existence of real physiological idiosyncrasies against, 
or antipathies to, certain foods, must be recognized 
by the physician and the general dietist, and must 
be given serious consideration in every dietetic plan 
and recommendation. 

In conclusion, it is to be borne in mind that the 
facts and suggestions here collected are presented 
from the point of view of the nutritional require- 
ments of a normal vigorous adult leading a more 
or less active life. Thus a normal digestive capac- 
ity is assumed, and no attempt has been made to 
suggest food articles particularly suited to the less 
vigorous digestive capacity of young children or of 
invahds. Dietetic prescriptions to meet such con- 
ditions are more properly included elsewhere. 

When, however, we have succeeded in arousing 
the interest and securing the cooperation of every 
normal adult, not only in understanding the relation 
between food and efficiency, but in practising the 
principles thus learned, we shall find fewer persons 
with subnormal digestive capacity, and we shall 
have made a tremendous stride in preventive medi- 
cine. 

Cocoanut Oil. — Oil expressed from the cocoa- 
nut and then refined and neutralized is being used 
more and more not only to replace fats, but cotton 
seed oil as well, for frying foods. It is also used 
as a substitute for animal fats such as butter and 
margarine. It is a clean, appetizing product and is 
easily digested. 

'Grindley and Mojonnier. Bulletin No. 141, U. S. Department of 
Agriculture. 

=Snyder. Frisby and Bryant. Bulletin Xo. 43, V. S. Department 
of Agriculture. 



A Lesson in Dietetics from the Dog. — Dog fan- 
ciers have lung noted that when a house dog begins 
to get fat and wheezy, it is likely that it has been 
attacked by a stubborn skin disease. In such a 
case they cut down the diet and increase the open 
air exercise, thus relieving the overburdened body 
of poisonous substances. 

The sin of gluttony is common and therefore 
much condoned, but, like every other violation of 
Nature's laws, has a penalty. Fat inefficiency, slug- 
gish mentality, the reddened nose, the pimpled face, 
certain of the chronic skin eruptions, and much 
fatigue and nervousness are due to abuse of the 
digestive apparatus. Rich, indigestible foods in 
large quantities, highly seasoned to stimulate the 
jaded palate, are forced into a body already re- 
bellious from repletion. Exercise is largely lim- 
ited to walking to and from the table, and bodily 
deterioration proceeds rapidly. Many on overfed 
dyspeptic, suddenly dragged by the stern hand of 
circumstances from a life of physical ease and 
plenty and forced to work out of doors, suddenly 
discovers that his semiinvahdism has gone, that a 
chronic skin derangement of many years' standing 
has disappeared, and that a new vigor and zest of 
life has been given to him. 

Not every one can spend his whole time in the 
t'pen air, but a certain amoimt of exercise and plain 
wholesome food in amount not exceeding the body's 
needs, can be had by almost everj' one. Simple 
moderate diet and exercise make for health. 

The Use of Large Quantities of Fruit Juice 
for Atrophic Infants. — H. B. Gladstone {Prac- 
titioncr, November, 1916) says that fruit juice can 
be taken to the extent of a pint daily with immediate 
benefit to a dyspeptic atrophic infant under one or 
two years of age. A carefully selected predigested 
food, low in albumin and fat and high in sugar, will 
then be both digested and absorbed and result in 
gain of weight. At first a loss of weight must be 
expected, but, by the end of the first week, this usu- 
ally is regained. Unless tlife juice is followed by a 
diet scientifically adapted to a weak digestion, it 
does no permanent good. The juice acts partlv on 
account of its acid reaction, rendering the bowel un- 
suitable for germs growing in an alkaline medium. 
It has a tonic, cleansing eflect on the mucous mem- 
brane of the digestive tract, and is a diaphoretic, diu- 
retic, and general alterative. It supplies an at- 
tractive drink, enjoyed by all babies, containing ten 
per cent, of soluble carbohydrate food, removes the 
irritability and restlessness of the child, promotes 
quiet sleep, and renders the digestive organs able 
to digest and absorb a light diet. Two parts of 
orange to one of apple juice, diluted with one quar- 
ter the quantity of water, seemed to give the best 
results. When oranges are unobtainable, melon and 
apple juice has been used with somewhat less good 
results. Strawberry, cherry, raspberry, and banana 
juices have been taken and enjoved bv babies with- 
out bad efTects, and it is probable that any fruit 
juice would succeed, provided that the acid fruits 
were not used in too large a proportion. When 
oranges are out of season, it may be well to add a 
small quantity of lemon juice to the sweeter fruit 
juices, to supply the necessary acidity. 



Editorial Notes and Comments 



NEW YORK MEDICAL JOURNAL 



INCORPORATING THE 



Philadelphia Medical Journal 
and The Medical News 

A Weeiiy Re'-vic-M of Medicine 



EDITORS 

CHARLES E. de M. SAJOUS, M.D.,LL. D., Sc. D 

CLAUDE L WHEELER, A. B., M. D. 

Address all communications to 

A. R. ELLIOTT PUBLISHING COMPANY, 

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Cable Address, Medjour, New York. 



NEW YORK, S.ATURDAY, JANU.'\RY 13, 1917. 

BRAINS AS AN ASSET 
It is a remarkable fact, with the general endorse- 
ment accorded in recent years to the necessity of 
physical examinations, and the wide latitude given 
to boards of health in the enforcement of recom- 
mendations for the identification and control of 
contagious diseases, that the public has acquired so 
little insight into the defects and disturbances of 
intelligence as factors in social unrest and ineffi- 
ciency. The government spends large siuns for the 
prevention and detection of the purely physical dis- 
eases, but it spends practically nothing for the study 
and prevention of mental diseases and intelligence 
defects. The proof of the wide distribution of men- 
tal incapacity is to be found on every hand, and 
large amounts have to be paid out for the late re- 
sults of insanity and criminal tendencies. It would 
seem only common sense for a government to look 
this matter in the face and to attempt to determine 
whether something could not be done earlier to make 
the list of its delinquents and dependents smaller in 
number. 

In his address at the annual meeting of the New 
York Academy of Medicine, on January 4th, Dr. 
Pearce Bailey drew attention to these matters, using 
the attitude of industrial enterprises toward its em- 



ployees as an example for the government to emulate 
in regard to its people. Industry rejects the unfit 
at the start. A government cannot reject them, but 
it can at least recognize them and make special pro- 
vision either for their education, their partial em- 
ployment, or their early custodial care. So far this 
idea has received recognition only by the establish- 
ment of graded classes in the schools. The same' 
principles should be applied to the mental disorders 
as those now coming into use for mental defects. 
This can only be done when the public realizes more 
fully how much psychiatry has to offer in the way 
of solving national problems. It can be a great aid 
in the helping of vocational choice for the partially 
fit, it can detect criminal tendencies at the outset, and 
in this way lead to the prevention of a great deal 
of crime, and its principles must be incorporated in 
the practical aspects of education if education is 
going to be of value to the person educated. In 
fact, it would seem as though an immediate recog- 
nition by educators of psychiatric principles would 
be the surest way of diminishing the ravages of in- 
sanity in this country. As there are substandard 
classes in the schools, so there should be a recog- 
nition of children predisposed to insanity, and even 
showing some of the symptoms of insanity in early 
youth, who should have special training and spe- 
cial drills. It Is confidently predicted that such man- 
agement of predisposed children would keep many 
of them from ultimately becoming insane. 

There are only three psychopathic hospitals for 
the insane in this country, and only three psychiatric 
institutes. The total budget is less than $50,000 a 
year. This is scant provision for a problem which 
runs into the hundreds of millions. The government 
would permit no such neglect of investigation if 
cotton or wheat were concerned. 



THE TREATMENT OF DIABETES BY 
ALIMENTARY REST. 
Prolonged fasting, as a treatment for diabetes mel- 
litus, otherwise known as the Allen treatment, is 
largely employed throughout the world. This man- 
ner of treatment appears to have met with a great 
deal of success, speaking generally. In the Practi- 
tioner, November, 1916, are three papers dealing 
with the starvation treatment of diabetes, one of 
which is by Dr. P. J. Cammidge. He points out 
that the treatment of diabetes mellitus by prolonged 
fasting was suggested by the experimental investiga- 
tion of von Mering and Minkowski, who conclusive- 
ly proved in 1889 that tlie pancreas exerts an impor- 



8o 



EDITORIAL ARTICLES. 



(New York 
Medical Journal. 



tant control over carbohydrate metabolism. How- 
ever, the hopes aroused by this discovery that ther- 
apeutic measures for the relief of diabetes would 
follow, have been doomed to disappointment until 
a comparatively recent date, when Thiroloix and 
Jacob in 1912 and Allen in 1913 pursued investiga- 
tions in this direction. The first named investiga- 
tors found that in suitably prepared animals, the 
onset and progress of the glycosuria of diabetes 
can be hastened by overfeeding with carbohydrates. 
Allen went further in the investigation of the mat- 
ter and first published his results in 191 3. 

The details of the treatment and the underlying 
principles are sufficiently well known to Ameri- 
can medical readers and therefore, some of Cam- 
midge's points will be only briefly considered. He 
lays stress on the fact that education of the patient 
is always an important part of any form of dietetic 
treatment, and, in the case of the fasting treatment 
of diabetes, is essential. In order, then, that this 
intelligent cooperation may be gained, the aims of 
the treatment and the means by which they are main- 
tained should be clearly explained, and the diabetic 
should be instructed subsequently in the more impor- 
tant points concerning the properties and functions 
of dififerent classes of food materials. Cammidge 
has found that a considerable number of patients do 
better when they are allowed to get about and oc- 
cupy themselves than when they are kept in bed. 

According to his way of thinking, one of the weak- 
nesses of the Allen treatment, is the manner in 
which the diet is regulated entirely by the presence 
of an abnormal sugar content in the urine and blood. 
This does not furnish a reliable guide to protein tol- 
erance, for although sugar is formed in the metab- 
olism of proteins, and while this may be passed un- 
utilized in the urine in some cases of diabetes, a large 
excess of protein food over what is really needed 
may be taken without there being any glycosuria in 
many instances. Cammidge is of the opinion that 
the effect of such an excess is to raise the level of 
metabolism, promote avoidable waste, and throw un- 
necessary work on the liver and kidneys, which are 
already defective and working under difficulties in 
more cases than is generally supposed. He con- 
siders that better and more permanent results will 
be obtained from the fasting treatment, if the nitro- 
gen loss in the urine, is taken as the chief guide in 
fixing the amount of nitrogenous food than if at- 
tention is solely confined to the appearance of 
sugar in the urine. In reviewing the effects of the 
Allen treatment, Cammidge holds that while this 
method is the best form of treatment at present 
available for cases of diabetes of the acute and 
subacute types, it must not be concluded that it is 
an easy road to a cure, or that it can be used indis- 



criminately in all cases in which reducing sub- 
stances are passed in the urine. Cases for the fast- 
ing treatment must be carefully chosen, for all 
patients do not do well on the method. Moreover, 
the fact must always be borne in mind that fasting 
is after all only preliminary treatment to the task 
of adjusting the diet to the patient's defective pow- 
ers of metabolism. The medical attendant, there- 
fore, must have an accurate knowledge of food 
values and of the composition and use of foods, 
if he is to treat diabetes or any disease successfully 
bv dietetic measures. 



VITAMINES AND BACTERIAL GROWTH. 

Almost every one is now more or less familiar 
with the existence of that ill defined group of ac- 
cessory food substances called by Funk, vitamines. 
Their varied roles in the maintenance of normal 
nutrition and the promotion of normal growth in 
animals and man are rapidly being defined, so that 
we now have a group of diseases which are gener- 
ally recognized as resulting from the deficiency of 
one or another of these accessory substances. That 
vitamines, however, may be of importance in the 
growth of such simple organisms, biologically, as 
bacteria, has not heretofore been considered, except 
perhaps by an isolated worker here and there. 

Some very recent observations made by Martin 
Flack {Brit. Med. Jour., November 18, 1916) there- 
fore, are of considerable interest in connection here- 
with. In the course of an extensive series of experi- 
ments designed to determine the growth require- 
ments of the meningococcus, certain media were elab- 
orated which seemed to give the best conditions for 
the artificial cultivation of these organisms. Flack 
found that the addition of a sterilized extract of pea 
flour to the best of the media greatly favored the 
growth and multiplication of the organisms. This 
material, however, did not have any effect upon pro- 
longing the period of life of the organisms in artifi- 
cial cultures. If, however, an extract from the 
wheat grain was added in place of the pea flour ex- 
tract the life of the organisms was greatly pro- 
longed. In this case the growth and multiplication 
of the organisms were not enhanced. 

Both pea flour and wheat germ are known to bo 
rich in vitamines, and the observations just recorded 
could not be attributed to the presence of any other 
substances contained in either of these materials. 
The differences in the effects of the two were strik- 
ing, and the only explanation forthcoming was that 
the pea flour contained a vitamine which was essen- 
tial to the growth of the meningococcus and which 
was capable of greatly enhancing it without influ- 
encing the viability of the organism. The vitamine 



January 13, 1917O 



EDITORIAL ARTICLES. 



of the wheat germ also influenced growth, but in a 
different way, prolonging the vitality. The conclu- 
sion is obvious that the two vitamines are distinct, 
at least in the biological sense. Their chemical con- 
stitution, as is the case with the other vitamines, is 
not known. 

Although seemingly of minor importance in them- 
selves, these observations are of great significance, 
for they open up a new field of bacteriological re- 
search which may be of inestimable importance. It 
would scarcely be going too far to suggest that as a 
result new and valuable knowledge might be 
gained for the bacterial therapy and the treatment. 
specific or otherwise, of certain microorganismal 
diseases. 



THE ACCURACY OF DEATH CERTIFI- 
CATES. 

There exists, unfortunately, too great a ten- 
dency to treat lightly, or even facetiously, the prob- 
lem of making a" complete and accurate return to 
the health authorities of the cause of the death of 
patients. This is especially true among those of 
us who have to do with a large number of indigent 
or public patients during the year, physicians to the 
poor, the resident or visiting physicians of alms- 
houses, insane asylums, and other institutions. 
This is not to be taken to mean that the patient was 
neglected during life, but when all that is possible 
has been done for him before death there is a temp- 
tation to close up the case by writing in the death 
certificate a cause of death which we know by ex- 
perience will be accepted by the health department 
without question and let it go at that, even though 
we entertain a secret doubt as to the accuracy of 
the diagnosis. The usual character of such cases, 
too, contributes to this state of affairs. In many 
of our aged patients in almshouses the flame of life 
burns so feebly that it is easily jostled out and our 
knowledge of geriatrics is so nebulous that it is 
often difficult to determine the cause. 

The writer of this recalls one able, though ven- 
erable physician, who was head of a charitable or- 
ganization in which he worked for a time. This 
doctor was fond of quoting the ancient dogma of 
the French physiologist about life resting on a tri- 
pod ; he held in consequence that immediate cause 
of death should either be the cessation of breath- 
ing, apnoea, or the stopping of the heart, syncope, 
or the paralysis of the nervous system, coma. 
Hence the medical certificates which were filled out 
by the internes and signed by him showed a start- 
ling lack of variety in the content of the space re- 
served for the immediate cause of death, how- 
ever variegated they might be regarding the space 
above that. In cases of doubt he was accustomed 



to question the physicians under him carefully as 
to whether coma, or apnoea, or syncope occurred 
first, which was a poser in the not infrequent in- 
stances when death took place while the interne 
was struggling with a refractory pair of trousers 
in a dark room, in a desperate endeavor to make 
himself sufficiently presentable to venture out into 
the wards. 

It is the custom of statisticians from other coun- 
tries, particularly Germany, to ridicule the vital 
statistics of this country, and, however jingoistic 
we may be along other lines, we are forced to ad- 
mit that their criticisms are not groundless. It is 
not too much to hope that at some future date there 
may be a national health department and uniform 
laws governing registration of all kinds. In the 
meantime steps are being taken to standardize 
causes of death ; the most intensive work is being 
done by a committee appointed by the Section on 
Vital Statistics of the American Public Health As- 
sociation in September, 191 5. This committee has 
held nine meetings since that time and in a recent 
Public Health Report^ has published the result 
of its thorough study of the 189 causes of death 
given in the International List. Of these, seventy- 
six are recommended for separation as unreliable 
unless verified by autopsy or supported by specific 
observation or laboratory proof. These seventy- 
six include such well known diseases as malaria, 
influenza, syphilis, general paresis, epilepsy, peri- 
carditis, and appendicitis. In their report they also 
consider each one of the 189 causes in detail, com- 
menting on whether or not it should be accepted 
without verification, what terms should be included 
under it, and what terms usually included under it 
should be classified elsewhere. 

Their whole report, which is easily procurable 
from the Government Printing Office at Washing- 
ton, D. C, for a nominal price, should be read by 
every physician. It is impossible to estimate the 
amount of good which would follow the universal 
application of care and accuracy to the filling out 
of death certificates. Certainly the field of pre- 
ventive medicine would be greatly enriched and the 
health, industrial, and life insurance companies 
would have their usefulness to humanity greatly 
extended. 



TREATMENT OF ACUTE CARDIAC FAIL- 
URE BY INTRAVENOUS INJECTION 
OF STROPHANTHIN. 

There occurs a fairly large number of cases of 
cardiac failure, in which, if the heart rate is not re- 
duced rapidly, the outlook is hopeless. These are 
emergency conditions and must be treated by heroic 

'The Accuracy of Certified Causes of Death. Its Relation to Mor- 
tality Statistics and the International List. Public Health Reports, 
September 22, 1916. 



82 



NEWS ITEMS. 



V York 

JoU«N 



measures, as half way measures, that is, a gradual 
slowing of the heart's action, in the vast majority of 
instances would be useless. In the Liverpool Medico- 
Chirurgkal Journal, No. 69, 1916, Dr. John Hay 
recommends in the treatment of these urgent cases 
the intravenous injection of strophanthin in doses 
varying from 1/500 to i /50 of a grain. He 
summarizes the important points as follows: i. 
Acute cardiac failure is due in many cases to the 
onset of auricular fibrillation in hearts already han- 
dicapped by disease. 2. It has been proved that of 
all drugs the digitalis group is the most potent in 
regulating such hearts. 3. The onset of the cardiac 
failure is sometimes so sudden and the downward 
progress so rapid that oral medication may prove too 
slow to be of any service. 4. At times the patient's 
stomach will not tolerate any member of the digitalis 
group, and a vicious circle is set up which ends in 
the death of the patient. 5. In such cases strophan- 
thin injected into a vein produces immediate definite 
slowing of the heart, with rapid amelioration of the 
patient's condition, and without doubt has saved 
many lives. 



N 



ews 



Itemj 



Change of Address. — Dr. Frank R. Starkey, from 
Philadelphia to Suite 812-815, Kresge Medical Building. 
Detroit, Mich. 

United Hospital Fund of New York. — Members of the 
Bankers and Brokers Auxiliary of this fund have do- 
noted $20,045. 

To Study Health Conditions in South America. — The 
Internationa! Health Board is planning to make a sur- 
vey of conditions of life among the people of .'\rgentina 
and Uruguay. Dr. Richard M. Pearce, John Herr Zins- 
ser professor of research medicine at the University 
of Pennsylvania, will sail on this mission on January 
iSth. 

A Sanatorium at Atlantic City Planned. — It is re- 
ported that plans are under consideration for the erec- 
tion of a sanatorium at Atlantic City, N. J., at a cost of 
about $1,000,000. Dr. Emory Marvel is said to be be- 
liind the project and has been assured unlimited sup- 
port. Several sites along the beach are under con- 
sideration, and as soon as the plans have been perfected 
further announcement will be made. 

St. Mark's Hospital, New York. — .\nnouncement is 
made by the president of the board of managers, Dr. 
Benjamin T. Tilton, that this hospital, which is situated 
at 177-1S1 Second Avenue, has added to its holdings by 
the purchase of the corner property at Eleventh Street 
and Second Avenue, adjoining the present hospital 
property. It is planned to make use of this enlargement 
of the hospital for the care of private patients. 

West Philadelphia Medical Association. — The follow- 
ing officers were elected at a recent meeting of this asso- 
ciation: President. Dr. William S. Newcomet; vice- 
president, Dr. Charles E. Price; secretary. Dr. Henry 
G. Munson; treasurer. Dr. Edmund L. Graf. Dr. A. L. 
Bishop. Dr. S. \. Brumm, Dr. George F. Levan, and 
Dr. Justus Sinexon were elected additional members of 
the board of directors to serve for three years. 

Yorkville Medical Society. — A stated meeting of this 
society will be Jneld on Monday evening, January 15th, 
at the Aschenbroedel Club. 144 East Eighty-sixth Street. 
New York, under the presidency of Dr. Adolph Schoen. 
The program will consist of a symposium on gonorrhea, 
as follows: The Genitourinary Viewpoint, by Dr. L. 
Sasover; the Gynecological Viewpoint, by Dr. .Arthur 
Stein; the Orthopedic Viewpoint, by Dr. Sigmund Ep- 
stein; the Sociological Viewpoint, by Dr. M. Rabino- 
vvitz. The discussion will be opened by Dr. Frederick 
B:crhoff. 



The Examination of Cancer Tissue by the Health 
Department. — :\i the request of the Department of 
Health, the budget for 1917 provides for the services 
of one patliologist for the purpose of examining speci- 
mens of tissue for cancer diagnosis. The work will be 
under the direction of the Bureau of Laboratories and 
will be undertaken as soon as certain important details 
can be arranged. When this is done announcement will 
be made in the Weekly Bulletin of the department as to 
how and where the specimens are to be sent. 

Registration of Births and Deaths. — In 1913 the legis- 
lature of the State of .'\rkansas passed a law providing 
for the appointment of local registrars of births and 
deaths by the State registrar of vital statistics and 
for the payment of local registrars by the counties on 
certification by the State registrar that prompt reports 
had been made to him. The Supreme Court of Arkansas 
has decided that under the constitution of the State 
the counties can not be required to pay the local regis- 
trars, as they are considered to be State officers. This 
feature of tlic law has therefore been declared uncon- 
stitutional. 

Insanity in Massachusetts. — One person in every 257 
in Massachusetts is suffering from some form of mental 
disease and is under observation, according to the first 
annual report of the Commission of Mental Diseases, 
the successor to the old State Board of Insanity. The 
report states that the number of these persons is in- 
creasing so rapidly that accommodations are necessary 
for 658 more patients and 114 more nurses. On October 
I, 1916, there were 18,710 persons under the supervision 
of the Commission, of whom 15.049 were insane, 2,876 
feebleminded, and 670 epileptic. 

Doctor Biggs to Study Tuberculosis Situation in 
France. — Dr. Herman M. Biggs, New York State Com- 
missioner of Health, has been granted a leave of absence 
to go to France to make a survey of the tuberculosis 
situation behind the trenches, to study measures for its 
relief, and to ascertain along what lines American as- 
sistance may be made most effective. This work is 
being undertaken by the Rockefeller Foundation. Dr. 
Linsley R. Williams, Deputy Health Commissioner, 
will act as commissioner during the absence of Doctor 
Biggs. 

A Department of Ophthalmology at Bellevue. — .\n 
ophthalmological service has been added to the other 
departments of Bellevue Hospital, New York. It is 
situated in the new surgical pavilion but is entirely dis- 
tinct from the rest of the hospital, having its own 
operating, examining, and dressing rooms, a staff of 
attending surgeons, special interns, and nurses; its 
capacity for the present will be fifty beds. The service 
is in charge of Dr. Charles H. May, attending surgeon, 
who will have as his principal assistants Dr. Julius 
Wolff and Dr. John M. Wheeler. 

Free Dental Clinic for Children. — Announcement is 
made by the New York College of Dentistry that it 
will hold a free clinic at 205 East Twenty-third Street 
on Saturday afternoons, at which children between the 
ages of seven and fourteen years may have their teeth 
cared for without charge. Dr. Thomas Darlington, 
formerly Commissioner of Health and now professor 
of anatomy at the college, said that the institution would 
have ninety chairs available for this new work. The 
clinic is the only free one for children now maintained 
by a dental college in this city. 

Sweeping the Sidewalks. — At a recent meeting of the 
Board of Health of the City of New York, a new sec- 
tion was added to the .Sanitary Code, regulating the 
sweeping and cleaning of sidewalks. This section holds 
householders responsible for the cleanliness of their 
sidewalks. All dirt must be swept up and removed: 
sweeping into the gutters is prohibited unless the sweep- 
ing be done between six and eight in the morning. This 
section of the code was adopted in response to numer- 
ous complaints from citizens concerning the filthy con- 
ditions of sidewalks in many parts of the city and after 
conference with the Street Cleaning Commissioner. In 
its enforcement, the Department of Health will cooper- 
ate with the Department of Street Cleaning 



NEIVS ITEMS. 



83 



Meetings of Medical Societies to Be Held in Phila- 
delphia during the Coming Week. — Monday. January 
15th. Clinical Association. Woman's Hospital Medical 
Society. Society of Normal and Pathological Physiology, 
Blockley Medical Society: Tuesday, January i6th. West 
Branch of the County Medical Society; Wednesday, 
January l/th. County Medical Society (.business meet- 
ing), Section in Otology and Larjmgology of the Col- 
lege of Physicians; Thursday, January l8th, Section in 
Ophthalmology of the College of Physicians, Northeast 
and Southeast Branches of the County Medical Society: 
Friday, January 19th, Jefferson Hospital Clinical 
Society. 

National Association for the Study and Prevention of 
Tuberculosis. — The next annual meeting of this asso- 
ciation will be held in Cincinnati. Ohio. May Qth, lOth. and . 
nth. under the presidency of Dr. E. R. Baldwin, of Sara- 
nac Lake. N. Y. Dr. W.'S. Rankin, of Raleigh. N. C and 
Dr. James Alexander ^Miller, of New York, are vice-presi- 
dents of the association, and Dr. Henry Barton Jacobs, of 
Baltimore, is secretary. The chairmen of the various sec- 
lions are: Dr. Roger S. Morris, of Cincinnati, clinical 
section ; Dr. Paul G. Woolley. of Cincinnati, pathological 
section; Dr. Charles P. Emerson, of Indianapolis, advi- 
sory council, and Mr. Frank H. Mann, of New York, socio- 
logical section. 

Universal Military Training Endorsed by Heads of 
Medical Schools. — The deans of ninety-five medical 
schools of the United States met in W'ashington, D. C, 
recentli" at the invitation of Secretary of War Baker 
to discuss plans for cooperation with the Council of 
National Defense, and adopted a resolution declaring 
that a system of universal military training would be 
"of great benefit to the health, development, and pro- 
ficiency of the youth of this land in both peace and 
war." The resolution also petitioned the Secretaries 
of War and the Navy to supply each medical school 
with an instructor in military sanitation and medicine, 
beginning not later than February i, 1917, in return, 
promising that such instruction would be made an ob- 
ligatory part of their courses. The resolution was intro- 
duced by Dr. Victor C. Vaughan, dean of the medical 
school of the University of Michigan. 

The Trudeau School of Tuberculosis. — The second 
term of this school opened on Wednesday, January 3d. The 
course lasts six weeks, closing on Saturday, February loth, 
and the third course will begin during the month of June. 
These courses are arranged for physicians who desire to 
study tuberculosis intensively, and to perfect themselves 
in diagnosis, including institutional methods. Both clinical 
and laboratory instructions are provided. The fee for the 
six weeks' instruction is $100 with $10 additional for inci- 
dentals. A limited number of fellowships w-ill be granted 
each year to qualified workers, preferablj' those who are or 
may have been under treatment for tuberculosis. The aim 
will be to give preference to graduate students, but under- 
graduates and nonmedical students are eligible. A 
detailed prospectus and information about the school will 
be sent upon application to the director. Dr. Edward R. 
Baldwin. Saranac Lake. N. Y. 

Institutions Must Report Puerperal Septicemia and 
Suppurative Conjunctivitis. — Hereafter the Department 
of Health will prosecute violations of that section of 
the Sanitary Code which requires reports from institu- 
tions of all cases of puerperal septicemia and of sup- 
purative conjunctivitis under their care. 

Section 91 of the Sanitary Code is as follows: "It shall be the 
duty of the manager or managers, superintendent, or person in 
charge of every sanitarium, day nursery, convalescent home, home 
for children, reformatory, training school, boarding school, hospital, 
dispensary, or other inst-tution for the care or treatment of persons, 
in the City of New York, to immediately report or cause to be 
immediately reported to the Department of Health, the name, age 
(90 far as can be ascertained), and residence of every person 
received therein or treated therat who is affected with puerperal 
septicemia or suppurative conjunctivitis, with the name of the 
disease with which such person is affected, and it shall be the duty 
of every physician in the said City to immediately make, or cause 
to be immediately made, a similar report to the said Department 
relative to any person found by such physician to be so affected, 
stating, in each instance, the name of the disease with which such 
person is affected. Every such manager, physician, and officer shall 
also report the name and address of the physician or midwife in 
attendance at the time of the onset of the disease, which information 
it is hereby made the duty of everj' institution herein specified to 
obtain and record among its records. 



Personal. — Dr. Simon Flexner, director of labora- 
tories of tlie Rockefeller Institute for Medical Research, 
New York, has been elected foreign associate member of 
the Paris .'\cademy of Medicine. 

Dr. Philip Skrainka, of St. Louis, Mo., announces that 
he is planning to establish a monthly medical journal, 
the name of which will probably be Medicine and 
Surgery. The first issue of this periodical will probably 
appear some time in February. 

Dr. Winifred Viers, of Ottawa County, Kansas, is the 
first woman to be chosen coroner in the State. 

Dr. E. G. Whinna, of Philadelphia, has been reelected, 
for the twenty-second consecutive year, physician in 
charge of the Philadelphia Home for Infants. 

Dr. M. J. Couret. of New Orleans, has resigned, as 
pathologist to the Charity Hospital. 

The Medical Association of the Greater City of New 
York. — A stated meeting of this association will be held 
in Du Bois Hall, New York Academy of Medicine. 
Monday evening, January isth, at 8:30 o'clock, under 
tlie presidency of Dr. Thomas S. Southworth. Dr. John 
Herbert Claiborne will read a paper entitled Some Re- 
marks on a Case of Stuttering in a Boy Relieved by 
Reversal of Manual Dexterity, with Remarks on the Sub- 
ject of Symbol Amblyopia, which will be discussed by 
'Dr. Edward Livingston Hunt. Dr. S. Philip Goodhart, 
Dr. Edgar Steiner Thomson, Dr. James Ramsay Hunt, 
and Dr. James Garfield Dwyer. Dr. George Livingston 
Brodhead will read a paper on the Treatment of Abor- 
tion, which will be discussed by Dr. Herman J. Boldt, 
Dr. Austin Flint, Dr. Frank Richard Oastler, Dr. John 
Osborn Polak, Dr. Brooks H. Weils, Dr. Leroy Broun, 
Dr. Abraham J. Rongy, Dr. Arthur Stein, and Dr. 
Thomas H. Cherry. 

College of Physicians of Philadelphia. — At a meeting 
held on Januarj' 3d the following officers and elective 
committees were chosen by the college for the year 
1917: President. Dr. Richard H. Harte; vice-president, 
Dr. William J. Taylor; censors. Dr. James Tyson, Dr. 
William W. Keen, Dr. George E. deSchweinitz, and Dr. 
Thomas R. Neilson; secretary. Dr. Francis R. Packard: 
treasurer. Dr. John B. Roberts; honorary librarian, Dr. 
Frederick P. Henry; committee of publication, Dr. G. G. 
Davis, Dr. Thompson S. Westcott, and Dr. Walter G. 
Elmer; library committee, Dr. Francis X. Dercum, Dr. 
George W. Norris, Dr. Astley P. C. Ashhurst, Dr. 
Charles W. Burr, and Dr. William Pepper; committee 
on Miitter Museum, Dr. Henry Morris, Dr. George P. 
Miiller, and Dr. George Fetterolf; hall committee. Dr. 
John K. Mitchell. Dr. Thomas H. Fenton, Dr. B. Alex. 
Randall, Dr. E. Hollingsworth Siter, and Dr. J. Norman 
Henry; committee on directory for nurses. Dr. Thomas 
G. Ashton, Dr. Frederick Fraley, and Dr. Arthur Newlin. 

Implied Warranty in the Sale of Foodstuffs. — An 
interesting decision of the Supreme Judicial Court of Mas- 
sachusetts is published in the issue of the Public Health 
Reports, for December 22, 1916. A Massachusetts man 
and his wife were made ill by eating pork, and they 
brought suit for damages against the dealer who sold the 
meat. The court stated the facts as follows: "His wife 
(the wife of the purchaser) acting as his agent, left to 
the defendant the selection of the meat, and paid for it 
at the current price for sound, wholesome pork chops. 
. . . The defendant Freshman undertook to make the se- 
lection so left to him. The meat was cooked, and was 
eaten by the plaintiff and his wife, and both were made 
sick." 

The law of Massachusetts applicable to the case was 
stated in the opinion as follows: "Where the' buyer at a 
shop relies on the skill and judgment of the dealer in se- 
lecting food, and it is made known to the dealer that his 
knowledge and skill are relied on to supply wholesome 
food, he is liable if it is not fit to be eaten ; while, in case 
the buyer himself selects provisions, the dealer's implied 
warranty does. not go beyond the implied assertion that he 
believes the food to be sound." The court decided that tlie 
husband was entitled to damages, but the wife could not 
recover because "the only sale was that made to her hus- 
band through her as his agent," and "there was no con- 
tractual relation, and hence no warranty," between her and 
the defendant. 



i 



Modern Treatment and Preventive Medicine 

A Compendium of Therapeutics and Prophylaxis, Original and Adapted 



SODIUM BICARBONATE IN GASTRO- 
INTESTINAL DISORDERS. 
By Louis T. de M. Sajous, B. S., M. D., 

• Philadelphia. 
{Continued from page 35.) 

The effect of sodium bicarbonate administration 
on the secretory functions of the stomach has in the 
last twenty years been the subject of considerable 
discussion, and from time to time diametrically op- 
posite views have been expressed. The time of 
administration, dose, and preexisting state of gas- 
tric secretion as compared to the normal have all 
been brought forward as factors influencing the 
effect of the drug on the secretion of hydrochloric 
acid. Linossier and Lamoine, supported by Robin 
and Mathieu, maintain that sodium bicarbonate, in 
its direct action, is an excitant of hydrochloric acid 
secretion under all conditions and in any dose — 
admitting also, of course, that acid already present 
in the stomach is neutralized by the drug. Another 
widely held view is that, while small doses excite 
secretion, large doses depress it. The drug is, 
moreover, supposed by many to excite secretion 
particularly when given before meals, while de- 
pressing it when given with or after meals. On the 
other hand, Bickel and Pawlow, from widely quoted 
experimental work, have been disposed to consider 
sodium bicarbonate a depressor of gastric secretion 
when given before meals. Finally, some have held 
the drug to be a secretory excitant in hypochlo- 
hydria and a depressant in hyperchlorhydria, thus 
proving useful under both conditions ; while Hayem, 
on the contrary, has attributed to it the property 
of making both these conditions worse. 

In researches published in 1908, and including 
both experimental and clinical observations, Linos- 
sier and Lemoine showed that the conflict of opin- 
ions referred to has been due in part to faulty ob- 
servation of results in previous experimental work, 
insufficient account having been taken of the time 
after administration at which the observation of the 
effect of the drug on secretion was made. The 
bicarbonate at first neutralizing the acid already 
present in the stomach, tests made during this early 
period would give the impression of a diminished 
secretion, evidence of increased secretion appearing 
only in a later phase, after the acidity, partly neu- 
tralized by the alkali, has had time to return to 
normal. Study of the acidity by repeated tests 
throughout the period of gastric digestion is thus 
necessaiy if a proper appreciation of the effect of 
the drug is to be obtained. Stress is also laid on 
the necessity in animal experiments of administer- 
ing the bicarbonate, not alone, but in conjunction 
with food, in order to approximate the conditions 
under which the drug is clinically used. Under 
these circumstances, using a Pawlow miniature 
stomach in a dog, they found the amount of gastric 
juice increased by 145 per cent., i. e., more than 
doubled, after administration of sodium bicarbon- 



ate. The percentage of acid in the gastric juice was, 
moreover, augmented from 0.468 to 0.483 per cent., 
the activity of the pepsin, however, being reduced 
by about one half, owing to its dilution in the in- 
creased amount of secretion. Experiments in hu- 
man subjects, in which the gastric contents were 
examined at hourly intervals after a test meal, vary- 
ing doses of bicarbonate having been administered 
one hour before the meal, gave similar results. The 
observation one hour after the meal showed only 
a slight increase of total hydrochloric acid over the 
control, but the two and especially the three hour 
observations showed a marked difference. At the 
three hour observation the total acidity, 0.80 in the 
control, rose to 1.72 in the experiment in which one 
gramme of sodium bicarbonate, and to 2.85 in that 
in which five grammes of sodium bicarbonate had 
been given, while the free acid rose from o.i to 0.6 
and 1.7, respectively. 

Another fact claimed to have been ascertained in 
these researches is that the sensitiveness of the 
stomach to sodium bicarbonate varies inversely with 
the percentage of hydrochloric acid present in the 
gastric secretion of the subject under observation. 
Thus, in hypochlorhydria, small doses of sodium 
bicarbonate suffice to increase acid secretion, where- 
as in marked hyperchlorhydria even large doses fail 
to do so. 

The experiments referred to are held by Linos- 
sier and Lemoine to disprove the earlier contention 
of Bickel that sodium bicarbonate has no stimulat- 
ing effect on gastric secretion, the observations of 
the latter having been made without regard to the 
action of food in initiating this secretion. Their 
results, from the standpoint of clinical application, 
are supported by such authorities as Wegele, Jawor- 
ski, Huchard, and Fiessinger. -Describing the man- 
ner of administration of the drug in cases where 
an effect of this kind is desired, Linossier urges at- 
tention to the period of time elapsing between the 
ingestion of the drug and the time at which the 
maximal increase of acidity will occur. This period 
varies according to the dose of bicarbonate given, 
the greatest acid percentage occurring two hours 
after a seven and one half grain dose, three hours 
after a fifteen grain dose, and four hours after a 
seventy-five grain dose. Where pronounced secre- 
tory weakness exists, a seven and one half grain 
or somewhat larger dose is to be given just before 
the meal, while if the weakness is less marked, a 
fifteen grain or larger dose is to be administered 
about an hour beforehand. Huchard sometimes 
used even smaller doses than Linossier, e. g., four 
grains. He advised against continuing this form 
of medication longer than two or three weeks, but 
held that lasting improvement in secretion would 
follow such a course of treatment. Hayem specifies 
the usefulness of this action of sodium bicarbonate 
in cases of accidentally diminished acid secretion, 
as by drugs (such as atropine). It seems clear, 
however, in view of the scant attention so far paid 



January 13, 1917.] 



MODERN TREATMENT AND PREVENTIVE MEDICINE. 



85 



to the use of sodium bicarbonate in question, that 
the drug is of far less value in states of diminished 
than of excessive acid secretion (the latter to be 
discussed in a succeeding issue). A fact to be borne 
in mind is that, according to the observations of 
Linossier and Lemoine, where acid secretion is in- 
creased, there is no concomitant excitation of pepsin 
secretion. The increase of acid secretion is doubt- 
less favored by giving the bicarbonate freely diluted 
in water, the latter itself having been shown to ex- 
cite the production of gastric juice. 
(To be continued.) 



b 



The Care of Nursing Women.' — Arthur H. 
Kettner i^Mcdizinische Klinik, October 29, 1916) 
states that the care of the bowels during the last 
days of pregnancy and the beginning of the period 
of lactation is often erroneous, and due to a mis- 
taken conception of the conditions pre^iling. It 
must be borne in mind that many women, especially 
those with their first child, incline to eat very 
sparingly toward the incqjtion of labor, and take 
food which leaves little residue so that their con- 
stipation is more or less physiological. Further, 
immediately after delivery the intestines are re- 
lieved from a prolonged period of congestion and 
are in need of a physiological rest. Finally, the 
blood is then directed from the pelvis to the region 
of the breasts. The genefal practice is to admin- 
ister castor oil or salines so as to secure a move- 
ment of the bowels every day. This practice is 
harmful in that it does not permit the rest physio- 
logically demanded by the intestine, because it with- 
draws the blood from the breasts, where it is most 
needed, and hence delays or prevents the onset of 
lactation, and it is often unsuccessful on account 
of a relatively empty intestine. The only safe and 
rational plan is to promote the emptying of the 
large intestine when this is needed by the use of 
bland enemas. \\ here, however, there is a real 
constipation under such circumstances the best plan 
for its correction consists in the proper regulation 
of the diet, and the prescription of regulin to aid 
the sluggish intestines. The nutrition of the nursing 
woman is a second field in which many errors are 
made. One of the commonest of these is the pre- 
scription of very large quantities of milk. Such a 
practice invariably leads to digestive disturbances, 
loss of appetite and a revulsion for food. The 
proper plan is to give the woman a full normal 
diet in frequent small feedings, provide an abund- 
ance of fat in the form of olive oil and butter, 
allow not over one liter of milk daily, and give 
half a liter of other fluid, preferably in the form 
of plain water. As soon as the woman is able to 
be up she should exercise in the fresh air, and her 
meals ordered regularly as in health. It is neither 
desirable nor beneficial to attempt to make the 
mother gain weight during the period of lactation, 
but we should be content with seeing that she main- 
tains Aer weight. The third point of importance 
is the care of the nipples and breasts. The nipples 
should be hardened before lalx)r by daily bathing 
with cold water, sponging with alcohol, and daily 
exposure of the breasts to the open air for a short 
time. Salves and other similar preparations should 



not be applied as they tend to make the infant re- 
fuse the breast. Small fissures should be cared for 
at once by cleansing and the application of pure 
alcohol, or by touching with a silver nitrate stick. 
W hen they form or when symptoms of mastitis are 
beginning the child should not be taken from the 
afiected breast as this tends to produce milk stasis 
and to aggravate the condition. 

Optochin in Croupous Pneumonia. — E. Becher 
{Alediciiiisclic Klinik, October 29, 1916) states that 
this drug was given orally in doses of 0.25 gramme 
every four hours to twenty cases of pneumonia with 
the most excellent results. When begun on the fifst 
day of the disease the average time to the disap- 
pearance of fever was under two and one half days ; 
when begun on the second day it was a little over 
three and one half days ; and the time grew longer 
the later in the disease the drug was started. No 
ill ettects from the drug were noted except -slight 
tinnitus in a few cases, and nausea and vomiting in 
two others. This latter occurrence prevented the 
use of the drug in these two cases and they ran 
the usual course. Two cases of pneumonia were 
not afiected by the drug at all; one was due to a 
streptococcus, the other was a bronchopneumonia. 
Aside from the prompt reduction of fever, the drug 
reduced the frequency of complications, prevented 
serious manifestations on the part of the heart, and 
mitigated the general course of the disease. 

Pulse and Blood Pressure Changes in the 
Soldier in Action. — Briscons and R. Mercier 
{Bulletin de I'Acadeuiie dc mcdecine, November 21, 
1916) collected the following data in healthy sub- 
jects: Temperature, 98.6° F. ; respiration, twenty- 
four; pulse, 69; diastolic pressure, 122, and systolic 
pressure, 170. In a group of twenty-one sick sol- 
diers the corresponding figures were 986° F., 26, 
96, 119, and 168, while in twenty-five slightly 
wounded men they were, 99.7° F., 27, 90, 115, and 
163. By similar tests they were able to secure di- 
agnostic information in a group of twenty-two men 
who had been, or asserted that they had been, with- 
out apparent external wound, injured by the explo- 
sion of a shell close at hand. Though apparently 
all alike, these cases could be divided, according to 
the results of the tests, into three groups : i. Those 
sustaining a contusion, having been partly buried 
by the explosion or struck by clods of earth ; these 
gave results comparable with those in the slightly 
wounded men already referred to, viz., pulse, 93, 
and pressures, 121 and 175. 2. Those sustaining a 
true concussion, due to the compression of air ; these 
showed acceleration of the pulse to one hundred 
and a distinct diminution in the differential or pulse 
pressure, the diastolic pressure being 135 and the 
svstolic 165. 3. Those sustaining merely an emo- 
tional shock, showing a normal pulse rate and ap- 
proximately normal diastolic pressure (100), in 
spite of an apparent marked angor and respiratory 
acceleration. By these tests it is held practicable to 
dififerentiate those suffering from true concussion, 
necessitating withdrawal of the subject from action, 
from those less seriously affected. The character- 
istic test findings of true concussion developed im- 
mediately after the explosion and were still present 
twelve hours later. 



86 



MODERX TKE.ITMENT AND I'KEl'liS'l If II MEDIC I XU. 



Angina pectoris. — S. E. JMunson {Illinois Medi- 
cal Journal, Xuvcniber, lyiOj considers that it is 
nol sut'ticieiU to treat the symptoms of the attack, but 
that food, digestion, assimilation, kidney, and bowel 
functions must be watched as well as work, worry, 
insomnia, and overindulgence in eating and alcohol. 
Nauheim baths help some cases, while digitalis is of 
value where tiiere is impaired myocardial function 
with eitiier hypotension or hypertension. Iodides 
are without benelit except in suspected syphilis. In 
the attack amyl nitrite pearls may be of service, as 
may nitroglycerin, but morphine gr. ^ p. r. n. is 
more efficient than any other drug and it may be 
combined with atropine, especially if there is sus- 
pected cardiac ischemia from coronary involvement. 
Hot applications to the precordia with hot drinks are 
of \alue. 

Hypophyseal Extract in Diabetes. — Guiseppe 
\'igevano (L'Ospcdalc Maggiore, September 30, 
1916) states that experiments made by him on dogs 
showed that both the whole extract and that of the 
posterior lobe of the hypophysis have a marked and 
constant antiglycosuric as well as antidiuretic action. 
Further that these actions are completely dissociated 
and constitute two independent phenomena. The an- 
tiduretic action is ordinarily maintained only during 
the actual administration of the extract and the dose 
varies from .30 to .45 gram of the fresh gland in 
twenty-four hours. The extract of the whole gland 
is more powerfully antiglycosuric in action than that 
of the posterior lobe. The diminution of the amount 
of glucose in the blood is in constant accord with the 
lowering of the glycosuria, while the diminution both 
of polyuria and glycosuria is always accompanied 
by an increase in the twenty-four hour elimination 
of urea. In cases thus treated there is always a 
lessening of thirst, hunger, insomnia, and toxic 
symptoms, while the general strength is much im- 
proved. Arterial pressure seems to have no influ- 
ence on the progress of cases treated by the hypo- 
physeal extract. 

Tendon Repair without Actual Suture. — W. 

Fletcher Stiell (Practitioner, December, 1916) ques- 
tions : "Why does a tendon, when severed by trauma 
arising in the course of daily employment, fail to 
heal without suture, while if it has been divided by 
the surgeon's tenotome it invariably undergoes firm 
union in the course of six or eight weeks?" This 
led him to treat a number of cases of accidental 
division of tendons on lines similar to those em- 
ployed in the aftertreatment of surgical tenotomy, 
and he has found it to be essential that four impor- 
tant details should be present at one and the same 
time. If any one is absent it is risky to do without 
a suture. He confined his eiTorts mainly to the ex- 
tensor tendons of the fingers and thumb. These 
points are: i. It is of the utmost importance that 
the injured finger should be kept in a position of 
hyperextension for at least three weeks. This may 
be secured by an aluminum splint on the palmar 
aspect of the hand and finger, fixed by strapping. 
2. It is necessary that the actual skin cut should have 
fairly close approximation of its edges, or, at least, 
the laceration must not be too extensive to render 
good apposition possible by means of skin stitches 
only. 3. It is inadvisable to employ drainage, first. 



because it tends to remove the necessary and 
benelicial Ijlood clot from between the ends of the 
divided tendon; second, because it provides one 
more possible entrance for microorganisms. 4. .\1)- 
solute asepsis is essential, at least as regards the 
tendon sheath. Slight suppuration confined to the 
skin wound may be followed by a perfect functional 
result, provided that the tendon sheath is unin- 
\olved. If these four points are strictly observed 
primary union will invariably occur between the di- 
vided ends of the tendon without any tendon suture, 
and will usually give a better result. 

Treatment of Tabes. — Morris Grossman {Inter- 
state Medical Journal, November, 1916) divides the 
treatment into causative and symptomatic. In caus- 
ative treatment five methods may be used, intramus- 
cular injections of mercury, intravenous injections 
of salvarsan, Ra\aut's intradural injection of sal- 
varsan, the Swift-i-lllis intradural injections of sal- 
varsanized serum, and Byrnes's intradural injections 
of mercurialized serum. In symptomatic treatment 
pain is met with in eighty-five per cent, of all cases 
and should at first be controlled if possible by dry 
heat, counterirritation, light cauterization, massage, 
and tight bandaging. If pain still persists, aspirin, 
antipyrin, sodium salicylate, pyramidon, and codeine 
may be tried, with morphine as a final resort. Blad- 
der disturbances, present in eighty per cent, of cases, 
iTiay be improved by small doses of strychnine and 
ergot to tone up the bla'dder wall, but where there 
is marked retention with decomposition of urine 
hexamethlenamine and bladder irrigations are indi- 
cated. Ataxia, found in seventy-five per cent, of 
cases, is best treated by reeducation, either by 
Frankel's or Maloney's method. Educational exer- 
cises are divided into breathing and relaxation, co- 
ordinated movements, and balancing. 

Chronic Suppurative Otitis media in Tonsil 
and Adenoid Work. — Harvey M. Becker {Annals 
of Otology, Rhinology, and Laryngology, June, 
1916) believes the diseased tonsil capable of causing 
numerous otitic suppurations, which are incurable 
so long as the offending tonsil is permitted to remain 
unmolested. For this reason, he begins his treat- 
ment of suppurative otitis by a thorough cleansing 
of the tonsillar fossse and the epipharynx. Imme- 
diately following the tonsillar operation, the canal 
of the affected ear is cleansed of all discharges, and 
the condition of the tympanum and the middle ear 
cavity determined, as far as possible. Free access - 
to the tympanic end of the Eustachian tube is neces- 
sary for the efficacy of the treatment. If this ad- 
vantage cannot be obtained as the result of partial 
or total destruction of the drum, a free posterior 
incision is made, gentle aspiration produced with a 
Siegle otoscope, and the canal again thorouohly 
dried. A five per cent, alcoholic iodine solution is 
then freely introduced into the canal and permitted 
to flow into the middle ear cavity and down the 
Eustachian tube by the favorable position of the 
head, occasionally assisting the proper appH^ation 
of the solution, when necessary, by the pressure and 
suction of the otoscope. .^ firm packing is inserted 
in the canal to prevent the passage of air, and is re- 
tained for about forty-eight hours, when it will be 
found usually that the discharge has ceased. 



MODERX TREATMENT AND PREVENTITE MEDICINE. 



87 



I 



k 



Amebic Conjunctivitis. — James AI. Parrott 
{^Charlotte Medical Jounial, December, 1916) de- 
scribes a form of chronic conjunctivitis to which 
he has given the name of amebic conjunctivitis. The 
symptoms are those of a chronic conjunctivitis. On 
examination the sclera is cloudy and on extreme 
retraction of the lower lid with the eyeball rolled 
upward a milk like injected fold is detected at the 
scleral attachment of the conjunctiva. The diag- 
nosis is made by detecting the entamosbje in the 
conjunctival discharge. The treatment consists in 
the installation of zinc sulphate solution, careful 
treatment of the gn-'"is, and the use of ipecac solu- 
tion in the mouth. All the cases treated showed 
pyorrhcea alveolaris. No cures have been observed, 
although the conjunctiva has been cleared of the 
cntamccbas and the symptoms have been ameliorated. 

Fasting. — C. D. Spivak {Colorado Medicine, 
December, 1916) emphasizes the importance of fast- 
ing as a therapeutic measure in diseases of the diges- 
tive canal, this representing the employment of rest 
for diseased conditions in other portions of the 
body. Such physiological rest for the digestive tract 
can best be secured by placing the patient in bed, 
the adjustment of a suitable, very low diet, and the 
application of hot poultices. In severe cases the 
diet should be left out and no food at all be allowed. 
This total fasting may be continued without harm 
for many days, usually with much benefit. A mod- 
erate amount of discomfort will be caused the pa- 
tient for the first day or two, but after that he will 
*not suffer from hunger or the desire for food. 
Where nutrition is necessary enemas may be given. 
Except in the more severe cases the rest in bed may 
be dispensed with and the patient be allowed up. 
In cases of gastrointestinal disturbance the first 
thought should be toward the restoration of a nor- 
mal condition by Nature's best remedy, rest. 

The Adrenal Reaction in Antityphoid Vaccina- 
tion- — M. Loeper {Pressc medicate, October iq, 
1916) writes concerning six cases of vascular dis- 
turbance noted in soldiers after vaccination against 
typhoid. On the evening of the day on which the 
first injection had been given, or on the next day, 
these subjects turned pale, and showed accelerated 
breathing, a small and even uncountable pulse, some- 
times with cyanosis of the lips and finger tips be- 
neath the nails, and with cold hands, .\ccompany- 
ing phenomena included malaise, marked general 
weakness, cramps in the legs, thighs, and lumbar 
regions, and sometimes diarrhea, nausea, and even 
vomiting. The blood pressure was found greatly 
lowered. Slight fever occurred. This condition 
persisted a day or two, or in the more severe cases 
up to four or five days, such cases showing cyanosis 
of the nose and malar eminences, oliguria, slight 
albuminuria, temporary hepatic enlargement, and 
pulse irregularity. These manifestations are to be 
ascribed to heart weakness, the result of adrenal 
insufficiency*. Twenty-six out of thirty soldiers 
showed a distinct reduction in blood pressure, in 
some cases attaining 40 mm. Hg. on the day follow- 
ing the first vaccine injection. Most cases of toxic 
and infectious hypotension being now admitted to 
be of adrenal origin, Loeper is disposed to maintain 
that the condition following typhoid vaccination. 



whether of slight or marked severity,' arises simi- 
larly. Injection of large doses, e. g., one c.c, of the 
vaccine in guinea pigs almost constantly caused con- 
gestion and even hemorrhages in the adrenals, in 
the absence of all change in other organs. The 
therapeutic test also aii'orded evidence of the ad- 
renal origin of the disturbances clinically noted, ad- 
ministration of one or two nigpns. of adrenaline by 
the oral or subcutaneous route causing prompt 
improvement in the cases in which it was tried. The 
remedy proved likewise of prophylactic value, no 
hypotension following vaccine injections in two sol- 
diers already exhibiting low blood pressure, after 
one mgm. of adrenaline had been given. Even 
the weakness frc((uently noted was absent in these 
cases, in spite of the appreciable febrile reaction 
which followed the injection. Loeper counsels blood 
pressure estimation as a routine preliminary to vac- 
cination, and cautions against inoculating greatlv 
fatigued subjects until a period of rest has been 
imposed. 

Treatment of Hookworm Disease. — W. C. Bil- 
Hngs and J. P. Hickcy (Journal A. M. A., December 
23, 1916) state that the practice of using thymol 
has been the general one for this condition, but re- 
recently better results have been reported from the 
administration of oil of chenopodium. This oil was 
tried in a series of patients to compare the results 
with those after thymol, and is was found much 
more satisfactory. Thus in 300 cases treated with 
thymol, seventy-four per cent, were cured with one 
course, fifteen per cent, required two, and nearly 
one per cent, needed as many as six courses for 
cure. With chenopodium no patients required more 
than two courses of treatment, and eighty-seven per 
cent, were cured with a single course. The plan of 
treatment adopted was to give sixty mils of 
a saturated solution of magnesium sulphate at 
7 a. m. and ninety mils of a saturated so- 
lution of sodium sulphate at 7 p. m. The 
following morning, beginning at 7 o'clock, fif- 
teen drops (appro.ximately 0.35 mils) of oil of 
chenopodium were given on sugar and the dose re- 
peated at 9 and 1 1 a. m. At i p. m. eighteen mils 
of castor oil with two mils of chloroform were ad- 
ministered, followed in half an liour by thirty mils 
of plain castor oil. A cup of tea was allowed at 
2 p. m. The chloroform was given as it seemed to 
have a marked synergistic action with the oil of 
chenopodium. The doses of oil of chenopodium 
were as follows : Aged six to seven years, five 
drops ; eight to nine years, seven drops ; ten to 
eleven years, ten drops : twelve to fifteen years, 
twelve drops, and sixteen years and over, and under 
si.xty years, fifteen drops, measured from an ordi- 
nary medicine dropper. For the corresponding age 
groups the doses of chloroform used were, in 
minims: Eleven, twelve, fifteen, twenty, twenty- 
five, and thirty. A stock mixture of castor oil. con- 
taining two mils of chloroform and eighteen of cas- 
tor oil, was kept, and the doses measured therefrom 
with respect to the chloroform desired, the whole 
being made up to twenty mils with plain castor oil. 
By this plan of treatment no toxic or unfavorable 
eiifects of chenopodium were observed. The effect 
of treatment was controlled by examination of the 
stools six davs after the course of treatment. 



88 



MODERN TREATMENT AND I'REVENTli-li MEDICINE. 



[ New York 
Meu.cal Journa 



Diphtheria Carriers. — Sophie Rabinoff {Journal 
A. M. A., December 9, 1916) reports the trial of 
ahiiost every method of local treatment advocated, 
including the application of silver nitrate, organic 
silver preparations, formaldehyde, iodine, iodized 
phenol, spraying with cultures of staphylococcus, 
Bacillus pyogenes aureus. Bacillus bulgaricus, and 
Bacillus acidi lactici, and the use of kaolin. Some 
results were apparently obtained with each method, 
but they were no better than those encountered in a 
control series of untreated cases. The only method 
which seemed to be of any certain value in the re- 
sistant cases was the surgical removal of the tonsils 
and adenoids. 

Arsenobenzol by Mouth.— Jay Frank Scham- 
berg, John A. Kolmer, and George W. Raiziss 
(Joitnial A. M. A., December 23, 1916) state that 
after proving that arsenobenzol could be adminis- 
tered orally to animals experimentally infected with 
trypanosomiasis with safety and with good thera- 
peutic results, this method of administration was 
tried in thirty human cases of syphilis in its various 
stages. The results were satisfactory so far 
as the effects on the lesions were concerned, and no 
ill effects or disturbing symptoms were produced 
other than mild digestive disturbance in a relatively 
small proportion of cases. The dose was thirty 
mgm. three times daily, and had to be continued 
for many weeks. The most satisfactorj- form for 
its administration was found to be in the following 
mixture : 

IjL Arsenobenzol 0.03 

Sodii hydrosulphitis 0.015 

Bismuthi subgallatis o. 12 

which was given in gelatin capsules treated with 
formaldehye to prevent their solution in the stom- 
ach. The sodium hydrosulphite was added to pre- 
vent oxidation of the arsenobenzol. 

Treatment of Woimd Infectioii.^John O'Con- 
nor {Brit. Med. Jour., December 2, 1916) states 
that after using almost every method and antiseptic 
suggested he has long practised the treatment of 
seriously infected wounds along lines which have 
given him the best of results. His treatment con- 
sists in converting the wound into an open surface 
and the use of a counter opening where necessary. 
When a counter opening is required for drainage it 
is made quite large and the wound is held open by 
the insertion of one or two large drainage tubes 
which are frequently changed to prevent their re- 
taining any of the infected secretions. Whether 
superficial or deep the wound is treated by irrigation 
every four hours with a hot solution of peroxide of 
hydrogen of the strength of sixty mils to the liter, 
followed instantly by an irrigation of hot phenol 
solution containing fifteen mils to the liter. Com- 
presses, wrung dry from hot bichloride of mercury 
solution, are then applied. Combined with these 
measures the patient is kept absolutely quiet and at 
rest in the open air and the wounded part is immo- 
bilized upon a suitable splint in such a wav as to 
permit of the irrigations without disturbing the fixa- 
tion. The irrigation is done by pouring the solu- 
tions over the wound from a pitcher to secure a 
forceful and large stream of fluid. By such treat- 
ment the worst wounds should take on a healthy ap- 
pearance and begin to heal in a very few days. 



Minor Emergency Surges-. — N. C. Speer 

{Junrnal Kansas Medical Society, December, 1916) 
reports a number of methods of procedure which 
give the best results with the least consumption of 
time on the part of either patient or physician. A 
sharp pointed knife proves better than a regular 
spud for the removal of foreign bodies embedded 
on the cornea. Four per cent, cocaine is the best 
for ocular anesthesia, and the discovery of foreign 
bodies is facilitated by the use of a jeweler's mag- 
nifying glass, and the removal of local congestion 
by the instillation of epinephrin. Deep contusions 
with concealed hemorrhage are best treated by inci- 
sion and evacuation of the blood. Severely bruised 
nails on the great toes or the thumbs should be re- 
moved at once both for the relief of pain and for 
prompt recovery. For all lacerations the immediate 
application of tincture of ioulne, without the use of 
any water, and the cleansing of the surrounding 
skin with gasoline should be the routine, followed 
by the suture of the wound. Superficial burns and 
abrasions are treated by the immediate application 
of camphorated oil dressings which are not to be 
changed frequently. Open air treatment, under a 
single layer of gauze elevated from the surface by a 
coiterdam, hastens healing in more extensive cases. 
Infections of the hands and fingers are best treated 
by prolonged application of Bier's hyperemic 
methods, which can be accomplished with rubber 
bands or common elastic webbing. Incision and 
gauze drainage is required even in the absence of 
evidence of abscess formation. 

Pellagra.— M. L. Tisdale (Jour. Florida Med. 
Ass., November, 1916) asserts that prevention 
should be attempted by the prescription of proper 
hygienic and dietetic measures, particularly the in- 
gestion of a sufficient amount of protein food and 
the avoidance of highly milled grains. When the 
disease has developed the treatment must be largely 
symptomatic. It is well to isolate the patient, pref- 
erably in a shaded tent rather than in a brilliantly 
lighted room. Carbohydrates should be largely elim- 
inated from the dietary and proteins given in abun- 
dance. Where nausea, vomiting, and diarrhea are 
troublesome the diet should be restricted to liquids 
such as milk, broths, and fruit juices. Later solid 
foods, such as lean meat, fruits, and vegetables can 
be introduced slowly. Constant rectal and subcu- 
taneous administration of salt solution is of help in 
the diarrheal stages and seems to aid in the elimina- 
tion of toxic substances. Simple or medicated hot 
or cold baths may be given, but exertion on the part 
of the patient must be avoided when they are pre- 
scribed. If possible the patient should be sent to 
a cool climate, particularly if his is a chronic recur- 
rent case. Among the drugs which have proved 
useful are : The intestinal antiseptics such as calo- 
mel, betanaphthol, and salt ; the arsenical prepara- 
tions such as small doses of neosalvarsan or of so- 
dium cacodylate after the skin lesions have subsided ■ 
and for the skin lesions ointments of balsam of 
Peru, zinc oxide, or betanaphthol. When the skin 
has become raw, tar, zinc oxide, or salicylic acid oint- 
ments are the best. In general the best results will 
be obtained if pellagrins are treated in hospitals 
rather than at their own homes. 



Miscellany from Home and Foreign Journals 



k 



Geographic Distribution of Amebiasis. — A. H. 
Sanford {journal A. M. A., December 23, 1916) 
reviews the results of stool examinations on a very 
large series of patients, showing that the occurrence 
of infection with Entamoeba histolytica is not at all 
uncommon among residents of the north temperate 
regions. The observations also show that in such 
regions the infection may often occur and run a 
chronic course with the production of few or no 
symptoms, rendering the host a carrier and a source 
of danger to the community. About forty per cent. 
of such cases, however, gave histories of constant 
diarrhea and thirty-three per cent, of intennittent 
diarrhcEa. The importance of examining the stools 
for amcebae in patients from the cooler climates is, 
therefore, considerable. 

Comminuted Fracture of Humerus from Mus- 
cular Action. — N. Howard Mummery and P. L. 
Giuseppi (British Medical Journal, December 9, 
1916) report an interesting case of a muscular, ap- 
parently healthy soldier, thirty-three years of age, 
who sustained a comminuted fracture of his right 
humerus from muscular action alone. He elevated 
his right hand, in which he held a dummy liand 
grenade weighing two pounds, suddenly and with a 
jerk to the level of and behind his shoulder as a 
preliminary to throwing. At the end of the move- 
ment he felt his arm break and it fell to his side. 
X ray examination and operative inspection showed 
the existence of four separate fragments. At au- 
topsy, following death from other causes, the find- 
ings were confirmed and the bone was found to pre- 
sent no evidences of previous disease or abnormality. 

Hereditary Syphilis Causing Chronic Invalid- 
ism. — -Henry Farnum StoU {Journal A. M. A., 
December 27,, 1916) writes that the importance of 
hereditary syphilis as a cause of chronic invalidism 
is emphasized by the results of an intensive study of 
approximately one hundred families. The diagnosis 
of syphilis when the disease makes its appearance 
twenty years or more after infection is often diffi- 
cult on account of the total absence of typical symp- 
toms and physical signs, its insidious onset and de- 
velopment, and the customarj'' absence of a positive 
Wassermann reaction.. These facts have combined 
to make the correct diagnosis relatively uncommon. 
It is often possible onl)^ through an intensive study 
of the family history for evidences of syphilis. A 
family history of the occurrence of tabes or paresis 
justifies a diagnosis of syphilis ; a probable diagnosis 
is warranted from a history of aneurysm, aortic dis- 
ease, or death from sudden heart failure or apo- 
plexy before the age of fifty ; and possible evidence 
of syphilis is given by a historv- of cardiovascular 
or renal deaths up to the age of sixty years. The 
family historj' should include the more immediate 
collateral relatives. As to the symptoms in the sub- 
ject under consideration, these may be of almost any 
type, are usually of insidious development and long 
duration, and usually have not been controlled or 
alleviated by previous treatment. Several illustra- 
tive case histories are given in detail. 



Late Syphilis. — Udo J. Wile and Joseph A. 
Elliott {Journal A. M. A., December 23, 1916) re- 
port that a critical study of 120 cases of the late 
manifestations of syphilis brought out strongly the 
fact that the occurrence of these was largely 
dependent upon the inadequacy of previous treat- 
ment. In only one of the cases had the patient had 
what would be considered as efficient treatment, and 
nearly half of the whole number had had no treat- 
ment at all. The one efficiently treated case was an 
instance of precocious malignant syphilis. The 
study also brought out the fact that the oral ad- 
ministration of mercurial pills, as still commonly 
practised, was wholly inefficient to control the dis- 
ease. Over thirty per cent, of the late manifesta- 
tions occurred within four years from the time of 
infection. In a group of efficiently treated syphil- 
itics observed for four years, ninety per cent, have 
had no late manifestations, and the majority were 
serologically cured. 

Elementary Forms of Delirium of Persecution. 

— Jean Lepine {Bulletin de I'Acadhnie de mcdccine, 
November 21, 1916) refers to the prevailing view 
of persecutory delirium as one of the most obstinate 
and hopeless varieties of mental disorder. Numer- 
ous clinical observations have suggested that the 
condition becomes established in a gradual way, 
the subject showing first a period of general anxiety 
—actually an expression of psychic depression — in 
the course of which appear illusions and delirious 
interpretations, repetition of these finally leading to 
hallucinations. Little thought of the possibility of 
a period in which treatment might prove successful 
has been indulged in, except in the few cases in which 
a surgical operation on a diseased part of the body 
has been known to cause sudden disappearance of 
the delirium. Of late he has met with a number of 
instances of delirious interpretations and even hal- 
lucinations, arising from external circumstances or 
organic disorder in a predisposed, psychically de- 
pressed subject, in some of which recovery took 
place, while in others delirium of persecution be- 
came established. Since the beginning of the war, 
moreover, he has had under observation many cases 
of actual persecutory delirium, some of which have 
completely recovered under treatment. Exposed to 
an unusual stress through war conditions, such sub- 
jects, all predisposed by a highly emotional mental 
constitution, passed into a persecutory delirium 
much more rapidly than is normally the case. 
Transferred at once to completely dififerent condi- 
tions, i. e., removed from the depressing action of 
danger, insomnia, watching at niglit, and artillery 
concussion, they sometimes regained their mental 
balance. This is taken as showing that it is the 
persistence of the causes which is responsible for 
the incurability of the latter under ordinary circum- 
stances. Like toxic psychoses, delirium of persecu- 
tion requires early treatment, and can in this way 
doubtless be cured in some cases. Removal from 
harmful influences is, to be sure, less difficult to ac- 
complish in those subject to military discipline. 



90 



MISCELLANY FROM HOME AND FOREIGN JOURNALS. 



[New York 

MliUlCAL JOURNA 



Angle of Dropping Pipette. — R. P. Garrow 
{Lancet, November 18, iyi6) contributes a brief 
note to illustrate the accuracy of measurements by 
dro]3S when the pipette is held properly and the drop 
rate is kept uniform. The proper angle is the ver- 
tical, since this gives the most constant results and 
is the one easiest to maintain. With a given pipette 
which drops 100 drops in a given amount of fluid 
when held vertical the number of drops falls and 
their individual sizes rise as the horizontal is ap- 
proached. Thus at an angle of fifty degrees there 
are only eighty-two drops and at the horizontal only 
forty-eight. The decline in the number of drops is 
not uniform for each equal reduction in the angle. 

Syphilis among Confined Criminals. — Eugene 
Boudreau {Medical Record, December 2, 1916) 
gives the results of the examination of the inmates 
of Auburn, with special reference to the Wasser^ 
mann reaction, It was found that 16.85 P^r cent, 
of the males, and 33.85 per cent, of the females 
showed a positive reaction, while 7.5 per cent, of all 
those admitted are potential sufferers from paresis, 
or tabes, or some other form of syphilis of the nerv- 
ous system. History, glandular enlargement, and 
physical findings in general are proved to be lack- 
ing as evidence of the presence of syphilis, while 
enlargement of the epitrochlear kland is not pathog- 
nomonic of the disease. 

Trichinosis. — William Lintz {Medical Record, 
December 2, 1916) states that having had access to 
some human muscle tissue containing live trichinae 
he fed it to albino rats with the idea of deciding 
whether the isolation of Trichina spiralis from the 
feces could be depended upon in the diagnosis of the 
disease. At no time could trichinse be found in the 
feces, and at autopsy none occurred either in 
the large intestine or feces, although they were 
found in the small intestine, so that they are evi- 
dently destroyed in the fecal mass. Therefore it 
would seem that the search of the feces is of no 
value in the diagnosis of the condition, and also 
that the feces play no part in the transmission of 
the disease. 

The Blood Platelets in Hemophilia.— G. R. 

Minot and R. I. Lee {Archives of Internal Medicine, 
October, 1916) state that they studied the platelets 
in two typical cases, and were impressed with the 
essential role of these bodies in the pathogenesis of 
the disease. Previous work had shown that the 
formed elements of the blood, the calcium and fibrin- 
ogen content, and the thrombin and antithrombin 
were practically normal in hemophilia. The plate- 
lets, however, proved strikingly abnormal in the two 
cases referred to. Whereas addition of normal 
platelets to hemophilic plasma caused it to coagulate 
in a normal period of time, hemophilic platelets, 
added in amounts seventy-five times as large, never 
reduced the coagulation to anywhere near normal. 
In a special thrombin forming procedure, hemophilic 
platelets required more time to form thrombin than 
normal platelets. The evidence obtained suggested 
that the delay in coagulation in hemophilia occurs in 
the initial step in clotting, which seems to be a ren- 
dering of the platelets available by some process re- 
sembling solution. In one of the hemophilic patients 
transfusion of 600 c.c. of normal blood reduced the 



clotting time from sixty to seven minutes, but a 
gradual retardation then took place in the course of 
three days, when the clotting time again reached 
sixty minutes. Tiiis agrees with the findings as re- 
gards the blood j)latclets, the fife of the latter gen- 
erally being put down as three days. On the whole, 
they are led to consider hemophilia the result of an 
hereditary defect in the blood platelets, this defect 
consisting of a slow availability of the platelets for 
clotting purposes. 

Appendicitis and Pulmonary Tuberculosis. — 
Hugh M. Kinghorn {Journal A. M. A., December 
16, 1916) states that the occurrence of appendicitis 
in tuberculous patients is not infrequent, and that 
the disease may run any of its usual forms or may 
be very slight in its symptoms and difficult of diag- 
nosis. Operation was necessary in two thirds of the 
cases and the results showed that such patients, 
when undergoing climatic treatment for their pul- 
monary disease, stand the operation quite as well as 
otherwise normal persons. Nitrous oxide or chloro- 
form seemed preferable to ether for anesthesia on 
account of their slighter local actions on the lungs. 

Infantile Kala Azar. — Fidel Fernandez Martinez 
{Revista de Medicina y Cirugia Praclicas, Novem- 
ber 21, 1916) reports a case of kala azar in a child 
of four years with fever, greenish icterus, and slow- 
ly progressive abdominal enlargement. There was 
hepatic^ enlargement, tympanites but no ascites, and 
splenic puncture showed abundant colonies of Leish- 
mania infantum. Massot's formula with euquinine 
and cacodylate of iron was prescribed, resulting in 
stomatitis and salivation. Then an intravenous in- 
jection was given of .03 grain tartar emetic in two 
c c. of distilled water repeated in two days with 
marked improvement in every respect, and a third 
was given forty-eight hours later. 

Acidosis in Children. — A. Campbell Stark 
(Brit. Med. Jour., December 2, 1916) asserts that 
the circulation of considerable quantities of acetone, 
diacetic acid, or of both, in the blood of children 
produces definite symptoms, which may be termed 
acidosis. Cases in which this condition arises are 
very common, but are not usually recognized, due to 
the failure to examine the urine of children for these 
bodies as a routine. The clinical features of the 
condition vary widely in different cases, according 
to the severity of the intoxication. Fever from 
100° to 103° F. may occur for one or two days, or 
fever may be entirely absent. Vomiting occurs in 
over half of the cases, and is often extremely severe 
and resistant. Constipation is usual, but may be 
absent. The majority of the cases have an odor of 
acetone on the breath. Prostration is frequent and 
may be very severe. The most constant character- 
istic feature, however, is the occurrence of a pale 
urine, markedly acid, of high specific gravity, and 
containing large amounts of acetone and diacetic 
acid. The treatment of such cases calls for free 
evacuation of the bowels, the administration of 
fairly large doses of potassium bicarbonate and an 
abundance of water, and the restriction of fats in 
the diet. The cases may be very alarming when 
first seen, but recovery always follows proper treat- 
ment. The cause of the condition is not known. 



MISCELLAXY FROM HOME AXD FOREIGN JOURNALS. 



91 



Report of a Case of Spinal Cord Tumor. — 

W. \\". Pluinmer {Aincricaii Journal of Orthopedic 
Surgery, December, 1916) reports a patient who 
complained of backache for one year before paraly- 
sis appeared. Spastic paralysis of both lower ex- 
tremities developed in three months. Upon oper- 
ating, a giant cell sarcoma was foimd at the site of 
the second and third dorsal vertebrs. The laminae 
and spinous processes of these vertebras were eaten 
thin. No nerve tissue was found in the specimen 
removed. He draws attention to the fact of the 
unusual extension of the paralysis and tlie deception 
of the X ray as far as bone destruction was con- 
cerned. 

Interpretation of Eye Symptoms. — A. J. Bal- 
lantyne {Glasgozu Medical Journal, November, 
1916), in the course of his discussion of such 
symptoms as pain, disturbance of vision, head- 
ache, and giddiness, states that he has been im- 
pressed by the frequency with which eye strain at 
the presbyopic period is manifested by chronic 
conjunctivitis or blepharitis. The patient complains 
of local heat, smarting, soreness, dryness, or some- 
times watering, and photophobia. Boric or other 
lotions give temporary relief, but hyperemia of the 
conjunctiva and lids increases, and a catarrhal se- 
cretion begins to form. At times examination of 
the secretions reveals the Morax-Axenfeld diplo- 
bacillus ; local treatment should not alone be relied 
upon. It is essential in all cases of conjunctivitis 
after the age of forty, and in many at an earlier age, 
to combine optical and medicinal treatment if a 
lasting cure is to be obtained. All possible rest to 
the eyes should be given and the conjunctivitis 
treated locally until the eyes are sufficiently well to 
allow of reliable measurement of the refraction, to 
be followed by habitual wearing of glasses. 

Agglutinating Properties of Sera against Bacil- 
lus typhosus and Bacillus enteritidis Gaertner. — 
Thomas T. O'Farrell {Lancet, December 9, 1916) 
states that agglutination tests were done upon the 
sera of 495 patients, some of whom had been pro- 
phylactically inoculated against typhoid, others of 
whom had not. The tests were made by the method 
of Dreyer with Bacillus typhosus, and certain of the 
sera were also tested against Delepine's strain 7160 
of Gaertner's Bacillus enteritidis, which was stated 
to be agglutinated by the serum of persons suffering 
from typhoid infection, but not by sera from those 
who had merely been inoculated. Of 270 inocu- 
lated men over eighty-seven per cent, showed agglu- 
tination for the Bacillus typhosus. The majority of 
sera from these men gave twenty-five standard units 
of agglutins per mil of serum, above which the pro- 
portion of cases droppyed rapidly so that only very 
few sera with as much as one hundred and twenty- 
five units were found. The maximum agglutinin 
titre was obtained during the first few months after 
inoculation ; this fell rapidly during the third month 
to reach a level which was fairly maintained from 
the fifth to the fourteenth month. The presence 
of syphilis in the men did not influence the power 
of typhoid agglutination. -The agglutinating power 
of serum against strain 7160 was not affected by 
antityphoid inoculation. Three out of thirteen sera 
from previous typhoid fever patients agglutinated 
7160. 



Microbiological Diagnosis of Typhus Fever. — 

R. Otto {Mcdiciiiische Klinik, October 29, 1916 ) 
states that there is often not a little difficulty in 
making a definite diagnosis of typhus fever by clini- 
cal means, and laboratory methods, if available, 
should be of great help. As yet there is no cer- 
tain specific laboratory method, since the causative 
organism has not been definitely established. Sev- 
eral methods are, however, available as adjuncts to 
the clinical diagnosis. The first of these is the find- 
ing of typical bipolar organisms in the intestinal 
tracts of the body lice taken from suspected cases. 
While these organisms are not known to be the-' 
causative agents of the disease, their occurrence in 
smears from body lice is almost wholly confined to 
vermin from typhus cases. Weil and Felix have 
isolated a proteus like organism from the urine and 
blood of typhus cases, and have found that it gives 
specific agglutination with the blood of infected 
cases. This agglutinin reaction is seldom positive 
in sufficient dilution to be diagnostic before the sixth 
day of the disease. Finally, there is a less useful 
method of diagnosis in the inoculation of guinea pigs 
with the blood of suspected cases. In typhus infec- 
tion the pigs are made ill, but without charac- 
teristic symptoms and only after many days. At 
autopsy the brains of such animals show localized 
lesions which are more or less typical. This reac- 
tion, however, is so slow in developing as not to be 
of great service in the diagnosis of the disease in 
man. 

Hypothyroidism in Certain Types of Uterine 
Hemorrhage. — S. Salzman {American Journal of 
Obstetrics, November, 1916) maintains that there 
occurs a type of hemorrhage from the uterus not 
caused by any discernible pelvic disease, nor related 
to any of the so called hemorrhagic states, but due 
to a deficiency in secretory activity of the thyroid 
gland. Every surgeon of large experience has at 
some time performed a hysterectomy on one of 
these cases as a life saving measure, all ordinary 
methods of treatment having failed. The blood 
coming from the uterus in cases of this type is non- 
coagulable, a fact suggesting that menstruation is 
controlled by the secretion of a substance which in- 
hibits coagulation. From the clinical results ob- 
tained by thyroid treatment in his cases Salzman 
is led to believe thyroid deficiency responsible for 
the unopposed activity of the inhibiting substance 
in these cases. In his first patient, that of a woman 
of thirty-eight yfears, with continuous bleeding for 
six months, unaccounted for by any local patho- 
logical condition, five grain thyroid tablets were 
given three times a day at first, cessation of hemor- 
rhage occurring in two days. The dose was then 
reduced to two tablets a day for a week and stopped. 
Within three days bleeding again started, but 
stopped at once upon resumption of two tablets a 
day. This continued for three months, at the end 
of which regular menstruation returned. One year 
after the beginning of treatment she was in good 
health, taking one tablet daily. Four other cases 
are reported, including one of severe bleeding dur- 
ing pregnancy and two of excessive menstruation, 
all benefited bv the treatment. Attention is direct- 
ed to the fact that in thyroidectomized goats preg- 
nancy invariably results in bleeding and abortion. 



Proceedings of National and Local Societies 



THE NEW YORK ACADEMY OF MEDICINE. 

Joint Meeting zmth the Section in Genitourinary 
Diseases, Held November 2, IQ16. 
The President, Dr. W-\ltkr B. James, in the Chair. 
The Relation of Chronic Infections of the Geni- 
tourinary Tract to Obscure Internal Disorders. — 
By Dr. Hugh H. Young, Professor of Urology at 
Johns Hopkins University, Baltimore. This paper 
appears in tliis issue of the Journal. 

Dr. Thomas McCrae, Professor of Medicine at 
Jefferson Medical College, Philadelphia, said that 
the infectious pelvic diseases in the male were be- 
coming more widely understood and, indeed, were 
perhaps as important as in the female. The im- 
portance of keeping the possibility of this condition 
in mind could not be overestimated. If a patient 
complained of urinary symptoms it was easy for at- 
tention to be directed to the urinarj' tract. But if 
he had other symptoms and nothing suggestive of 
genitourinary trouble, it was possible to miss the 
essential etiological factor. 

Several points were to be taken into consideration. 
For instance, disease of the prostate was often re- 
sponsible for general nervous disturbance. This 
was instanced by the case of a young man of thirty 
who had advanced rapidly to a position of impor- 
tance in a large business house and had suddenly 
begun to lose his efficiency. His chief nervous 
symptom was a feeling of worry and anxiety over 
trifles. There was no history of venereal disease, 
he did not drink, and there were no local symptoms. 
iclL ^^'^^ found that there was some disease of the 
- "■' r„^- which had given no symptoms. The local 
prostate *■ treated for three months, when there 
condition was ^^r , , ^ .-^ j^jg nervous condition, and, 
was a marked change ,/ ^ ^^ tj^^ 

though this occurred ovi^ ' recurrence and the 
present time, there had been nir ^^ „ _ ,:,^,. 
patient was perfectly well, the fear, 'VTl anxieiy neu- 
rosis having totally disappeared. 

He said he did not wish to give the impression 
that he believed all cases of neurasthenia in males 
were due to disease of the prostate, but some of 
them undoubtedly were and in many there were no 
symptoms of the real etiological cause. 

One might refer to the great number of condi- 
tions, met in one's own practice, similar to those 
mentioned by Doctor Young which confirmed the 
speaker's belief that there was no doubt_ that the 
genitourinary tract was often a focus of infection. 
It also produced far reaching psychical effects of 
which one could convince himself by following 
these cases closely. Many of them gave no local 
symptoms. It was very easy to recognize local trou- 
ble if one took the pains to make a local examina- 
tion in spite of the lack of symptoms. 

Dr. Walter A. Bastedo, of New York, said that 
Doctor Young had brought out the important point 
that in hunting for the cause of obscure diseases 
the genitourinary system should not be forgotten. 
The speaker did not quite understand whether Doc- 
tor Young meant to convey the impression that, in 
the prostatic cases in which low phthalein output, 



high filtrate nitrogen, and high blood pressure dis- • 
appeared after proper catheterization or an opera- 
tion, the kidney disturbances were due to infection. 
If bacteria were not found in the blood and the 
kidney began to act when drainage was established, 
though the urine was still infectious, it would seem 
that Ijack pressure and not infection was the etio- 
logical factor. 

A point of passing interest, not always thought 
of, was that in the laboratory, if the vein of a kid- 
ney was clamped off so as to make venous back 
pressure, the urine flow stopped; if clamped slightly 
the urine flow slowed. A little venous back pres- 
sure, therefore, might be sufficient to cause stagna- 
tion in the kidney or ureter and result in ascending 
infection. This would suggest that urinary infec- 
tion might be secondary to disturbances of the cir- 
culation. 

Dr. E. L. Keyes, Jr., of New York, said that he 
had not been able to get the results obtained by 
Doctor Young in exorcising the tuberculous seminal 
vesicle. The operation in his own hands had 
seemed dangerous to the patient, though he had 
been fortunate in some cases. 

Doctor Young had said that rheumatism was 
unusual as a complication of infection of the 
kidney ; he agreed with that statement, but he had 
seen a case of rheumatism, due to stone, disappear 
when the stone was removed. 

The symptoms of pyelonephritis in infancy were 
far removed from the urinary tract. The chronic 
infections of infancy often exhibited only digestive' 
disturbances, while acute infections were often 
characterized only by high fever and repeated chills. 
Doctor Young had commented on the great vari- 
ety of symptoms arising from retention infections 
in the bladder and kidney. He had also referred 
to some of these cases having been treated for 
paresis. The speaker haci seen some cases ot which 
the most striking symptoms were cerebral, and the 
renal infection was suspected only when pus \yas 
found in the urine, the cerebral symptoms being 
relieved subsequently by some form of drainage. 

In regard to the psychic side, the phobias and 
anxieties, it seemed as though there should be a 
distinction made between genital and urinary af- 
fections ; the first brought out this class of nervous 
symptoms, while the bladder, ureter and kidney af- 
fections did not. Further, the same psychic dis- 
turbances came in cases not generally considered 
infectious but where the genital tract was involved, 
whether in male or in female. The question arose, 
could the psychic disturbances, whether the result 
of infection or not, be manifestations of something 
sexual. Some were relieved by the removal of 
genital tension, whether by the draining of the 
seminal vesicles, removing the prostate, adjusting 
the uterus, or functional relief. The speaker had 
had people suffering from tension referred t6 him 
as cases of ulcer of the stomach, or duodenum, or 
cardiac disease. They were invariably unmarried 
persons. In such supposed ulcer cases, for ex- 
ample, one did not find blood in the stools or 



January 13, 191-.] 



PROCEEDINGS OF SOCIETIES. 



93 



stomach contents, or other characteristic findings; 
they had the pain and symptoms of ulcer though 
one could not get the string test. Such patients, 
put to bed for an ulcer cure, would' in a week or 
two become highly restless, and the symptoms 
might return in aggravated form. But if, in spite 
of the diagnosis of ulcer, after a short period of 
treatment for hyperacidity, they were kept in vig- 
orous activity out of doors, in the woods with a 
gun for instance, or horseback riding, or if they 
married, the symptoms soon disappeared. These 
internal disorders were the result of psychic dis- 
turbances related to the sexual region. These 
psychic cases should not always be referred to the 
genitourinary specialist, but to a physician who was 
also a philosopher. 

Dr. Reginald Sayre, of New York, said that he 
agreed with Doctor Squier about the necessity of 
discovering the exact focus of infection which was 
causing the trouble. It was said by many men that 
when this was done the arthritic patient got well. 
But if a jomt was involved, removing the focus of 
infection did not ciu-e the joint unless it was given 
rest and attention. 

Dr. Emanuel Lib.man, of New York, said that 
while he appreciated the fact that focal infections 
were of great importance in causing various forms 
of disease and that their role had been for a time 
underestimated, at the present time there was a 
tendency to blame conditions upon local focci that 
were not due to such a cause. This was particularly 
true with relationship to the question of chronic 
appendicitis causing various forms of infections. 
The cases of chronic appendicitis generally showed 
more or less complete obliteration. The lesion con- 
sisted of a mass of fibrous tissue and it did not apn 
pear clear how such a focus could be the origin of 
any infections. It was only rarely nowadays that 
appendicitis, where pus was present, was allowed to 
become chronic. The only general effect that one 
could imagine could come from a chronic appen- 
dicitis would be through the intoxication caused by 
stasis in the ileum and by reflex action, especially 
on the pylorus. 

It was important to be careful in one's use of the 
word "rheumatism." The term rheumatism should 
be used in the old clinical sense and in no other 
way. The disease called rheumatic fever was char- 
acterized by the tendency to recur, by the lack of 
suppuration in any joint, by the tendency to the de- 
velopment of pericarditis, chorea, and verrucous 
endocarditis with Aschoff bodies present in the heart 
muscle. The only primary focus of rheumatism 
was a preliminary tonsillitis. Therefore, if any local 
focus was present aside from a tonsillitis, the case 
could not be properly grouped as rheumatism. Cases 
of joints infected with hemolytic or nonhemolytic 
streptococci should be called "stereptococcic ar- 
thritis" and not rheumatism. Up to the present 
time it had not been definitely proven that strepto- 
cocci caused rheumatism. If these cases could all 
be proven to be due to streptococci, then the term 
rheumatism could be dropped and the name strepto- 
coccic arthritis used to replace it. It was better, 
however, for the present to use the term rheumatism 
for this special group of cases as described above 
and try to find out what these were due to. 



The speaker believed that Doctor Rosenow's the- 
ory of mutation of the streptococcus and pneumo- 
coccus must be accepted. At the Mt. Sinai labora- 
tory they had for many years believed in such muta- 
tion as evidenced by the publication of the work of 
Doctors Buerger and Ryttenberg in 1907. Doctor 
Libman himself had shared in those studies at that 
time and since then Doctor Aschner and he had 
made studies from time to time and would in the 
near future publish some further examples of mu- 
tation. It was much more common to see a pneu- 
mococcus take on streptococcus features in the body 
than the other way around. 

There was no doubt that Doctor Bastedo was per- 
fectly right in his statements concerning the impor- 
tance of sexual tension as an etiological factor. To 
show how far in error one may go in blaming con- 
ditions on a focal infection, one of his old patients 
had recently been advised by a specialist to have 
lier tonsils and teeth removed for headaches which 
she herself had confided to the speaker to be due to 
such tension. 

Dr. Hugh H. Young, of Baltimore, in closing 
the discussion said that he wished to assure Doctor 
Bastedo that he did not intend to imply that every- 
one suffering from obscure internal disorders should 
be referred to a urologist for examination, but he 
wished to emphasize the fact that prostatic exami- 
nations were among the most accurate clinical mi- 
croscopical tests. General practitioners should real- 
ize that this is one of the important parts of a thor- 
ough examination, and make rectal examinations, 
obtain the prostatic secretion by massage and ex- 
amine it microscopically more frequently. 

It was certainly true that back pressure led to the 
deterioration of the kidney, but when infection was 
also present the symptoms were increased and the 
secondary changes were more rapid. 

The neurological and psychic symptoms were not 
due absolutely to focal infection, but rather to the 
effect on the nervous system of conditions produced 
bv focal infection. 



ASSOCIATION OF AMERICAN 
PHYSICIANS. 
Thirty-first Annual Meeting, Held at Washing- 
ton, D. C, May p, 10, and ij, 1916. 
The President, Dr. Henry Sewell, in the Chair. 
(Concluded from page 47.) 
Factors in Normal Blood Destruction. — Dr. 
Peyton Rous and Dr. O. H. Robertson, of New 
York, stated that the subject was studied with the 
etiology of cryptogenic anemia in view. It was 
not satisfactory to speak of hypo- or hypersplen- 
ism; but the accepted idea of blood destruction 
rested on a hemolytic action of the spleen. Quincke, 
however, held that there was a gradual deteriora- 
tion of cells in the circulation. In dogs and rab- 
bits, phagocytosis could account for blood destruc- 
tion, but some other mechanism must be sought 
for in cats, monkeys, and man. 

Conclusions reached from experiments were that : 
(i) Phagocytosis was not sufficient to account for 
blood destruction in man. (2) There was a grad- 



94 



PROCEEDINGS OF SOCIEriES. 



[New York 
Medical Joubna 



ual disintegration of red blood cells, with removal 
in the liver. 

Dr. S. J. Meltzek, ol New York, asked if ad- 
renaline was used in Doctor Rous's work. Obser- 
vations of Lamson and Adler on polycythemia had 
shown that when there was an accumulation of 
cells in the liver, the use of adrenaline would cause 
the stored cells to be driven out. 

Observations on the Metabolism and Treat- 
ment of Rheumatoid Arthritis. — Dr. Ralph Pem- 
BERTON, of Philadelphia, gave the report of fifty 
cases of rheumatoid arthritis treated by an unusual 
and useful method. The method was not opposed 
to the focal infection theorj' of the causation of 
this disease, but it was useful where treatment of 
the focal infections did not benefit the arthritis. 

Curtailment of carbohydrates was the basis of 
the method ; and experiments showed subsidence 
of symptoms on the regimen suggested, with ex- 
acerbations following renewed carbohydrate feed- 
mg. The restriction in diet might regulate the 
symptoms whether focal infections were present or 
not. 

The Vital Capacity of the Lungs and Its Re- 
lation to Dyspnea in Heart Disease. — Dr. Francis 
W. Peabody and Dr. John A. W'entworth, of 
Boston, stated that the production of dyspnea in 
patients with heart disease depended, in part at 
least, on inability to increase the minute volume of 
air breathed to as great an extent as in the case of 
normal persons. This was due to a decrease in the 
vital capacity which limited the depth of breath- 
ing. The tendency of a patient to become dyspneic 
on exertion varied closely with the degree of the 
decrease in vital capacity. The determination of 
the vital capacity gave an indication of the amount 
of exercise which would produce dyspnea, and was 
a guide as to the severity of the functional disabil- 
ity of the case. 

Dr. Francis W. Peabody^ of Boston, said that 
the effect of training on vital capacity was very 
marked indeed ; this did not affect the clinical be- 
havior of respiration in heart disease, however. 

The Immunizing Effect on Swine of Desiccated 
Sensitized Hog-Cholera Virus. — Dr. C. W. Duval 
and M. J. Couret, of New Orleans, stated that the 
hog cholera immune serum of De Schweinitz and 
Dorsett very quickly deteriorated, must be used in 
large quantities, and was quite expensive. Hereto- 
fore, defibrinated blood had been used as a virus ; but 
it was now found that tissues, by extraction and des- 
iccation, yielded a virus which would remain potent 
for at least thirteen months, which could be used in 
small doses, and which could be produced cheaply. 
The best effects were obtained by sensitizing the 
virus ; it then could be used safely and effectively. 
Animals might be immunized by doses ranging from 
0.05 mgm. to 5 mgnis. Duration of immunity de- 
pended on the amount of virus used. Heretofore, the 
immimizing virus had been given in one dose ; it was 
now found that immunity was more persistent when 
after an initial minute dose, three weeks later a dose 
of five to ten mgnis. had been given. 

Action of Opium Alkaloids and Their Com- 
binations on the Vomiting Centre. — Dr. David I. 
Maciit. of P.ahiniore, said that nausea and vomit- 



ing were the most annoying symptoms produced by 
opium and its derivatives. In a study of the seven 
principal alkaloids of opium, it was found that they 
could be divided into two groups: (i) Morphine, 
which caused vomiting; (2) all the others, which 
produced nausea feebly. The minimal dose of mor- 
phine which produces vomiting in the dog was 
found to be (average) 0.3 to 0.4 mgm. per kilo body 
weight. Not only was vomiting produced by mor- 
phine, but the drug puts the vomiting centre out of 
gear; no vomiting was induced thereafter by apo- 
morphine. Morphine and narcotine given together 
produced less vomiting than smaller doses of mor- 
phine alone ; moreover, the combination did not pro- 
duce exhaustion qf the vomiting centre: the same 
held true for morphine in combination with nar- 
ceine, and even more remarkable effects were seen 
when a mixture of all the alkaloids (pantopon) is 
given ; the vomiting centre was not put out of work- 
ing order by this preparation. Clinical observations 
had demonstrated the superiority of pantopon. 
The explanation of its favorable action probably lay 
in the molecular structure of the alkaloids : the com- 
bination of opposites reduced the tendency to pro- 
voke nausea. 

Dr. R. H. Babcock, of Chicago, said that he had 
used pantopon with most gratifying results; it had 
a better somnifacient eft'ect than morphine and it 
acted better upon cardiac patients than morphine. 

Dr. David I. Macht, of Baltimore, said that pan- 
topon had been found to serve as an excellent anes' 
thetic for experimental dogs. 

The Role of the Liver in Acute Polycythemia. 

— Dr. Paul D. Lamson, of New York, recounted 
efforts to determine the cause of the sudden increase 
of red cells in acute polycythemia. Two theories 
were held in view : ( i ) That polycythemia was 
tlue to sudden diminution of blood fluid with con- 
centration of cells; (2) there was a sedimentation 
of red cells somewhere in the body, which if stirred 
up would suddenly increase the red cell count. 
Epinephrin would cause a polycythemia in a few 
minutes ; this reached its height in fifteen minutes 
and began to fall in another fifteen minutes. 

Experiments (described in the paper) were made 
to fix the liver as the source of the influx of cells. 
It appeared that the increase of cells was not due to 
loss of plasma alone, but also to a sudden influx of 
stored cells. The liver seemed to be the organ that 
was responsible for both factors. It was suggested 
that a physiologic influx of epinephrin might ac- 
count for acute polycythemia, such as occurred after 
fright, etc. 

Blood Sugar Estimations as a Test of Carbohy- 
drate Tolerance. — Dr. Louis Ham man, of Balti- 
more, stated that frequent examinations of the blood 
and urine after the administration of glucose to fast- 
ing persons revealed four types of reaction : i. The 
Normal Reaction : The blood sugar rises rapidly to 
a level not exceeding 0.15 per cent. From this point 
it again rapidly declines, the whole reaction being 
over in less than two hours. 2. The Diabetic Reac- 
tion : The blood sugar rises more slowly, but reaches 
a higher point, 0.2 per cent, and over. The high 
point is maintained for some time, and the decline 
occurs gradually, the whole reaction occupying threr 



January 13, 1917.] 



BOOK REVIEIVS.— LOCAL MEDICAL SOCIETIES. 



95 



hours or longer. If the blood sugar rises above 
0.175 per cent., sugar appears in the urine. 3. The 
Renal Reaction : In a small number of persons, al- 
though the blood sugar cur\e is in all other respects 
like the normal reaction, still sugar appears in the 
urine. In severe cases of diabetes this same low 
renal threshold is often found. 4. The Nephritic 
Reaction : In many cases of nephritis the blood su- 
gar rises to a high level, often exceeding 0.2 per cent., 
and the blood sugar curve resembles the diabetic 
reaction ; however, no sugar, or only a trace of su- 
gar, appears in the urine. Studies of the blood sugar 
reaction after the administration of glucose and its 
relation to glycosuria give valuable clinical data in 
diabetes and other conditions. 



Book Reviews 



[We publish full lists of books received, but we acknowl- 
.edge no obligation to review them all. Nevertheless, so 
far as space permits, we review those in which we think 
our readers are likely to be interested.] 



The Healthy Marriage. A Medical and Psychological 
Guides for Wives By G. T. Wrench, M. D., B. S. 
(Lend.), Past Assistant Master of the Rotunda Hos- 
pital, Dublin; Second edition. New York: Paul B. 
Hoeber, 1917. Pp. 299. (Price, $1.50.) 
We live in an era marked by efforts to educate the general 
public in matters concerning health, and a host of the 
efforts that have been made in the form of books have 
dealt with one or another of the phases of sex hygiene. 
Some of these have been good, others only fair and many 
so bad as to have been unwarranted. The truly good ones 
have been decidedly few and it is always a pleasure to wel- 
come an addition to their number. The present volume 
gives this pleasure to the fullest extent, for it is truly ex- 
cellent both in what it teaches and in how it teaches it. 
The author deals intimately with all of the factors which 
go to make up a normal, healthy and happy marriage, and 
of necessity speaks often of the sexual sides of married 
life. Wherever he does so he handles his subject in a way 
that is altogether pleasant, though intimate and quite to 
the point. He gives the woman the facts which should 
guide her in the proper conduct of marital relations in 
general and in particular, but he gives them in such a man- 
ner as to leave a pleasant impression rather than one tinc- 
tured with an element of disgust. But he goes much fur- 
ther than the sexual side of the married life and gives 
sound advice on most of the matters which are concerned 
in the maintenance of normal health and happiness. Thus 
he includes discussions of the causes of neuroses, the 
value of exercise, food, ventilation, baths, and hygiene in 
general, and even deals with the subject of appropriate 
dress. He also presents chapters on the menstrual func- 
tion, pregnancy, and some of its more common abnormal 
aspects, labor, the puerperium, and the climacteric. The 
whole work is of the tj'pe that carries conviction of the 
author's fitness for treating of the subject, which was 
born of his experiences as a past assistant Master of the 
Rotunda Hospital. He has written frora the view point 
of the woman, and to her the book can be recommended, 
but it can also be commended to the attention of the 
phj-sician who is often called upon for advice in the 
matters here considered. 

The Practice of Urology. A Surgical Treatise on Genito- 
urinary Diseases Including Syphilis. By Ch.\rles H. 
Chetwook, M. C, LL. D., F. A. C. S. Professor of 
Genitourinary Surgery, New York Polyclinic; Visiting 
Surgeon to Bellevue Hospital ; Special Consulting Sur- 
geon to Knickerbocker Hospital. Profusely illustrated. 
Second edition. New York : William Wood & Co,, 
1916. Pp. 825. (Price, $5.50 net.) 
This is the second edition published within a period of 
three years. There are several changes : the department 
of cystoscopy has been enlarged, an addition has been 



made to the operative technic and, finally, a section on 
local anesthesia has been included. The volume is com- 
plete, especial attention being paid to the macroscopical 
and microscopical anatomy of the genitourinary tract, 
the technic of operations, the instruments required, and 
the various blood reactions and their significance. In the 
chapter on instruments and surgical technic the author's 
alternating urethral irrigation clamp, by means of which 
the urethra is alternately filled and emptied, is described 
and illustrated. In this chapter the care and sterilization 
of the urologist's armamentarium is also carefully consid- 
ered. Diagnosis receives an adequate amount of space, be- 
ing subdivided into oral examination, physical examina- 
tion, uranalysis, chemical, microscopical, and bacteriologic- 
al, serodiagnosis, with several pages on serum and vac- 
cine therapy, urethroscopy, cystoscopy, functional renal di- • 
agnosis, and roentgenography. In enumerating the va- 
rious complement fi.xation tests the author points out that 
the gonococcus complement fixation test possesses even a 
greater percentage of reliability than the complement fix- 
ation test for syphilis. The diseases of the various parts 
of the genitourinary tract from the penis to the kidney, 
together with their etiology, diagnosis, prognosis and treat- 
ment, both medical and surgical, make up the bulk of the 
volume. A short but excellent section on local anesthesia 
gives the details for the performance of such operations 
as suprapubic cystotomy, external urethrotomy, and oper- 
ations on the external genitals. The final chapter is de- 
voted to syphilis, embracing syphilitic infection of all parts 
of the system, and a resume of the newer methods of 
treatment of this disease, Wliile not strictly a part of 
urology this chapter is added because the author's inves- 
tigations and teachings, covering a period of over twenty 
years, have been in the sphere of genitourinary diseases, 
including syphilis. 

The arrangement of the subject matter and the details 
of illustrating and printing — the important facts being 
outlined in bolder type tliroughout the text — deserves 
special commendation. 

Meetings of Local Medical Societies 

Monday, January 15th. — New York Academy of Medicine 
(Section in Ophthalmology), Yorkville Medical So- 
ciety; Medical Association of the Greater City of 
New York (annual) ; Medical Society of the County 
of Erie; Elmira Clinical Society; Psychiatric Society 
of Ward's Island, 

Tuesday, January i6th. — New York Academy of Medi- 
cine (Section in Medicine) ; Tompkins County Medical 
Society; Medical Society of the County of Monroe; 
Tri-Professional Medical Society of New York ; 
Medical Society of the County of Kings ; Bingham- 
ton Academy of Medicine; Syracuse Academy of 
Medicine; Ogdensburg Medical Association; Oswego 
Academy of Medicine (annual) ; Medical Society of 
the County of Westchester ; Federation of Medical 
Economic Leagues of New York (annual). 

Wednesday, January i/'ih.—;t^evf York Academy of Medi- 
cine (Section in Genitourinary Diseases) ; Alumni 
Association of City Hospital, New York ; Schenectady 
Academy of Medicine ; Women's Medical Association 
of New York City (New York Academy of Medi- 
cine) ; Medicolegal Society, New York; Buffalo Med- 
ical Club ; Northwestern Medical and Surgical So- 
ciety of New York ; Bronx County Medical Society ; 
Dunkirk and Fredonia Medical Society; Buffalo 
Academy of Medicine (Section in Obstetrics and 
Gynecology). 

Thursday, January i8th. — New York Academy of Medi- 
cine (stated meetin.g) ; Auburn City Medical Society; 
Geneva Medical Society (annual) ; German Medical 
Society, Brooklyn ; /Esculapian Club of Buffalo ; New 
York Celtic Medical Society. 

Friday, January igth. — New York Academy of Medicine 
(Section in Orthopedic Surgery) ; Mount Vernon 
Medical Society ; Clinical Society of the New York 
Post-Graduate Medical School and Hospital ; New 
York Microscopical Society; Alumni Association of 
Roosevelt Hospital; Saratoga Springs Medical So- 
cietv. 



96 



OFFICIAL NEWS.— BIRTHS. MARRIAGES. AND DEATHS. 



[ New York 
Meuical Journal. 



Official News 



United States Public Health Service : 

Official list of changes in the stations and duties of com- 
missioned and other officers of the United States Public 
Health Service fur the fourteen days ending January 3, 
1917: 

Galloway, T. C, Assistant Surgeon. Relieved from duty 
on the Texas border and ordered to proceed to Denver, 
Col., for cooperation with the Colorado State Board 
of Health in prevention of interstate spread of typhus 
fever. 
Gardner, C. H., Surgeon. Granted fourteen days' addi- 
tional leave of absence from December 27, igi6. 
Gassaway, J. M., Senior Surgeon. Ordered to report to 
the chairman of the board convened at the Bureau, 
January 9, 1917, for physical examination. 
Hurley, J. R., Passed Assistant Surgeon. Detailed to 
conduct First Aid Classes at School of Preparedness 
at Washington, D. C, durmg the month of Jan- 
uary, 191 7. 
Smith, H. F., Assistant Surgeon. Relieved from duty in 
investigations of poliomyelitis, and ordered to return 
to station at Cincinnati, Ohio. 
Stout, J. D., Assistant Surgeon. Relieved from duty at 
Norfolk, Va., and directed to proceed to Spartanburg, 
S. C, for duty in investigations of pellagra. 
White, M. J., Surgeon. Directed to proceed to Chicago, 
111., for conference ; thence to various railway camps 
of Mexican laborers in Illinois, Missouri, Oklahoma, 
Texas, and Kansas, relative to measures for the pre- 
vention of occurrence and spread of typhus fever. 
Board Convened. 
Board of commissioned medical officers convened at the 
Bureau from time to time, upon the call of the chairman, 
for the purpose of making physical examinations of such 
senior surgeons as may be ordered to appear before it. 
Detail for the board : Assistant Surgeon, General A. H. 
Glennan, chairman ; Assistant Surgeon General W. G. 
Stimpson, member ; Senior Surgeon Fairfax Irwin, re- 
corder. 

United States Navy Intelligence : 

Official list of changes in the stations and duties of offi- 
cers serving in the Medical Corps of the United States 
Navy for the four weeks ending January 6, 1917: 
Carr, E. C, Assistant Surgeon. Ordered to Naval Re- 
cruiting Station. Nashville, Tenn., for duty. 
Cole, H. W., Jr., Passed Assistant Surgeon. Detached 

from the San Diego and placed on waiting orders. 
Cottle, G. F., Passed Assistant Surgeon. Detached from 
the North Carolina and ordered to the Bureau of 
Medicine and Surgery, Navy Department, Wasliington, 
D. C. 
Downey, J. O., Passed Assistant Surgeon. Detached from 
the Navy Yard, Mare Island, Cat, and ordered to the 
Oregon on December 28, 1916, for duty. 
DuREETT, J. H., Assistant Surgeon. Ordered to the Navy 
Recruiting Station, New Orleans, La., on January 2, 
1917. 
Eytinge, E. O. J., Detached from the Milwaukee and given 

a six months' sick leave from January 2, 1917. 
Fauntleroy, a. M., Surgeon. Detached from the Naval 
Medical School, Washington, D. C, from January 29, 
1917, and ordered to command the Yokohama Hos- 
pital. 
Hunt, Daniel, Assistant Surgeon. Detached from the 
Florida and ordered to the Navy Recruiting Station, 
Jackson, Miss. 
LowMAN K. E., Assistant Surgeon. Ordered to the Navy 
Recruiting Station, Scranton, Pa., on January 2. 1917. 
Odell, H. E., Surgeon. Detached from the Yokohama 

Hospital and placed on waiting orders. 
Priest, H., Assistant Surgeon. Detached from the Talla- 
hassee and ordered to the Navy Recruiting Station, 
Montgomery, Ala. 
Short, W. H., Passed Assistant Surgeon. Detached from 

the Oregon and placed on waiting orders. 
Smith, H. W., Passed Assistant Surgeon. Detached from 
the Nevada and ordered to the North Carolina for 
duty. 



Steadman, W. G., Passed Assistant Surgeon. Detached 
from the Naval Hospital, Mare Island, Cal., and or- 
dered to the Milwaukee. 

Taylor, J. S., Surgeon. Detached from the Connecticut 
and ordered to the Bureau of Medicine and Surgery, 
Navy Department, Washington, D. C. 

Thomas, G. E., Passed Assistant Surgeon. Detached 
from the Utah and ordered to the Tallahassee for 
duty. 

Warner, R. A., Passed Assistant Surgeon. Detached from 
the Neiv York and ordered to the Connecticut for duty. 

Waterhouse, R. M., Assistant Surgeon. Detached from 
the Melville and ordered to the Nevada for duty. 



Births, Marriages, and Deaths 



Died. 

Axuerton. — In Morristown, N. J., on Tuesday, January 
2d, Dr. George A. Anderton, aged thirty-five years. 

ANDzULAns. — In New Britain, Conn., on Saturday, De- 
cember 30th, Dr. Joseph Julius Andzulatis, aged fifty-one 
years. 

Blossom. — In Caribou, Me., on Saturday, December 30th. 
Dr. William Ripley Blossom, aged fifty-eight years. 

Borland. — In Franklin, Pa., on Tuesday, December 26, 
Dr. John R. Borland, aged eighty-eight years. 

Cav.\naugh. — In Duluth, Minn., on Sunday, December 
24th, Dr. Richard Edward Cavanaugh, aged forty-eight 
years. 

Ci^RY. — In New Britain, Conn., on Saturday, December 
30th, Dr. George Clary, aged eighty-seven years. 

Eakin. — In Philadelphia, Pa., on Tuesday, January 2nd, 
Dr. A. Louis Eakin, aged seventy-seven years. 

Fulton. — In Lawrenceville, Pa., on Wednesday, De- 
cember 27th, Dr. Henry D. Fulton, aged fifty-seven years. 

Galbraith. — In Dresden, Ont.. on Wednesday, December 
27th, Dr. Daniel Galbraith, aged seventy-seven 3'ears. 

Gilnack. — In Roclc\'ille, Conn., on Wednesday, January 
3rd. Dr. Frederick Gilnack, aged seventy-two years. 

Haight. — In Sacramento, Cal., on Friday, December 29th, 
Dr. Herbert N. Haight. 

Hardeman. — In Portersville, Cal., on Saturday, De- 
cember 30th, Dr. John Locke Hardeman, aged sixty-one 
years. 

Harris. — In San Francisco, Cal., on Sunday, December 
i8th. Dr. Henry S. T. Harris, aged fifty-three years. 

Jones, — In Los Angeles, Cal., on Tuesday, December 
26th, Dr. Cummins B. Jones, aged sixty-nine years. 

Landt. — In Mohawk, N. Y., on Thursday, December 
28th, Dr. William Landt, aged eighty-three years. 

Luyties. — In St. Louis, Mo., on Saturday, December 
23rd, Dr. Carl J. Lujties, aged fifty-six years. 

McCoRMiCK. — In Philadelphia, Pa., on Saturday, De- 
cember 30th, Dr. W'illiam S. McCormick, aged forty years. 

McKee. — In Carnegie, Pa., on Monday, December 25th. 
Dr. Joseph H. McKee, aged fifty- four years. 

O'Brien. — In Alexandria, Va., on Friday, December 
29th, Dr. Matthew Watson O'Brien, aged sixty-one years. 

Paine. — In Eugene, Oregon, on Wednesday, December 
27th. Dr. DeWitt A. Paine, aged sixtj-three years. 

Ramsburch. — In Washington, D. C, on Wednesday, Jan- 
uary 3rd, Dr. Jesse H. Ramsburgh, aged forty-six years. 

Reber. — In Philadelphia, Pa., on Saturday, December 
30th, Dr. Wendgl! Reber. aged fortv-nine years. 

Rice. — In Fitchburg, Mass., on Saturday, January 6th, 
Dr. Charles Henry Rice, aged seventy-three years. 

Spear. — In Boston, Mass., on Monday, December 25th, 
Dr. Edmund Dow Spear, aged sixty-five years. 

Sweet. — In Geneva, N. Y. on Tuesday, January 2nd, 
Dr. Amos L. Sweet, aged seventy years. 
. Tatum. — In Stuart, Va., on Friday, December 20th, Dr. 
Benton F. Tatum. aged fortT,--five years. 

Thomas. — In Jonesboro, Tex., on Friday, December 
22nd. Dr. George T. Thomas, aged sixty-one years. 

Walsh. — In Olyphant, Pa., on Thursday, December 21st, 
Dr. James J. Walsh, aged thirty years. 

Warriner. — In Philadelphia, Pa., on Friday, January 
5th, Dr. Harry Blair W'arriner, aged twenty-eight years. 

White — In Bloomfield. N. J., on Thursday, December 
28th. Dr. William H. White, aged sevent\'-nine years. 



I 



New York Medical Journal 

INCORPORATING THE 

Philadelphia Medical Journal ^u Medical News 

A Weekly Review of Medicine, Established 1 843. 



Vol. CV, No. 3. 



NEW YORK, SATURDAY, JANUARY 20, 1917. 



Whoie No. 1990. 



Original Communications 



MEDICOEDUCATIOXAL PROBLEMS IN 

THE TREATMENT OF ATYPICAL 

CHILDREN.* 

By G. Hudson-Makuen, M. D., 
Philacklphia. 

In the newer order of things the physician is be- 
ginning to reahze more and more the importance of 
treating his patients rather than their diseases, and 
therefore in his preparation for the practice of med- 
icine he IS finding it necessary to study psychology 
as well as physiology, anatomy, and chemistry. It 
is found that the disease itself is not so important 
as the manner in which the patient reacts to the dis- 
ease, and on the same principle the modern physi- 
cian is giving more attention to the effects of reme- 
dies than to the remedies themselves. 

All this is a natural consequence of a fuller reali- 
zation of the fact that there is something which dis- 
tinguishes the human organism from a mere labora- 
tory receptacle or test tube, and this something is 
obviously the patient's mind or the personality. The 
time has come when the physician must be more 
than a mere doctor or prescriber of drugs, and it 
would be interesting to speculate upon the condi- 
tions which are responsible for the change, but it is 
enough perhaps to recognize its existence, and also 
the fact that it has been in a measure forced upon 
us by circumstances over which we have had little 
or no control. It is not greatly to our credit per- 
haps that we should feel called upon to make this 
confession. 

The practice of medicine, like the practice of 
every other profession, must improve in character 
largely as the result of opposing principles, and our 
methods of practice, like the methods of any other 
art. must change to meet the ever changing condi- 
tions of a progressive age. 

The fact of the close relationship between mind 
and matter is now generally recognized, and we 
know that the physical organism of man is the basis 
of his psychical development. We know that the 
brain is the seat of the mind and that intellectual 
development can come only as a result of the phys- 
ical development of certain cerebral structures, and 
vice versa, it being a poor rule that will not work 

•Address delivered at a joint meeting of the New York Academy 
of Medicine, the New York State Society, the New Jersey Pediatric 
Society, the Philadelphia Pediatric Society, and the New England 
Pediatric Society, Boston, November 4, 1916. 



both ways. We are becoming convinced that 
physical health is in some way related to, and de- 
pendent upon, psychical health, and that we always 
tend to be what we will or desire to be, if for no 
other reason than that we always strive consciously 
or unconsciously to reach the height of our ambi- 
tion. This is probably what Browning had in mind 
when he said, "A man's reach should be beyond his 
grasp, or what's a heaven for?" 

Moreover, modern thought leads us to the con- 
viction that the prevention of disease is even more 
desirable than cure, and to no class of physicians 
should this belief appeal so strongly as to those who 
have the care of children. It is well known that 
the inefficiency of adult life is due largely to the 
mistakes of childhood, but it is not so well recog- 
nized that many of the actual diseases of later years 
may be traced to faulty habits acquired during in- 
fancy and adolescence. The physician is usually 
the first to receive and welcome the child into the 
world, and he should be the first therefore to outline 
and direct methods for its education and develop- 
ment, and thus enable it to avoid the mistakes which 
lead to inefficiency and disease. 

Medicoeducational methods are applicable in a 
measure to all classes of patients, but they are espe- 
cially indicated in the treatment of so called atypical 
children, and, as Oliver Wendell Holmes suggested, 
to be curative in every instance they should be in- 
stituted several generations before the birth of the 
child. Medicoeducational methods, therefore, have 
a twofold function, the prevention of disease and 
the cure of it. 

The principle of eugenics has been advocated as 
a means of preventing disease, and but for the diffi- 
cnilties of establishing or enforcing the principle, it 
would doubtless be of great value. The chief obsta- 
cle to the successful practice of any medicoeduca- 
tional methods, whether for the prevention or cure 
of disease, is the difficulty arising, first, in outlining 
a suitable course of procedure, and, second, in hav- 
ing the course properly carried out. 

To meet these difficulties successfully the medico- 
educationalist must be a specialist in the true sense 
of the term. He must be a medical man and an 
educational man ; he must be at once a physician and 
a teacher ; a physiologist and a psychologist ; he must 
know his medicine well and he must know the work- 
ings of the human mind equally well. He must 



Copyright, 1917, by A. R. Elliott Publishing Company. 



nUDSON-MAKUEN: TREATMENT Ol- ATYl'lCAL CHILDREN. 



[New Vork 
dical journai 



know, not only what should be done for the pre- 
vention and cure of certain abnormal conditions, 
but he must also know how to go about it and how 
to teach others. "To do" is not so easy as "to know 
what to do," and the great niedicoeducational prob- 
lem is to make men do the things that are good for 
them and leave undone the things that are not good 
for them. 

Failure in the successful application of medico- 
educational methods of treatment may be due to the 
physician's own lack of belief in them. If we would 
convince another of the error of his ways, we must 
ourselves be keenly alive to the error, and when we 
have once really convinced our patient of his error, 
we have him in the true psychological condition for 
the adoption of means which make for its complete 
eradication. Physicians are constantly making the 
mistake of separating the mind from the body in 
their diagnosis and treatment, and this is especially 
true in the diseases of children. The mind of the 
child is always a product or function of the child's 
brain, and defective mentality always suggests a de- 
fective action in some of the cerebral structures. 
This defective action does not necessarily indicate 
organic cerebral defects, but it may be due merely 
and wholly to a bad start in the growth and devel- 
opment of the brain tissues. 

A study of child psychology teaches that of all 
the organs of the body the brain is the most suscep- 
tible to physical and fimctional development. The 
cerebral convolutions increase enormously in num- 
ber, and the enveloping gray matter, which forms 
the so called cortex of the brain, undergoes a corre- 
sponding increase in its surface growth during what 
we call mental development. Moreover, the so- 
called associational fibres of the brain, upon which 
its mental functions so largely depend, are merely 
rudimentary in early childhood, and attain their full 
functioning powers only after years of growth and 
development. 

These anatomical and physiological facts must be 
taken into consideration in the application of medico- 
educational methods, and we should keep in mind 
that the physical development of the child's cen- 
tral nervous system is largely the result of, and di- 
rectly dependent upon, his early psychical activities. 
A striking difference between the mentally normal 
and abnormal child appears in the fact that the one 
develops automatically, while the other halts in his 
development or actually, in some instances, loses 
ground or undergoes retrograde development. The 
physician's aim in the treatment of atypical children 
should be to assist them in both their physical and 
mental development, and the phrase that best ex- 
presses this work is "psychophysical education." 

The two important things to keep in mind in the 
psychophysical education of children are: i. The 
correction of postural attitudes ; and, 2, the develop- 
ment of nonnal respiration, phonation, and articula- 
tion. These two things have been said to constitute 
a cardinal principle in the treatment and prevention 
of disease, and at all events they should form the 
starting point of all medicoeducatiOnal systems of 
•treatment. Their application in the case of normal 
children is comparatively simple, but in subnormal 
or atypical children the problem is more difficult and 



more complex. These physical exercises have a 
psychical value far beyond that which is usually at- 
tributed to them, and when they can be made use of 
in the training of atypical children they should not 
be neglected or supplanted by the usual methods of 
manual training. 

Atypical or backward children should not be cod- 
dled, but encouraged, and, like plants of slow 
growth, in some instances they may be "forced." 
I'his may be done by supplying favorable conditions 
for growth and development, and by directing their 
physical activities in the right channels. Compara- 
tive poor health is not always a contraindication, but 
often a decided indication for this forcing process. 
Many a nervous child immediately begins to improve 
physically as well as mentally when well directed 
pressure is brought to bear upon him in psychophys- 
ical education. 

This is due to the fact that the child may have 
been wearing himself out nervously by his aimless 
and ill directed activities, and judicious training in 
such a crisis often results in a much needed rest to 
both mind and body. It is said of older people that 
it is not work that kills, but worry, and we are in- 
clined to overlook the fact that this is equally true 
even of young children. The satisfaction of having 
performed constructive work in a successful manner 
is not confined to mature men and women, but may 
come verv early in the lives of children, and it is not 
too much school work that impairs the health, but 
too little that is well adapted to individual needs. 

Nervousness is the most characteristic state of the 
atypical child, and manifests itself in a thousand and 
one ways. In the majority of instances it is due to 
a neuropathic heredity, coupled with an unsuitable 
or unfortunate environment. Although the physi- 
cian can do nothing directly to change the child's 
heredity, he may do much to make the environment 
more suitable and more favorable by at once insti- 
tuting medicoeducational measures. These measvires 
must be really medicoeducational, and only the phy- 
sician can direct them because he alone knows 
whether the symptoms are of organic origin, or 
whether they are more or less functional and there- 
fore subject to psychical and emotional treatment. 

So called hereditary tendencies are frequently ag- 
gravated and encouraged by faulty parental atti- 
tudes, and these are usually the result of ignorance, 
selfishness, or it may be overanxiety with reference 
to the condition of the young offspring. In this 
way the mistakes of the parents may indeed be vis- 
ited upon the children, even to the third and 
fourth generation. Atypical children are for the 
most part spoiled children, and they usually acquire 
ner\'ous habits which, if allowed to continue long, 
can never be quite eradicated or supplanted. 

The most difficult thing in the treatment of atyp- 
ical children is to control and direct this parental in- 
fluence and enlist its services in behalf of the child's 
welfare. In some instances the parents are hope- 
less, and it becomes necessary to remove the child 
entirely from the home environment before satisfac- 
tory progress can be made. Mother love is undoubt- 
edly a great factor in child development, but if 
wrongly directed it may be so misunderstood as to 
be subversive of all medicoeducational influence? 



HUDSON-MAKUEN: TREATMENT OF ATYPICAL CHILDREN. 



99 



The bright mother of in many respects a bright 
boy consulted me in behalf of her child while this 
paper was being written, and I may add that the 
father of the boy was a successful practitioner of 
medicine, although now retired. The purpose of 
the consultation was to devise measures for the cure 
of the boy's stammering. He is ten years of age 
and fairly well developed both physically and men- 
tally, and, as is often the case, I found the stammer- 
ing to be only one of several striking symptoms of 
a general nervous condition. The boy has occa- 
sional crjing spells without any apparent reason. 
He is afraid to be alone in the dark, and at night he 
will not go unattended to bed. 

In explanation of this condition I found that in 
early childhood he had a governess who was accus- 
tomed to recount to him all the terrible things that 
might happen if he did not "watch out," and he was 
frequently allowed to be present in the family circle 
during the recital of interesting and thrilling tales 
of adventure. As a result we have a boy who stam- 
mers in his speech and who, in spite of an otherwise 
good mind, is unable to control adequately certain of 
his emotional and psychical faculties, and it will now 
be a difficult task for him to overcome these acquired 
tendencies. 

In contrast with this little story let me tell another 
of another son of a physician, who was brought to 
me at the age of two and a half years on account of 
a tendency to stammering speech. I had a brief 
consultation with the father of the child and outlined 
a little course of treatment, which consisted purely 
of what I have called medicoeducational measures. 
After two weeks a second consultation was held, and 
as a result of the father's well directed methods 
speech began to develop in a perfectly normal man- 
ner, and there is now no trace of stammering or 
other ner^-ous affection after a period of about ten 
years. 

Overanxiety and undue manifestations of solici- 
tude as to the child's welfare on the part of the par- 
ents is a frequent cause of nervous fear in children, 
and I have recommended as a substitute a course of 
what someone has called "intentional neglect" in 
order to develop in the child greater independence of 
feeling and action. It takes courage for a mother 
completely to ignore the cr>-ing and pleading of her 
young hopeful, but she should understand that there 
are many occasions when this is the very best thing 
to do. 

A case showing the disastrous results of too much 
coddling was that of a boy thirteen years of age, a 
Canadian by birth, who was a bad stammerer, and 
at the same time had acquired other curious nervous 
conditions. The mother requested me prior to his 
arrival to allow no one of pro-German proclivities 
to come in contact with him because it always 
aroused him to such a high pitch of excitement; in 
other respects also she herself insisted upon direct- 
ing the manner if not the method of treatment. She 
was overanxious with reference to the slightest 
symptoms, and especially lest the boy should become 
too much fatigued, and I could not make her under- 
stand that by suggestion she was aggravating some 
of his most important and serious symptoms. Need- 
less to say that in spite of all that we could do the 



boy continues to stammer and, what is of greater 
importance, he continues to be a psychophysical 
weakling, because, to use a well known expression, 
he is tied to his mother's apron strings, and the 
mother herself is guided by her heart rather than 
her head. In other words, her affections so domi- 
nate in the management of her son that whatever 
judgment she may have had originally is now wo- 
fully warped or completely held in abeyance. 

These three cases illustrate very well how atypical 
psychophysical conditions may be acquired by chil- 
dren prior to the school age, owing to faulty en- 
vironment and inadequate training, and the second' 
case illustrates what may be done by way of pre- 
vention. 

SUMMARY AND CONCLUSIONS. 

Children are largely what we make them, and the 
factors which determine their psychophysical condi- 
tion as well as their personality are heredity and 
environment. 

Heredity is an important factor in the develop- 
ment of children, but environment is even more 
important because it is always subject to change and 
improvement, and in addition is probably even more 
resjwnsible than heredity for putting the prefix, 
a, in the word atypical as it relates to children. 

The most important feature of a child's environ- 
ment is his education and training, and the most 
important neglected period in the life of anyone is 
that which comes prior to the so called school age. 

Teachers believe that the failures of their pupils 
are due chiefly to faulty habits fonned before their 
entrance into the schools and colleges. 

The so called fixed habits are the early ones 
formed during the child's physical and mental de- 
velopment in the first years of his existence. 

The Jesuits have a saying, "Give me the first 
seven years of a child's life and I care not who has 
the rest." 

While the mind of the child has a physical basis, 
yet his mental activities determine to a great ex- 
tent the character of this basis by regulating its de- 
velopment, and hence it is that the general physical 
condition of the child may be influenced for good or 
ill by the character of his mental and emotional ac- 
tivities. 

Medicoeducational methods become real measures 
of prevention only when employed during infancy. 

A mother once asked at what age should a child 
learn to be obedient, and the significant reply was, 
"If your child has not learned obedience now, he 
never will learn it." 

Medicoeducational measures should aim, not to 
remake the child, but to make the "absolute best" 
of what has already been made. 

Nervousness is the most characteristic malady of 
children, and its treatment should be, first, pre- 
ventive and, second, remedial or curative. 

Preventive treatment is applicable in the earliest 
infancy, and consists largely in an attempt to control 
the child's physical activities through careful direc- 
tion of his psychical and emotional activities. 

If the child is normal physically, this treatment 
should result in a development of normal psychical 
and emotional faculties, but if the child inherits 
])liysical abnormalities, such as cleft palate or other 



ROJilXSON: GRIPPE PNEUMONIA. 



[New York 
:dical Journa 



irregularities of structure, surgery and some form 
of medication may be indicated in addition to the 
psychophysical training. 

Punishment should never be inflicted except per- 
haps at the very beginning and before the child is 
mentally susceptible to medicoeducati.onal measures. 

it is said that there arc upward of 300,000 stam- 
merers in the United States alone, and I am of the 
opinion that if this vast army of defectives had had 
the right kind of early training there would now be 
few if any stammerers to contend with, and what is 
true of stammering is true of similar and allied ner- 
vous diseases. 

The remedial and curative treatment of atypical 
children is physicopsychical in character. It is an 
efifort to improve their condition through their physi- 
cal activities. 

The personality of the child is modified antl 
moulded by what someone has called the reflex 
infltienccs of its own acts and expressions. "To 
make any act or gesture or mode of speech or mo- 
tion habitual through deliberate repetition is to stim- 
ulate in the personality the appropriate moral quality 
or emotion of wliich sucii an act or gesture is the 
expression." 

The Japanese have a theory that for one to be 
what one would like to be, it is only necessary for 
one persistently to act the part, and according to 
this principle if we would have a child become po- 
lite, for example, and good, we have but to persist 
in the teaching of the principles of politeness and 
goodness, and encourage the child to practise them. 

Doing things with what Frankel has called "pur- 
poseful intent" is found to have a greater educa- 
tional value than doing shem carelessly or even in 
play. 

The play instinct is an important factor in child 
development, but at the present time is the most 
overworked of all, both in the home and in the 
primary school. 

What may be called the work instinct is equally 
important, and is now greatly neglected in the early 
training of children. 

The difference between play and work should 
be clearly understood by the child, and the greater 
dignity of the latter should be impressed upon his 
mind at an early age. 

The child should be taught to do things, not be- 
cause they are easy, but because they are right, and 
the greater the difficulty of doing them, the greater 
the educational value. 

Moreover, work and play should not be com- 
mingled, but should form two distinct factors in 
education. 

Mr. Roosevelt gave good advice when he said: 
"When you play, play hard, and when you work, 
don't play at all." 

Correct postural attitudes and good respiratory, 
phonatory, and articulatory habits should have a 
conspicuous place in all medicoeducational methods, 
because of their esthetic value and because they 
tend to give greater selfrespect, selfreliance, and 
self control. 

The training of speech is of special importance 
because of the close relationship between the so 
called mental faculties and the organs of phonation 
and articulation. 



GRIPPE PNEUMONIA. 

By Bevi;kli£y Robinson, M. D., 
New York, 

Emeritus Clinical Professor of Medicine, University Bcllcvuc 
Hospital Medical College. 

At this season we never read a daily paper with- 
out seeing the report of many deaths from pneu- 
monia. Many of these are due primarily to grippe. 
By avoiding^ or treating grippe efl:ectively, we can 
prevent intercurrent or succeeding pneumonia. If 
we cannot prevent it or cure it, in all cases, we can, 
at least, lessen its severity and prevent many cases 
of death. 

I know of no remedy at the present time equal to 
the salicylate of ammonium, when properly given 
in sufficient doses and at an early period. It should 
be given in capsules or solution, as preferred. 
When given in capsules it should be combined with 
caffeine and given every two hours. When given 
in solution it should also be combined with caffeine 
and a carminative like peppermint water and a little 
syrup of tolu, used as menstruum and corrective of 
slightly unpleasant taste. With young people it is 
preferable to use the solution. 1 have given hith- 
erto, as a rule, in beginning treatment of grippe two 
capsules every two hours, each capsule containing 
three grains of salicylate of ammonium and one 
quarter grain of caffeine. Five or six doses may 
ustially be given with good effects. Later, two cap- 
sules should be given every three or four hours. 

In all colds at the present time, I order these cap- 
sules because I am satisfied, whether they are due 
to grippe or not, the capsules are remedial and do 
no harm. 

As a preventive of grippe when it is prevalent, or 
when there is exposure to it, two capsules taken 
three or four times in twenty-four hours for twentj'- 
four or forty-eight hours, are desirable. Their use 
may often be supplemented with advantage, by giv- 
ing two grains of quinine at meal time, in a cap- 
sule. I prefer the muriate of quinine to the sul- 
phate, as it agrees better with a sensitive stomach. 
I do not combine quinine with salicylate of ammo- 
nium, because practically they do not seem to work 
well together, so far as being helpful in grippe. This 
I have found out by experience. Whenever I can 
do so, in the beginning of grippe, when the patient 
is suddenly attacked with chilly feelings, fever, de- 
pression, and cough, I make use of inhalations of 
beechwood creosote. I make use of the ordinary 
croup kettle, filled with water and kept simmering 
in the room, constantly for a while, sometimes for 
hours or days, depending somewhat upon the way 
it affects the patient and the nurse. The creosote 
may be dropped upon the surface of the water five, 
ten, or fifteen drops at a time, and renewed as re- 
quired or when the odor of creosote becomes slight- 
ly faint. The windows are kept open despite the 
use of the creosote, as fresh air is. very desirable. 
All drafts, however, are most dangerous. Besides 
being useful to the patient, creosote vapor in the 
room prevents all danger of the grippe or pneumo- 
nia being contracted by the nurse or relatives. 
Other than these no one should be permitted to en- 
ter the sickroom. For stimulants or heart tonics, 
there are only two worth considering — one is stro- 
phanthus, the other is old brandy. The strophanthiis 



KNOX: STREPTOCOCCEMIA IN EPILEPSY. 



should be given in small doses, one to two minims, 
even,- two or three hours, at the same time as the 
brandy. The latter may be given in doses from a 
teaspoon ful to a tablespoon ful in a very little water, 
or \ ichy water, ice cold. 

Whenever there is stomach or intestinal disturb- 
ance — -such as nausea and flatus, nothing equals 
Kirschwasser, made in Amsterdam from the product 
in the Black Forest, Germany. It allays these symp- 
toms as nothing else will and helps save life not 
infrequently. 

Too much interference with pneumonia patients 
is radically wrong. It is of no value to be listen- 
ing to the lungs frequently and determining the pre- 
cise march of the disease locally, at the expense of 
the patient's strength and vitality. In strong, ro- 
bust men, even when stricken with grippe pneu- 
monia, leeches applied locally over the liver or car- 
diac region, or a moderate bloodletting by venesec- 
tion, will save life when nothing else will. These 
are cases where an acutely dilated heart can- 
not withstand the increased blood pressure thrust 
upon it. But let me now warn every practitioner 
not to infuse saline solution after bloodletting. By 
so doing, we often destroy life where we might 
have saved it by letting well enough alone. 

The best remedy for the bowels, if need be, is 
cascara evacuant by the mouth, or one or more 
glycerine suppositories to unclog the loaded rectum. 
The nutriment should consist of fermented milk, 
beef juice, panopepton, light broth of chicken, or 
mutton, jelly, eggnog. curds, etc. In addition, a 
little hot, well made tea or coffee, is frequently val- 
uable. Dry champagne is also helpful, and oxygen 
inhaled frequently, without increased fatigue to the 
, patient, will lessen dyspnea and relieve cyanosed 
lips and extremities. 

With the foregoing treatment, carried out intelli- 
gently, many lives will be saved, and thus the "cap- 
tain of death" will have fewer victims, even among 
those who have passed the meridian of life. 

_|2 West THrRTY-SFVENTii Street. 



FAT.^L STREPTOCOCCEMIA IN AN 

EPILEPTIC. 

Due to Heinolyzing Short Chain Streptococci. 

By Howard A. Knox, M. D.. 
Skillman, N. J. 

.•\cting Clinical Director, New Jersey State Village for Epileptics. 

The following report is rendered because of the 
unusual behavior of Streptococcus brevis and the 
fulminating reaction it produced. The atypical fea- 
tures may in part be due to the fact that the pa- 
tient was an epileptic, for the reason, as everyone 
familiar with epilepsy can testify, that in those so 
afflicted ordinary medical entities are sometimes so 
distorted as to be unrecognizable by the iminitiated, 
and again many pseudoconditions are seen which 
simulate real pathological conditions ; indeed the 
medical anomalies seen in this disease would form 
the subject of a most interesting thesis. 

Our patient (case 2981) was admitted to the 
Henry M. Weeks Hospital, October i. 1916: he 



was a chronic epileptic of many years' duration, 
twenty-eight years old, and of unusually powerful 
physitjue. He gave a history of trauma of the 
right supraorbital region received about two weeks 
previously as the result of a fall during a seizure. 
The brow became swollen, red, and painful a few 
days afterward, and was incised transversely; a 
thin seropurulent fluid was obtained in small f[uan- 
tity, and for about four or five days he seemed to 
be improving and then suddenly the palpebral tis- 
sues and right supraorbital area became reddened, 
edematous, and painfvfl ; in this condition he was 
admitted to the hospital. 

October ist. — On admission he had an axillar>' 
temperature of 104° F.. and aside from the con- 
dition for which he was admitted, the physical ex- 
amination was negative, except for persistent con- 
stipation which is practically universal in epilepsy. 
His pulse was of low tension and 138 to the min- 
ute, his respiration was 40; he was considered to 
be in a dangerous condition and the last rites of 
the church were administered. He was given atro- 
pine grain i/ioo and strychnine sulphate grain one- 
thirtieth. One hour later streptoserobacterin (500,- 
000.000) was. injected into the subcutaneous tissues 
of the right forearm. The edematous right lid was 
freely incised and nothing but blood was obtained, 
the tissues being almost cartilaginous in consistence ; 
tincture of iodine and glycerin, equal parts, was ap- 
plied to the wound. The lids were retracted with 
difficulty and argyrol twenty per cent, and sterile 
petrolatum applied to the conjunctiva. Liquid diet 
was given. 

October 2nd. — The morning temperature was 
99.8° F. A saline laxative was ordered and the 
argyrol solution applied to the conjunctiva. At 4 
p. m. the temperature had reached 102.6° F. which 
was its maximum for that day. He was mentally 
clouded. He had one grand mal convulsion during 
the night. 

October 3rd. — The morning temperature was 
100° F. ; the eye could be opened, but the swelling 
was extending backward over the temporal muscle 
and there was carphologia and subsultus despite 
the relatively low fever. At 4 p. m. the tempera- 
ture was 104.2° (axillary) and the patient was in a 
noisy occupation delirium, evidently reacting to 
both auditory and visual hallucinations. This was 
controlled to some extent by sponging and alcohol 
rubs, but the most marked effect was obtained by 
colonic irrigation with cool water. 

October 4th. — At 8 a. m. the temperature was 
103.2° F. and could be reduced by sponging and 
fanning, The indurated, boardlike swelling was 
extending backward over the parietal bone and was 
tender to touch. Streptoserobacterin was again 
given (500,000,000) at 9:30 a. m. He was given 
calomel in fractional does followed by a saline with 
good effect. By 3 p. m. the right ear became enor- 
mously edematous, and the patient's face, hands, 
and feet were cyanosed. At 8 p. m. his tempera- 
ture was 106° F., and the nervous manifestations 
were again in evidence. The right ear and right 
side of face were painted with ichthyol and col- 
Ipdion, equal parts, and he was bathed and given 
colonic irrigations with unsatisfactory results. 



KNOX: SriiEFTOCOCCEMIA IN El'ILEl'SY. 



I New York 
Medical Journal, 



October 5ih. — At 8 a. ni. the temperature was 
102° ]■". and at 4 p. 111. it was 103'' F. The tissues 
were niarkedly distended and indurated on the right 
side of the head, and it was thought by a consultant 
that fluctuation was present over the right parietal 
eminence. A two inch incision was accordingly 
made, which extended to the calvarium, but abso- 
lutely no pus was obtained, only the same cartilagi- 
nous condition, and the scalp here was 3.5 cm. thick. 
The head was dressed with wet bichloride (one in 
5,000) dressings -and hydrotherapy continued. 

October 6th. — The morning temperature was 101° 
F., but it went to 105° at 4 p. m. and 106° 
at 8 p. m. Slow proctoclysis with normal salt solu- 
tion was used throughout the day, and dressings 
of this solution were used on the face and head, as 
hot as could be borne. The other side of the face 
and head became involved in the process, and he 
was given morphine sulphate grain one-half by 
mouth for the pain. This relieved the pain and 
produced sleep. 

October 7th. — Morning temperature 103° F. It 
went to 105° at 4 p. m. and to 106° at 8 p. m., 
which was practically duplicating the chart of the 
previous day. The proctoclysis was discontinued and 
the saline packs to the head were continued. Every 
effort was made to reduce the temperature, but the 
results were poor. It promptly went up as soon as 
active measures were discontinued. 

October 8th. — Morning temperature 100.6° F., 
evening temperature 105°. Pulse, 120 a minute and 
weak, thready, and intermittent. Respiration was 
24. The local process on the right side of the head 
was purplish and swollen more than ever, and the 
left eye was closed completely. Hot bichloride of 
mercury solution (one in 5,000) was substituted 
for the saline pack to the head. The mouth had 
to be frequently cleansed, as the tongue was brown 
and furred and the teeth were covered with sordes. 

October 9th. — Morning temperature 101° F. and 
evening temperature 104.4°. Two free incisions 
were made in the left ear, which was enlarged to 
at least twice its natural size. The patient was in a 
state of coma vigil. 

October loth. — The morning and evening temper- 
atures were practically the same as on the previous 
day. At about 8 p. m. the patient became almost 
pulseless and exhibited Cheyne-Stokes respiration, 
and the surface of the body was cold and moist. 
He was given strychnine grain one-thirtieth and 
atropine grain i / 100 hypodermically, and black- 
coffee by rectum. One thousand c. c. of physiologi- 
cal salt solution were also given intravenously under 
strict asepsis by the left median basilic veiru The 
result from this treatment was most remarkable. 
In fifteen minutes he had a severe chill which lasted 
for from ten to fifteen minutes, the respiration in- 
creased in depth and regularity, and he passed forty 
ounces of urine and had a copious bowel movement. 
At midnight he was reported by the nurse as "much 
better." 

October nth. — The morning temperature was 
normal for the first time since admission to the hos- 
pital ; the patient regained consciousness and seemed 
in every way better. At noon he had suddenly a 
profuse hemorrhage of bright, red blood from the 



bowel ; his jnilse became weak and rapid. Opiates 
were given and the hemorrhage apparently subsided. 
He became stronger toward night and the tempera- 
ture went only to 101° V . in the evening. 

October 12th. — The patient became weaker again 
through the night, and in the morning was noted to 
be in extremis. He expired in spite of our efforts 
shortly before 10 a. m., and his temperature at death 
was 104.6° F. He was cyanotic and lemon yellow 
at the time of death. 

One half hour before he expired, a blood smear 
was prepared and blood cultures were made on the 
medium used by Schottmiiller, two parts of human 
blood to five parts melted agar. The blood used for 
the smears was a part of that taken from the median 
cephalic vein of the right arm with a small sterile 
record syringe for the blood cultures. It was spread 
on slides and after drying was stained with Wright's 
blood stain ; the findings were interesting. In fifty 
immersion lens fields there were fourteen leucocytes, 
and of these one was a poorly developed polymor- 
phonuclear leucocyte and all the others were small 
lymphocytes. There was considerable change in the 
erythrocytes ; most of them were small, and they not 
only varied in size but in shape ; there was polychro- 
matophilia and basophilic degeneration. The most 
interesting observation in the smear was the pres- 
ence in every field of from two to eight or even more 
round, blue, reticulated, nonnucleated bodies, about 
half the size of a normal red cell. They were not 
platelets or "blood dust." I called in my associates, 
but we were unable to identify them. It is possible 
that they were atypical white cells. There were no 
bacteria observed in the smear. 

In describing the blood cultures it will be best 
perhaps to go into some detail as to procedure. The 
media used were nutrient broth, Dunham's p)eptone, 
plain agar, and blood agar, and all were sterile ex- 
cept the last, and a description of the preparation of 
this alone will be given. The blood used in making 
this medium was obtained by Dr. Dan S. Renner 
and myself from a case of cerebral congestion in an 
elderly man afflicted with chronic interstitial nephri- 
tis, who had had one attack of cerebral hemor- 
rhage about a year previously. This man was not 
an epileptic. The ann was washed with alcohol and 
the area over the right median cephalic vein was 
painted with tincture of iodine. A seventy-five c. c. 
record syringe, platinum needle, and connecting tube 
were carefully sterilized, and the hands of the oper- 
ator were surgically clean ; the field was made asep- 
tic with sterile towels. The right median cephalic 
vein was punctured and sixty c. c. of blood with- 
drawn and deposited in a warm sterile flask. The 
operation was repeated on the right median basilic 
vein and also on the left median basilic until 190 c. c. 
of blood were obtained. Clotting prevented our ob- 
taining enough blood from one vein, and we did not 
wish to use oils, paraffin, hirudin, or other artificial 
means of preventing coagulation. The flask was 
agitated and shaken in a water bath at 35° C. for 
fifteen minutes and then placed in the ice box for 
forty-eight hours. A specimen was cultured when 
it was obtained to insure sterility. The agar was 
prepared in the usual way, except for its reaction. 
One thousand c. c. were made up. Beef extract. 



OLIVER: GENERIS. 



103 



Witte's peptone, and sodium chloride C P. were 
used. Three samples of five c. c. each of the melted 
agar were boiled with forty-five c. c. of distilled wa- 
ter and after adding five drops of 0.33 per cent, phe- 
nolphthalein solution to each, they were titrated with 
X/20 ammonium hydroxide ; the average amount 
of the latter required to produce a faint pink was 
0.5 c. c. 

The medimii was allowed to retain that reaction 
and no alkali was added. The blood was quickly 
brought up to a temperature of 45° C. and two parts 
of it were added to five parts of the agar at the same 
temperature. The mixture was filtered in sterile 
filters, containers, and tubes under applied heat, and 
after tubing had been completed the loaded tubes 
were autoclaved under low pressure for one half 
hour. Controls have remained sterile. 

This blood agar was inoculated from the sterile 
record syringe which was used to obtain the blood 
from the patient. The blood, 0.5 c. c. to each tube, 
was allowed to strike the surface of the agar and 
flow down into the water of condensation at the 
lower surface of the slant. The tubes were incu- 
bated at 38° C. (fever temperature) in an automatic- 
ally regulated electric incubator. 

At the end of the twenty-four hours six colonies 
appeared on the dry surface of one slant and two on 
another. They were about 0.5 mm. in diameter on 
an average, and gray in color, faintly tinged with 
green. They were circular in outline, the edges 
were smooth and even, and the surface was slightly 
convex. At the end of forty-eight hours they had 
increased in size and showed a marked tendency to 
coalesce. The patient's blood in the water of con- 
densation showed hemolysis and the phenomena ex- 
tended down into the media and faded off at a depth 
of one cm. At the end of seventy-two hours hemo- 
lysis extended throughout the lower part of both 
tubes. Smears made at the end of twenty-four 
hours and stained with Kiihne's methylene blue 
showed small cocci in chains of three to six. and 
many were single or in pairs. At the end of forty- 
eight hours they were practically all in short chains 
and larger in size. At the end of seventy-two hours, 
involution forms began to appear. The strain has 
been retained and its pathogenicity will be deter- 
mined for laboratory animals. 

No necropsy was permitted, but it is supposed 
that the enteric hemorrhage was due to a local py- 
emic process. Streptococcus mitior or viridans, a 
short chained organism, usually produces small 
green colonies and ver\' little hemolysis. 

I wish to thank Dr. Dan S. Renner, first assistant 
physician, for his generous assistance and advice. I 
also wish to thank Dr. David F. Weeks, superin- 
tendent, for his kind encouragement and permission 
to report the case. 

BIBLIOGRAPHY. 
:. SCHOTTMULLER: Minchen. med. Wochnschr., p. 849, 1903. 

2. GORDON: Reports Med. Officer Local Gov. Board, p. 388, 1903. 

3. AXDREWES and HORNER: Lancet, ii, p. 1400, 1905. 4. PUE- 
DIGER: Ibidem, ii, 1906; Journ. Infect. Diseases, iii, p. 755. 
t. BESREDKA: BuU. de I'Inst. Pasteur, iii, 6. NIETER: Ztschr. 
f. Hyg., Ivi. p. 307, 1907. 7. MANDELBAUM: Ibidem, Ivii, p. 26, 
1907. S. LEVY: Arch. f. path. Anat., ccxxxvii, p. 327, 1907. 
9. Centralbl. f. Bakteriol. «. Parasitenk., I, xliii, p. 793, et seq, 
(hemolytic properties). 

271 Avenue C, Bayonne, N. J. 



GENERIN. 

The Agent which both Induces AIe)ustruation and 
Starts Gestation, 

By James Oliver, M. D., F. R. S. (Edin.), 

London, 

Gynecologist, London Hospital for Women; Consulting Gynecologist, 

Ilford Emergency Hospital, Essex. 

In consequence of statements which from time to 
time have appeared in books, there has prevailed and 
still even today prevails the belief that women who 
have never menstruated and who are incapable of 
menstruating, but who are physically fit to five a- 
marital life, have and may nevertheless become 
pregnant. I am quite confident, however, that such 
statements originated and have been disseminated 
inadvertently through some error of judgment and 
carelessness in the investigation and interpretation 
of the facts. 

Most medical men who have been actively en- 
gaged in practice for any length of time, have come 
across patients who never menstruate while bearing 
children purely and simply because the recurring 
conceptions have taken place in spite of lactation 
and while the menstrual function was held in abey- 
ance by the mammary activity, or have had again 
patients who became mothers although they seldom 
menstruated at all. In both these cases, however, 
the uterus was capable of menstruating, and because 
it was capable of displaying the phenomena of men- 
struation, it was fit to harbor and carry to maturity 
a fertilized ovum. 

In hospital and private practice I have seen alto- 
gether nine patients of ages ranging from twenty- 
four to fifty years, who were actually living in wed- 
lock and who were physically fitted to five a marital 
life, but who had never even once menstruated. 
Three of these had married at an age when concep- 
tion was possible, but had already reached the rec- 
ognized menopausic age before coming under my 
observation, and not one of these had ever been 
pregnant. The remaining six continued under my 
care for three or more years, and during this time, 
in spite of well directed treatment, none of these 
ever menstruated and none ever became pregnant. 
Now we may very reasonably assume that ovulation 
occurred at least occasionally in some of the aforesaid 
cases, considering that I detected Graafian follicles 
in the ovaries which I had occasion to remove from 
an unmarried woman aged twenty-nine years, who 
was physically fitted for hving a marital life and 
who had never once menstruated. As, moreover, 
it is practically impossible to allow that all the hus- 
bands of the nine married women referred to were 
impotent, we are undoubtedly justified in conclud- 
ing that a woman who is incapable of menstruating 
is also incapable of conceiving. 

Discoursing on the purpose of the menstrual loss 
in his work, the Science and Practice of Midwifery. 
Playfair sums up the full extent of our knowledge 
thereon in the following terms: 

The cause of the monthly periodicity is quite unknown 
and will probably always remain so. The purpose of the 
loss of so much blood is also somewhat obscure. To a 
certain extent it must be considered an accident or com- 
plication of ovulation produced by the vascular turgescence. 
Nor is it essential to fecundation, because women often 



I04 



OLIVER: GEN ERIN. 



[New York 
Medical Journa 



cuiiccive during lactation when menstruation is suspended 
or before the function has become estabhshed. It may, 
liowever, serve the negative purpose of relieving the con- 
gested uterine capillaries, which are periodically hlled with 
a supply of blood for the great growth which takes place 
when conception has occurred. Thus immediately before 
each period, the uterus may be considered to be placed by 
the atliux of blood in a state of preparation for the func- 
tion it may be suddenly called upon to perform. 

This is truly a fair sample of the vague uotions 
which up to tile present time ha\e existed and found 
place in our textbooks regarding the meaning and 
purpose of menstruation, but they will be forever 
banished so soon as we realize that (jencrin, the oxi- 
dizing agent which is responsible for the induction 
of the oxidative processes connected with menstru- 
ation, is the same oxidizing agent which is essential 
for starting gestation. 

Already on several occasions I have, both in Brit- 
ish and American inedical periodicals, adduced well 
considered and incontrovertible clinical facts in sup- 
port of my contention that menstruation is a secre- 
tory jihenomenon — evidence which squashes wholly 
and renders absolutely untenable the hypothesis that 
the menstrual discharge is blood poured out by 
capillary vessels which hjive been opened into as a 
result of a more or less extensive degeneration and 
disintegration of the lining membrane of the uterus 
Hitherto I have never even touched upon the strong 
presumptive evidence in favor of the menstrual dis- 
charge being a secretory product rather than mere 
blood poured out by disrupted capillaries furnished 
us by the very great differences so patent to every 
one in the physical characters, the color, the odor, 
and the mobility of the menstrual discharge, not 
only in different individuals, but in the same indi- 
vidual at different times. In connection with the 
])eriodical secretory activity of the uterus, however, 
it must be borne in mind that capillary hemorrhage 
may accidentally occur because the endometrial 
capillaries are large and very tliin walled, and rup- 
ture on the slightest provocation. Hence we find 
it is altnost impossible at any time to pass a blunt 
sound into a normal uterus without causing some 
hemorrhage. 

It is now a well established fact that during the 
two or three days prior to and in anticipation ol 
menstruation, there is an increased determination of 
blood to the internal organs of generation, an in- 
crease which is gradually induced and reaches its 
maximum just as menstruation is about to take 
place. This heightened vascularity is brought about 
by the vasodilatory action of the agent, generin, and 
is necessitated by the greatly increased demand for 
oxygen inade by all glandular cells during activa- 
tion. During secretory activity, as is well known, 
the cells require probably four times the amount of 
oxygen that they do during the resting stage, and 
the source of the energ)- involved in the production 
of the menstrual discharge is an oxidative process 
occurring in the cells of the uterine glands. I ven- 
ture to suggest too that generin, like pilocarpine in 
the case ofthe submaxillary salivary- gland, exerts 
its influence either on the uterine gland cells them- 
selves or on the nerve endings in these cells, and 
that the vasodilatation in preparation for the in- 
creased oxidation which is to take place during se- 
cretory activity, is brought about by the direct action 



of the generin on the vessels. That this is so is in 
my opinion incontestably supported by the fact that 
the reflex dilatation of the vessels in the generative 
tract which results during sexual intercourse, nei- 
ther hastens the onset of menstruation nor yet re- 
establishes tli(^ menstrual discharge under ordinary 
physiological conditions once it has ceased. 

The mere fact that menstruation may be sudden- 
ly arrested and even suspended for a greater or less 
length of time by physical or mental shock sustained 
while menstruation is progressing, does not in any 
way militate against the aforesaid theory of the 
action of generin. 

We have, moreover, the very strongest clinical 
reasons for believing that the agent, generin, not 
only penneates the ovary, the Fallopian tube, and 
uterus, but is produced in each of these structures, 
and that the unity of these structures in its produc- 
tion with a dominating influence emanating from the 
ovary, is necessary for its activity. Regarding the 
chemical nature of this generin, I am not yet in a 
position to express an opinion, but in the manifes- 
tation of its activity iron undoubtedly plays a most 
iuiportant role, for we know that menstruation, 
which is not infrequently restrained in chlorosis — 
a disorder in which each red blood corpuscle and 
each cell of the uterus has less hemoglobin than it 
should have — becomes reestablished as the iron con- 
tent of the body becomes reinstated under the judi- 
cious administration of some inorganic preparation 
of iron. 

The energetic oxidizing powers of generin, which 
are probably not unlike those of nitric oxide with 
sulphurous acid, are expended, however, only on 
the production of menstruation in the absence of a 
fertilized ovum, as the latter is a much more pow- 
erful acceptor of oxygen than any group of adult 
cells can be. Menstruation thus becomes suspend- 
ed whenever the energies of generin are used wholly 
in starting gestation, and this, as I have on previous 
occasions pointed out, happens invariably during 
the two or three days prior to an expected menstru- 
ation. 

Up to the present time clinicians, in reckoning the 
duration of gestation, and embryologists in tabulat- 
ing and depicting the various changes attributable 
to definite stages in the development of the human 
embrj'o and fetus, have been content to base their 
calculations upon the date of the cessation of the 
last menstrual period just as though fertilization al- 
ways took place immediately after menstruation, and 
gestation followed immediately upon fertilization ; 
assumptions which are in direct opposition to clin- 
ical facts and which can never have been considered 
sound. Balfour {Comparative Embryology, ii, p. 
265) says: "Our knowledge as to the early devel- 
opment of the human embryo is in an unsatisfactory 
state." Hertwig {Textbook of the Embryology of 
Man and Mammals) says : "A little, although very 
scanty information has been acquired, but this con- 
cerns only the second and subsequent week. A 
small number of ova have been described in the lit- 
erature, which for the most ])art have come froin 
miscarriage, and the age of which has been esti- 
mated at from twelve to fifteen days." Hertwig 
(Fig. 141. loco citato) depicts even a htiman embryo 



OLIVER: GENERIN. 



105 



with yolk sac, amnion, and belly stalk of fifteen to 
sixteen days after Coste from His. Quite inciden- 
tally I would here remark, that as no woman ever 
considers that she can possibly be pregnant and no 
medical man is ever suspicious of the existence of 
uterine gestation, until and unless a menstrual pe- 
riod has been missed, and as, moreover, we have no 
knowledge of abortion occurring earlier than four 
teen days after a menstrual period has been missed, 
it is difficult to understand how it ever will be pos- 
sible to reconcile such a statement as that of Hert- 
wig's w'ith our every day clinical facts. Again, 
Keith (Human Embryology and Morphology, third 
edition) says: "It is difficult to estimate the pre- 
cise age of an embryo or fetus, because the exact 
date at which fertilization occurred can, as a rule, 
be only guessed. It is usual to presume it occurred 
soon after the last menstruation, for conception ar- 
rests the process of menstruation." Now the arrest 
of the process of menstruation as a consequence of 
gestation, it must be remembered, is itself an event 
which may be separated from that of fertilization 
by even more than three weeks. 

For a comparative study of the phenomena of 
germination, incubation, and gestation, we are 
forced to the conclusions : a, That fertilization does 
not convert the ovum from a nonvital to a vital sub- 
stance, although it appears nevertheless to endow it 
with the power of life ; b, that the oosperm is abso- 
lutely incapable of starting its own life and requires 
to be influenced and acted upon by some agent out- 
side itself before it becomes a living body ; c, that 
the process of gestation does not necessarily begin, 
as embryologists would have us believe, immediately 
fertilization has taken place. In support of these 
pronouncements, and to enable us the better and 
more readily to understand the action of generin as 
the starter of gestation, let me cite some well estab- 
lished facts connected with the germination of seeds 
and the incubation of the bird's egg. 

Cereal seeds, it is alleged, after having lain dor- 
mant in the Pharaoh's tombs for thousands of years, 
have germinated when placed under favorable con- 
ditions. Such statements may or may not be reli- 
able, but whether they are true or not, we most as- 
suredly do know that the seeds of barley, wheat, and 
oats are fully capable of germinating after having 
been preserved under ordinary general conditions 
for ten and even more years. All seeds, however, 
do not withstand equally well the efifects of desicca- 
tion, for it has been obser\-ed that rye seeds lose 
more quickly the power of germinating than most 
of the other cereal seeds. It is notew-orthy, too, 
that seeds buried at great depths in the ground have 
been known to lie there dormant for a great number 
of years without losing the power of germination, 
for they have germinated when tossed up in the 
same ground and brought nearer the surface where 
they could be influenced and acted upon by the sun's 
rays. Again, the spores of certain fungi are unable 
to germinate unless subjected to certain chemical 
stimuli. Hence the spores of Merulius lacrymans 
will germinate only in alkaline media, and those of 
Onygena equina only after being subjected to the 
action of gastric juice. For available facts it is 
quite evident that the enzyme which in the cereal 



seeds starts the oxidative processes connected with 
germination, requires not only moisture, but the aid 
of the sun's heat and light rays, and we have good 
reason to believe, moreover, that the activity of the 
oxidizing enzyme outlasts the germinating propen- 
sity of most seeds. 

To all, even the uninitiated, it must, therefore, be 
very obvious that the cereal seed at least does not 
forthwith burst into life merely because it has been 
fertilized, and that the cereal embryo has neither the 
power to start its own life nor the power to evince 
any of the recognized signs of life until and unless 
oxidation has been started in it through the agency 
of an oxidant the activity of which in turn is de- 
pendent uport well defined external conditions. 

What is true of the cereal seed is equally true of 
the animal egg, and so far as the points just enun- 
ciated relate to the animal world, the knowledge 
which we glean from the behavior of the egg of the 
common barnyard fowl is that which is most reli- 
able and will best suit our purpose. 

In the freshly laid fertile, but as yet unincubated 
hen's egg, the germ mass is hterally a colony of cells 
possessing, but not yet showing any of the signs of 
life. That every living thing respires will readily 
be conceded. Now for respiratory purposes the 
calcareous shell of the bird's egg is porous and per- 
vious to gases, but as the unincubated egg is not yet 
the abode of a living entity, it does not respire, and 
if left exposed purely and simply to the tender mer- 
cies of the atmospheric air, it will never respire, but 
will most assuredly undergo decomposition. In or- 
der that intracellular respiration in the germ mass 
may be started, the egg must be subjected to a con- 
tinuous and fairly steadily maintained temperature 
of about 100° F., and the atmosphere around it must 
have more or less moisture. If we attempt to incu- 
bate the hen's egg in a too confined space, or var- 
nish the shell and thus interfere with its permea- 
iiility, the embryo will perish, and it will likewise 
die if incubation is attempted in an atmosphere in 
which there is no oxygen. In clumps of frog's 
spaw-n, it has often been observed that the eggs sit- 
uated in the centre of the mass never develop be- 
cause oxygen cannot get at them. 

I would here remark that, although the hen's egg 
contains a large amount of water and an air space, 
yet for successful incubation the air surrounding it 
must be more or less moist, a fact which would seem 
to indicate that ionization of the atmospheric oxy- 
gen is effected by the oxidant which acts as an in- 
termediary betw-een the air and the germ mass. 

Now it is common knowledge that eggs need not 
necessarily be incubated immediately they are laid, 
and that eggs fertilized on different days — with a 
known difference even of ten or twelve days — may 
be incubated together and will hatch out on the 
same day. 

Regarding the human female we have abundant 
and incontestable clinical evidence that fertilization 
may take place at any time during the intermen- 
strual period, except during the two or three days 
immediately preceding an expected menstruation. 
In support of this contention I would adduce the fol- 
lowing facts : It sometimes, for example, happens 
that a w-oman w^ho marries six or seven days before 



io6 



WOIIL: GRANULOMA PYOGENICUM. 



[New York 
Medical Journal. 



an expected menstruation conceives forthwith, and 
the lirst expected menstruation after marriage is 
consequently suspended; or, again, we not uncom- 
monly are confronted with the case of the woman 
who marries immediately after a menstrual period 
and whose husband, because of his vocation in the 
navy or the mercantile marine serv'ice, lives with his 
wife only a few days after marriage before he is 
compelled to leave her, and she nevertheless con- 
ceives, and in her case, too, the first expected men- 
struation after marriage fails to make its appear- 
ance. Or take again the strict Jewess, who observes 
devoutly the Mosaic law, and who so soon as she 
comes "unwell" renounces intercourse until she has 
been able to number seven clear days ffom the day 
of .the cessation of the menstrual discharge and has 
had her prescribed bath. It is a most noteworthy 
fact, too, that the strict and devout Jewess ever 
since the time of Moses has not been one whit less 
prolific than her gentile sister, who in her relation- 
ships with her husband follows her own inclinations. 
Now no matter when fertilization may probably 
have taken place, whether soon after the cessation 
of menstruation or shortly before an expected pe- 
riod, in no case is it possible to diagnose the exist- 
ence of uterine gestation earlier than fourteen days 
after the first menstrual period has been missed, and 
it is an indisputable fact that in every case of nor- 
mal pregnancy at this stage the uterus is one and a 
half time the size of the unimpregnated uterus. Here, 
then, we have the strongest possible proof that 
gestation begins invariably at a definite and fixed 
time, and as during the autogenetic resting stage 
the oxidative processes going on in the internal gen- 
erative organs are moderate in amount and continue 
so until two or three days before an expected pe- 
riod, when they become energetic, we have every 
reason to believe that it is at this time that gesta- 
tion begins. In anticipation of menstruation, as I 
have already stated, there is an increased determina- 
tion of blood to the internal organs of generation, 
because during the actively functioning period more 
oxygen is required than during the autogenetic rest- 
ing stage, which is an inherited property. This 
heightened vascularity, as we have observed, is 
brought about by the chemical agent, generin, an 
oxidizing substance whose function primarily is to 
start oxidation in a fertilized ovum if it should 
chance to be situated in the internal generative tract, 
but which otherwise expends itself on the glandular 
cells of the uterus and induces menstruation. 

It is very evident, therefore, that the fertile hu- 
man egg, no more than the fertile bird's egg or the 
fertile cereal seed, has power to start its own life, 
but requires the mediation of an oxidant to start 
intracellular respiration. The facts which I have 
just enunciated, unless they can be satisfactorily 
controverted, prove conclusively that the human 
embryo which is obtained fourteen days after the 
first menstrual period is missed, is not five or six 
weeks old, but merely sixteen days old, and that the 
ages of the various embryos depicted in books are 
purely fictitious reckoned, as they are, from the date 
of the cessation of the last menstruation and on the 
assumption that gestation follows fertilization im- 
mediately. 

T23 Harley Street, W. 



GRANULOMA PYOGENICUM.* 

By Michael G. Wohl, M. D., 
Omaha. 

(From Pathological Dept., Nicholas Senn Hospital.) 

Granuloma pyogenicum is too often mistaken by 
the clinician for chancre or a malignant growth, and 
not infrequently the pathologist makes a diagnosis 
of sarcoma. The recognition of the condition is 
important, and therefore a brief consideration of 
the subject is of 
sufficient interest to 
warrant the publi- 
cation of two cases 
that came under 
our observation at 
the Nicholas Senn 
Hospital during the 
last year. 

Case I. P., boy 
eight years old. 
S ma.l 1 bright red 
growth developed on 
the lower hp, about 
one cm. from the 
mucocutaneous junc- 
tion. The tumor grew 
gradually until it 
reached the size of a 
half pea. The nodule 
was excised, but re- 
curred six months 

later, when patient Fig. i (Case I). — Granuloma pyo- 

was brought to the genicum of the lip. 

Nicholas Senn Hos- 
pital. At this time the tumor had a dark brown appear- 
ance; the edges were indurated. It appeared to be sur- 
rounded by a collar, through which it popped up (Fig. i). 

The tumor was completely excised; no recurrence re- 
ported. 

Pathological report. The tumor was the size and shape 
of a pea, of dark brown appearance. Histologically it 
was made up of connective tissue, which was interspersed 
with a great number of embryonic thin walled bloodvessels, 
having in places the appearance of an angioma. In the 






■■•■ ''-■■yi^"' ^^'' ' *" 



■-'i^Mi 



Fig. 2. — Photomicrograph, low power, showing embryonic blood- 
vessels and distinct round cell infiltration. 

Stroma and around the bloodvessels there was a pronounced 
round cell infiltration. The surface epithelium of tumor 
was not altered (Figs. 2 and 3). 

•Read before the Botna Valley Medical Society, Atlantic, Iowa, 
August 24, 191 6. 



January 



HAYNES: GIANT VENTRAL HERNIA. 



107 



The clinical appearance of the lesion was like 
chancre, but the induration was less, and the tribu- 
tarj- lymph nodes were not indurated. The fact that 
the tumor recurred after excision made us think of 
malignancy (sarcoma), but, although there are re- 
corded cases of sarcoma on the lip in very young 
children, yet the condition is of great rarity. The 
microscopical study of the tumor revealed its true 
nature. 

Case II. Mr. M., aged titty years, had noticed a small 
nodule near the outer angle of left eye. In a short time 
it broke down. He was treated by x ray for a year for 




though trauma is generally supposed to play a part 
in the production of the lesion, in our cases no such 
history- could be elicited. 

The staphylococci become first implanted in the 
intima of bloodvessels as a result of which granula- 
tion tissue forms (10). This fact explains why 
recurrence follows incomplete excision without cau- 
terization. Although many terms have been used 
in literature to describe the condition, granuloma 
pyogenicuni, as suggested by Hartzell (11), we be- 
lieve, is the most appropriate, since it designates the 
exact nature of the disease. 




rodent ulcer without benefit, and the ulcer increased in size. 
When the patient was admitted to Nicholas Senn Hospital, 
the tumor presented a reddish appearance ; it was indurat- 
ed, but not to the same extent as in carcinoma. There was 
no tenderness. It had, however, the tj'pical appearance 
of granuloma pyogenicum, the tumor resembling a lead 
pencil stuck through a piece of paper. 

The tumor was completely excised and there was no re- 
currence (Fig. 4). 

Histologically, there was distinct hypertrophy of the 
epithelium, but no malignant alteration was observed. 
There was a great abundance of newly formed blood- 
vessels with pronounced round cell infiltration (Fig. 5). 

This case was 
diagnosed and 
treated as rodent 
ulcer. The fact that 
the patient was not 
improving under x 
ray made us suspect 
sorne other condi- 
tion, and microsco- 
pically we proved 
it to be granuloma 
pyogenicum. Gran- 
uloma pyogenicum 
is caused by a sta- 
phj-lococcus of low 
virulence. This was 
first established by 
Sabrazes and Lau- 
bie (8), and later by Bodin (9). The lesion de- 
velops most frequently upon the fingers, feet, and 
face (6). It has also occurred on the lip, as re- 
ported by Poncet and others (i, 2. 3, 4, 5). Al- 




FiG. 4 (Case II). — Cranulo 
genicum of the face. 



The treatment consists in complete excision and 
cauterization of the base. Sutton (12) prefers to 
freeze the base with a hard pointed stick of Pusey's 
carbon dioxide snow. 

REFERENCES. 

I. PONCET: Rev. de chir., xviii, 1897, p. 996; Archives glnlralei 
de mid., iii, i9oo, p. 129. 2. SAVARIAUD and DEGUY: Gazette 
des kopitaux, November, 1900. 3. VALZER and A'LQVIE'R: Annales 
de dermat. et de syph., 1901, p. 479. 4. GILCHRIST: Journal 
Cutan. Dis., 1904, p. 524. 5. SUTTON; Journal A. M. A., May 
20, 1916, p. 1613. 6. BROCQ: Traiti ilimentaire de dermat. prat., 
i> 795, 1907- 7. WESTCOTT: Journal A. M. A., June 24, 1916. 
9: SABRAZES & LAUBIE: Archives gin. de mid., 1899. 9. 
BODIN: Annates de derm, et de syph., iii, 1902. 10. J. WILE: 
Journal Cutaneous Diseases. December, 1910. 11. HARTZELL' 
Ibidem, 1904, p. 520. 12. SUTTON: Ibidem. 



GIANT VENTRAL HERNIA.* 

Results and Technic of the Inversion {Author's) 

Method of Treatment, 

By Irving S. Haynes, Sc. D., A1. D., F. A. C. S., 

New York. 

While this method is particularly adapted to the 
treatment of the very large ruptures, it is equally 
simple and successful with the smaller ones, espe- 
cially those at the umbilicus with weak linea alba 
and separated recti muscles. From experience in 
twenty-two cases I feel justified in asserting that 
my method is simple, safe, and efifective. As to sex, 
there were five males and seventeen females. The 
youngest patient -was a man thirty years of age and 



*Read at a meetincr of the Soc 
Hospital, May 3, 1916. 



of the Alumni of Bellevuo 



io8 



IIAVNES: GIANT VENTRAL HERNIA. 



[New York 

Medical Journa 



Ihe oldest a woman of sixty-rive years. There have 
been no deaths, notwithstanding conditions of exces- 
sive obesity, coniphcated by strangulation of the 
intestine in two cases. The average weight of these 
patients is 200 pounds, several of them going much 
higher, up to 280 pounds at the time of the opera- 
tion. 

The hernia is usually postoperative, below the level 
of the umbilicus. Most of the hernias have existed 
for years, and operation was undertaken as a last re- 




FlG. 1. — Photograph of Case XI before operation. 

sort to secure relief from intestinal disturbance and 
the drag and pain of the rupture. The hernia, it 
self, varies in size from that of a large grape fruit 
to one as large as a "watermelon," as the historian 
in the Hartford Hospital described it. To express 
the size in inches, they vary from six to ten inches 
in diameter, and project from the abdominal wall 
from four to ten inches. The sac may be single, but 
is often multilocular. If a typical ventral, postoper- 
ative type, it may be complicated by a protrusion at 
the umbilicus above. The hernial orifice varies. It 
is usually a single large oval opening. My largest 
measured eight by five inches in its longest and 
broadest diameters. The actual size of these ori- 
fices are as follows : Case i, 8 by 4. Case v, 6 by 
2. Case VII, 7 by 4. Case x, 6 by 3. Case xii, 5 
by 2. Case xiii, 4 by 2. Case xvii, 4 by 3. Case 
xviii, 6 by 4. Case xix, 8 by 5. Case xxii, 6 by 4. 
While some of the remaining cases had single small 
orifices, others had two or even three separate open- 
ings, demanding a wide and long inversion. 

In many instances the omentum is found adherent 
to the sac. This does not present such a difficult 
complication as one might imagine. Provided the 
intestine is not attached to the sac and entangled in 
the omentum, I deal with such adhesions when deal- 
ing with the sac. In the large hernias the sac is 
excised, as a rule, about three inches from the her- 
nial orifice. If the omentum is attached to that por- 
tion of the sac excised, or, if it is firmly attached to 
the remaining portion of the sac, the omentum is 
clamped at the level of the incised sac and the distal 
portion severed, this being removed with the sac. 
Usually to the sac is attached a large elliptical mass 
of skin and fat. 

The raw edge of the omentum is now sutured be- 
tween the margins of the sac, when closing the latter, 
by a locked stitch of No. 2 plain gut, doubled. This 



stitch arrests all oozing. From such inversion, there 
has never arisen a single symptom. This method 
should be used, however, only in selected cases. The 
previous condition and present slate of the patient, 
as well as the situation within the hernial sac, must 
help to decide whether to treat extensive omental 
adhesions in this way or not. Usually the intestine 
has been free, or attached by adhesions of moderate 
extent. Such adhesions must be dealt with accord- 
ing to accepted technic. A little detail which I have 
found helpful is to excise a liberal portion of the 
sac in releasing the adherent intestine, then turn the 
raw surfaces of the excised portion of the sac to- 
gether and whip over the edge with fine gut. I have 
liad several very interesting experiences in dealing 
with intestines in mass adhesions. I will refer to 
two cases only. 

Case XI. A woman, sixty-five years of age, weighing 
230 pounds, the mother of eighteen children. She had had 
an immense hernia for twenty years. During the last five 
years it had been irreducible, and had been strangulated 
several times. She had worn a belt and hard rubber pad 
as large as a soup plate over the hernia for many years. 

When I was called to operate, in June, 1913, there had 
been fecal vomiting for twenty-four hours and she was in 
a desperate state. I found the intestines matted into a 
mass, fan shaped, two inches wide at the hernial orifice, six 
inciies at the free margin, and one and a half inch thick. 
From the long continued pressure of the truss and the 
frequent strangulations the intestinal loops were so ad- 
herent that no single loop could be discovered. Consider- 
ing the critical condition of my patient, that the fecal 
current had been able to pass through this mass for many 
years, and that the cause of the present strangulation — 
recent accession of intestine and omentum into the sac — 
had been relieved and the current might again resume its 
course, I split the hernial ring for several inches, returned 
the adherent mass of intestines to the abdominal cavity, 
and carried out the technic of my method for cure of the 
hernia. The result has been a permanent cure of the rup- 
ture with daily bowel action without pain, the first in over 
twenty years. 

Case XXII. A second instance is furnished by a pa- 
tient of Doctor Connors's. We found a great mass of 
small intestines adherent to each other and to the entire 
inner surface of the sac. These adhesions were recent, 
soft, vascular, and thick. They oozed freely. They were 
all severed, hot sponges were packed over the intestines 
until the first and second courses of sutures had been in- 




FiG. 2.— Case XI. Photographed Fig. ■ 3.— Same patient as in 
eleven months after operation. Figure 2. 

serted, then, when the sac was ready to be closed, the 
sponges were removed and half an ounce of sterile petro- 
latum was rubbed over the entire mass. The operation was 
finislied in the usual way, picture wire being used for the 
last row of retention sutures. The patient did not have a 



January 20, 1917.] 



HAYNES: GIANT VENTRAL HERNIA. 



109 



single symptom, 
ever since. 



The bowels acted on the fifth day and 



As stated in my first communication upon this 
subject, this method by which I have treated many 
immense hernias was forced upon me in September, 
191 1 (i). The case was that of a woman who 
weighed over 225 pounds and who measured more 
than four feet about the abdomen at the center of 
the hernia. The hernial orifice measured eight 




F'c. 4. — Photograph o* Case 
the prevailing type of patieni 
patient, the hernia is almost bu 



XXII, before operation, illustrating 

and post(jperativc hernia. In this 

■ied in four inches of adipose tissue. 



inches vertically and four inches at its widest part. 
The protrusion was as large as a child's head. The 
usual flap splitting operation had been contemplated, 
but owing to the terrific expiratory- efiforts of the 
patient when under the anesthetic, I dared not open 
the sac, and determined to attempt a cure by total 
inversion of the sac, its contents, and the adjacent 
abdominal wall. This was accomplished by the tech- 
nic to be presently described. The course of the 
case was uneventful and the result was a perma- 
nent cure. 

In a review of the literature I find that the first 
attempt at the inversion of the sac, in a surgical 
manner, was by Edebohls (2). He said he was the 
first to attempt the inversion of a hernial sac with- 
out opening it. The similarity between his and my 
methods ceases here, for he formed flaps along the 
denuded margins of the recti muscles and sutured 
these flaps in separate layers. Doctor Polk (3), 
three years previously, had stated in a discussion 
"that it ought to be possible to unite the fascia with- 
out opening the peritoneal cavity." I find no record 
that he ever devised a technic for this purpose. 

So far as I can determine, no operator has at- 
tempted to secure relief of the hernia by the method 
which I have been using; that is, by inversion, coap- 
tation, and union of the abdominal wall adjacent to 
the hernial margin. I am aware that this method 
is contrary to the generally accepted teaching and 
practice, that there must be layer coaptation of the 
separate strata of the abdominal wall. My first at- 
tempt was attended with many misgivings. So much 
time has now passed, however, and the results of my 
fir^t and subsequent operations have been so satis- 
facton-, that I feel that I can confidently affirm the 



reliability of my method. So far as I can deter- 
mine, there have been relapses in two cases, viii and 

XVII. 

The first, Case viii, was presented about a year 
ago to a medical society as cured, which was the 
condition at that time. This is the patient who suf- 
fered infection at the original operation from lacer- 
ation of the intestine while extensive adhesions were 
l)eing separated. Profuse and long suppuration fol- 
lowed, but healing eventually took place with a thin 
but firm scar. She tells me that during the past 
winter she had a very severe cough and neglected to 
wear her abdominal belt. On examination there was 
a protrusion the size of half an English walnut, 
through an orifice half an inch in diameter, about 
two inches to the outside of the inversion scar 
Whether this case can properly be called a relapse 
is a question, but it is placed on record as such. 

Case xvn was that of a patient upon whom two 
operations were performed, the second for a recur- 
rence of the hernia due to the breaking of rotten 
linen sutures, used for retention purposes, before the 
expiration of five days. A return of the hernia was 
expected, and when it became evident a second oper- 
ation was performed. The patient had a severe 
cough through the entire convalescence, owing to a 
severe cold she caught the day before the second 
operation. We did not know of this until after the 
operation. Notwithstanding the cough, I hoped for 
a cure, as all the sutures apparently held. A hernia 
recurred in the lower third of the area operated in. 
The protrusion was not large and could easily be 
repaired. 

I shall not discuss tlie various other operations for 
the cure of this type of hernia, except to say that 
their general plan depends upon extensive flap for- 
mation with layer to layer or overlapping suturing ; 
either alone or combined with no less extensive mus- 




cle and fascia sliding ; or by fascial grafting ; or by 
the reinforcement of such areas by the use of vari- 
ous wire filigree screens. Those familiar with these 
methods are fully aware of the great technical diffi- 
culties involved in the formation of suitable flaps, 
their correct apposition, and disappointments in 
healing. 



IIAVNES: GIANT VENTRAL HERNIA. 



(New YokK 
Medical Journal. 



THE author's inversion METHOD FOR TREATING 
GIANT ABDOMINAL HERNIA (4). 

Large elliptical incisions expose the sac, which, 
with the external fascia of the abdomen, is cleansed 
for more than two inches beyond the hernial orifice. 

If the sac is to be left practically intact^ the ellip- 
tical portion of skin must be dissected cleanly away.' 



three fourths of an inch and are half an inch apart. 
Then the sac is closed, and this first row of mattress 
sutures tied — first above and then below until all 
have been tied. I use three knots in all these su- 
tures. By this first series of sutures the bulging 
mass of sac, also the omentum, if present, is inverted 
into the abdominal cavity. A second row of the 
same suture material is placed one inch outside the 
first row so as to "break joints." 

Retention sutures are next inserted. These are 




KiG. f-' — A sectional view of hernia. The content.^ ; 
regarded; the construction of the sac is the important feature. The 
different structures are lettered the same throughout: a. Skin. b. 
Suhcutaneous tissue, c. External fascia covering the abdominal 
muscle.s. d. Muscular layer, e. Internal muscular fascia and peri- 
toneum. 

Usually, however, the portion of sac corresponding 
to the elliptical mass of skin is removed with the lat- 
ter, thereby freely opening into the peritoneal cavity. 
Complications are dealt with in the usual manner. 

In my experience, the intestine can be freed and 
any raw spot covered with omentum. Extensively 
adherent omentum need not be freed from the sac 
unless it seems to be exercising a deleterious trac- 
tion on the intestine and stomach. The excess of 
omentum, usually very thick and adherent, may be 
trimmed off at a suitable point and the peritoneal 
cavity closed by uniting the edges of the sac with 




Fig. 7. — ^The figures 7 to 10 inclusive depict the steps in the 
operative treatment when the sac is not opened. This shows 
the skin dissected from the thin sac and the skin and sub- 
cutaneous tissue dissected bacK from the hernial orifice so as to 
leave a wide margin of the adjacent fascia cleanly exposed. The 
first suture, to take up Ihe slack or fullness in the sac, is shown. 
This suture is often omitted. 

this adherent omentum between, by an overcasting 
suture of No. 2 plain gut. Interlocking the stitch is 
sufficient to arrest oozing from the omentum. 

Before the sac has been closed the first row of the 
inverting sutures of heavy kangaroo tendon is in- 
serted. These are placed at the edge of the hernial 
orifice ; they bite deeply into this edge for a width of 

*The sac should be opened by two or three incisions, large enough 
to admit a finger, so placed that the contents of the sac can be 
examined and the first row of mattress sutures inserted witliout 
danger of penetrating the rieritoneal cavity. Later these small in- 
cisions are sutured. 



section to show the infolding produced by the 
the placement of suture No. 2. While t' 
s represented as being inserted at right angles to the hei 
.Tin, in reality it is introduced parallel with the margin of the 
iiernial opening and penetrates deeply into this margin. 

introduced through the skin from two to four 
inches from the margin of the incision. They are 
placed not more than two inches apart and in a fig- 
ure of eight manner, taking a deep bight into the 
fascia. When tightened they invert the last row 
of kangaroo sutures and take all the initial strain 
They should be selected with regard to the partic- 
ular case. The very largest hernias require either 
double strands of bronze wire, gauge No. 30, or 
single strands of a medium sized twisted wire cable.' 
In the smaller hernias double strands of silkworm 




Fig. 9. — Suture No. 2 has been tied ai 
the hernial orifice have been brought together. 
shown in place. 

gut or Pagenstecher's linen may be used. All these 
sutures are doubled for a purpose. If one breaks 
the other is strong enough to hold; and, doubled, 
they do not cut so fast through the tissues. I used 



*In Cas? XIX, I used comnio 
Doctor Wells, as the silver or 
taii'.cd. The picture wire. No 
Case XXII, I used No. o picture 
the ninth day. 



ure wire, at the suggestion of 
e wire cable could not be ob- 
.^as perfectly satisfactory. In 
but this began to brea': about 



Tanuarj' 



HAVyES: GIANT VENTRAL HERNIA. 



chromic gut in Case xii. The result was perfect, 
but the gut absorbed at the end of ten days and I 
was anxious for the next week. These sutures are 
tied over rolls of gauze half an inch thick so as to 
afford a broad surface for traction and not necrose 
the skin from the pressure. 

A drain of rubber tissue is laid over the retention 




Fig. io. — Suture No. 3 
fascia over a wide area h 
last suture rolls inwar'l, 
bemial orifice. A figu; 



of 



as been tied and the surfaces of tlv 
e been brought in firm contact. This 
e edges of the muscles forming the 
•ight retention suture is shown in posi- 
and the skin edges coaptated 



sutures and the skin is closed by plain gut, Pagen- 
stecher thread, or silkworm gut. The material is 
unimportant. 

The drain should not be disturbed for three days 
It is then withdrawn for an inch, and this is repeated 
every other day until it is entirely removed. These 
wounds ooze a great deal of serum. Do not irrigate 
the drain tract, or remove the drain to insert an- 
other. Infection is possible. Leave the drain as 



and night for twenty-four or thirty-six hours. Mor- 
phine, from one eighth to one quarter grain with 
eserine salicylate one sixtieth to one fortieth grain, 
is given if necessary once or twice during the first 
twenty-four hours. ^ 

These patients have no more pain than the aver- 
age patient after laparotomy. The urine is drawn 
every six or ten hours as necessary. The patients 
are turned every hour from side to back and to side, 
if not asleep. This plan I follow out in all my ab- 
dominal cases to facilitate intestinal peristalsis 
These patients should be kept in bed about a week 
longer than for the usual abdominal section. Their 
entire stay in the hospital is usually three weeks. 




of kangaroo mattress sutures should be inserted. 

this suture is not deeply enough placed, and it lies parallel with 

the long axis of the hernia. 

Some I have allowed to go home in two weeks under 
favorable circumstances. 

An abdominal belt is used in the majority of cases. 
I do not feel that it is a necessary part of the treat- 
ment, but it gives the patients comfort until the mus- 
cles resume their normal function. . 

In my first paper I made the following statements : 
In these enormous hernias, with multilocular sacs, 
with adherent viscera, and similar complications, the 
saving of time secured by not having to dissect out 
the necessary flaps is very considerable, while the 
method of suturing is so simple and easy that it adds 
lo the celerity of the operation. 

The objection that will at once suggest itself is 
that in case the hernial sac is not opened there is 
great danger of perforating the intestines in intro- 
ducing the sutures. This I grant, and urge great 




long as there is a free exudate of serum, and remove 
it gradually as this ceases. Keep the retention su- 
tures tight. I usually tighten them up at the end of 
five or seven days, and remove them from the tenth 
to the fourteenth day after the operation. 

Following the operation, a pint of normal saline 
solution is given per rectum every four hours day 



care in placing the first and second rows. Further- 
more, this danger may be entirely avoided if through 
small incisions in the sac a finger is inserted beneath 
it and under its guidance the suturing is carried out. 



^During the past year, 
; 1 after operating. The 



I have been using petroleu 
oil has seemed to help sec 



BOGGS: X RAY IN BONE DISEASE. 



[New York 
Medical Journal. 



Another danger that I feared was the tremendous 
increase in the intraabdominal pressure by rolling 
into the abdomen a mass of sac and further narrow- 
ing the space by inverting the walls themselves. In 
actual practice, however, there has been no disturb- 
ance from this cause. 

Obstruction and possible strangulation of the in- 
testines might seem to be another real danger. If 
it is, it has not appeared in my experience. In the 
cases with the largest hernias the bowels have acted 
spontaneously on the second or third day. I believe 
such prompt action is aided by the greater tension 
within the abdomen. 

Neither has the fascia become necrotic or sloughed 




Fig. 14.— The inver 


sion of 


the her 


lial 


liargin 


s has 


he 


n com 


pleted. The figure of 


eight 


etentioii 


sutlir 




the 




suture 


are yet to be inserted. 

















in any of my cases. Primary union has resulted 
in all. 

In the second paper the following statements were 
added : Fourteen cases were all cured. Six cases 
may properly be termed giant hernia. The others 
were either large or ordinary, and were operated on 
by this method to demonstrate its applicability to any 
form of ventral hernia, postoperative or umbilical. 

Primary union occurred in twelve cases ; superfi- 
cial suppuration in one case, skin only. Fecal fistula, 
fascial necrosis, and protracted convalescence oc- 
curred in another. Hernia was cured in both. 

No postoperative complication happened in any 
case from increase of intraabdominal tension. Bow- 
els acted spontaneously or easily from assistance on 
the second to fourth day, and regularly thereafter. 
There was no intestinal damage from insertion of 
sutures. To these fourteen cases I wish to add the 
following two. 



Case XV. Mr. G. K., aged fifty-eight years, German, 
admitted to Red Cro.ss Hospital, April 2, 1914. Diagnosis, 
incarcerated, inflamed umbilical hernia. Weight, 275 
pounds. Had a girth of fifty inches at the umbilicus. Had 
had an umbilical hernia from infancy. This had been ob- 
structed a number of times. Examination showed a small, 
inflamed, incarcerated umbilical hernia; no intestinal 
symptoms ; contents of the hernia, probably omentum. 

Operation, April 2, 1914, vertical elliptical incisions enu- 
cleating sac and mass of attached omentum. Hernial 
orifice only about an inch in diameter. Peritoneum with 
sac margin sutured with plain gut. Two rows of kangaroo 
mattress sutures, two double silkworm gut sutures com- 
pleted the inversion. Small rubber tissue drain. Skin 
closed with plain gut. Bowels moved on the fourth day 
after the operation. Patient was out of bed on the fifteenth 
dav, and left for home the following day. cured. 

Case XVI. Mrs. A. B., Harlem Hospital, admitted 
September 8, 1914, large, stout woman, aged forty-three 
years, weighing about 180 pounds. In 1909 she had been 
operated upon for a pelvic abscess. The following winter 
a hernia showed at the site of the ventral scar. Since 
then the hernia had steadily grown in size. At present 
the hernial mass is as larf;e as a large grape fruit. The 
scar extended from the umbilicus to the symphysis. The 
centre of the scar had given away, forming an opening 
about four by two or three inches. There were smaller de- 
fects above, so that the entire extent of tissue between the 
umbilicus and symphysis must be dealt with. Author's 
inversion operation. The sac was opened and the omentum 
found extensively adherent. It was ligated and excised. 
The edges of the sac were trimmed ofT and whipped over 
with plain gut. Two rows of heavy kangaroo tendon 
placed and double silkworm retention sutures. Coaptation 
obtained without undue tension. Time of the operation, 
ninety minutes, delayed by omental adhesions. Bowels 
moved the third day after the operation. Pituitrin was 
started first day after operation, TTLviii morning and even- 
ing, hypodermically. Recovery uneventful. 
REFERENCES. 

I. HAYNESt New York Slate Journal oj Medicine, Dec, 1913. 

2. EDEBOHLS: American Journal of Obilelrics, xxiv, 1891, p. 544. 

3. POLK: Quoted by R. H. i-'owler in his discussion of Haynes's 
first paper, Rochester, 1913. 4. HAYNES: American Journal of 
Surgery. June, 1914- 

107 West Fifty-Fifth Street. 



DIFFERENTIAL RONTGEN DIAGNOSES 
IN BONE DISEASES.* 
By Russell H. Boggs, M.D., 

Pittsburgh, 

Rontgenologist, Allegheny General Hospital; Dermatologist and 

Rontgenologist, Pittsburgh, Columbia, and St. Francis Hospitals. 

It is accepted that the Rontgen ray is a valuable 
aid in the diagnosis of diseases of the bones, and it 
is being employed as a routine procedure. In no 
other field has rontgenology proved more helpful 
than in pathological osteology. The rontgenographs 
not only show the surface and the outlines of the 
bones, but also dislocations and enlargements, the 
architecture within the bones as well as the his- 
tolog}' and chemical state. 

In interpreting the radiographs many points must 
be considered : i. History ; 2, physical signs ; 3, evi- 
dence of disease or tumor in other parts of the body ; 
4, radiographic appearances and their correct inter- 
pretation. Chief among these, so far as our pur- 
pose is concerned, are the rontgenological appear- 
ances. 

In making a diagnosis of bone diseases the ront- 
genologist must have a knowledge of the laws gov- 
erning physics and know the normal, as shown by 



the reprints of thi; 



-^Six additional cases will be found in full 
communication. — Eds. 

•Read before the Rontgen Ray Society of Central Pennsylvani; 
October 21, 1916. 



BOGGS: X RAY IN BONE DISEASE. 



"3 



the rontgenograph, as well as the changes due to 
age and tne variation of the individual. The funda- 
mental law of Kontgen rays is that a picture is re- 
corded according to the specific density and the 
thickness of the part under examination. The rays 
diverge as they pass out from the anode of a tube, 
and It is only the central rays that give the true 
image, while the outer rays of the cone may pro- 
duce much distortion of the shadows. This is to be 
determined by the distance of the part to be exam- 
ined from the plate as well as the tube distance. If 
this is not taken into consideration there is the lia- 
bility to error in inteqjreting, regardless of the qual- 
ity of the radiographs. This accounts for many mis- 
takes, not only by the physician and surgeon, but 
also by the rontgenologist. Many who are inter- 
preting their own plates are not familiar with varia- 
tions in density of bones due to age, nonuse, or dis- 
ease, nor do tney know the appearance of the epi- 
physes at all ages, and that only the part of the 
epiphyses that is ossified is seen on the rontgeno- 
graph. 

The interpreter will make many mistakes unless 
he takes many points into consideration and knows 
the technic used in making a plate. It has been sug- 
gested that the rontgenologists standardize a technic 
in making bone plates, but not much has been accom- 
plished along this line. Until this is done, every one 
should interpret his own plates. It is advisable to 
have the surgeon see the rontgenographs, but we 
must not let him convince us that the plate shows 
disease when nothing abnormal is seen. In early 
bone lesions the disease may be in the soft parts 
and cause no change in the density of the osseous 
structures. In such cases we should make this ex- 
planation and let the surgeon make his early diag- 
nosis by other means. To illustrate, acute osteo- 
myelitis in the very early stage does not usually cause 
any change in density, and it might be dangerous to 
the life of the patient to depend on the x ray plate 
or wait until bone changes can be shown rontgeno- 
graphically. 

It is generally recognized that Rontgen rays have 
certain limitations, both in the diagnosis and in de- 
termining the exact extent of the disease. The diag- 
nosis of diseases of the bone is made by variations 
of density and architecture, together with certain 
lesions having a predilection for certain sites, while 
in certain other diseases the rontgenograph is so 
characteristic that, when considered with the clinical 
history, the diagnosis may be made without diffi- 
culty. Several diseases may show the same changes 
in densit)-, but the pathological changes produce an 
entirely different architecture. In other diseases the 
picture is very similar, and the only value of the 
Rontgen rays is to disclose bony destruction. In 
such cases the diagnosis must be made by other 
means. In other diseases the rontgenograph may be 
so characteristic as to be diagnostic, giving us ac- 
curate knowledge of the extent of the disease. 

It is my purpose to consider this subject only in 
its application to four or five of the more common 
bone diseases, excluding the rarer infections, such 
as osteomalacia, osteitis deformans, and others. The 
physician must be familiar with the rontgenological 
aspects of these common diseases before he is com- 
petent to differentiate between the rarer lesions. 



Tuberculosis of bones and joints, more common in 
young than in old people, is the usual disease afi'ect- 
mg these parts. Some of the bones and joints are 
more frequently affected than others ; the spine, hip, 
and knee more often than the shoulder and skull. 
In making a diagnosis it is always essential that clini- 
cal history and other tests should be carefully con- 
sidered wuh the Rontgen examinations. Assistance 
is often obtained by examining the chest, because 
the bronchial glands may be the source of infection. 
In the early stage it is to be noted that if the disease 
starts in the synovial membrane, no bony changes 
are seen, though it may be suggestive, not diagnostic. 
When the disease starts in the bone, Rontgen evi- ' 
deuce is seen sooner. Rarefaction is nearly always 
constant when the disease is of some duration, and 
is due to absorption of the lime salts. It is to be 
remembered that increased translucency occurs in a 
bone from nonuse, for instance, after fractures, as 
well as in tuberculosis. The extent or presence of 
such conditions can be determined by comparison 
with the joint of the opposite side. In tuberculosis 
the rontgenograph shows bone atrophy or rarefac- 
tion, bone destruction, sequestra, and abscess forma- 
tion. When the disease is of a few months' dttra- 
tion, one or more of these are always present ; it 
should be realized that they may be catised by other 
diseases. 

In tuberculous osteitis there is no abnormal ap- 
pearance until the nutrition of the trabeculse is in- 
terfered with. But as soon as this occurs bone atro- 
phy or rarefaction is present. The typical rontgeno- 
graph of tuberculous osteitis shows atrophy, one or 
more areas of bone destruction, and a hazy or foggy 
appearance. The clinical symptoms are pain, spasm 
of the muscles, and great tenderness. 

There are some special points in making a diag- 
nosis of bone tuberculosis by Rontgen rays which 
are characteristic in regard to certain sites. In chil- 
dren, the vertebra are the most common site, usually 
the middle or low'cr dorsal. It may have its origin 
in the periosteum or the synovial membrane, but 
rarely begins in the transverse or spinous processes 
or laminje. More frequently it starts in one of the 
bodies near the intervertebral cartilage and is first 
noticed on the rontgenograph as a small area of 
rarefaction. Later the intervertebral disc is affected 
and eventually destroyed, and the disease thus 
spreads to the body of the next vertebra. When the 
dorsal vertebrre are affected, the position and direc- 
tion of the ribs may show deformity. When the 
disease starts in the periosteum a periostitis is noted, 
hut usually rontgenographic evidence is not recorded 
until the bone becomes infected. In making the di- 
agnosis it is necessary to differentiate from iajur)-, 
typhoid spine, sarcoma, and metastases secondary to 
carcinoma. 

The hip joint in early life is another part fre- 
quently affected with tuberculosis, which may begin 
in the neck or head of the femur or great trochanter, 
but rarely in the synovial menbrane. In the begin 
ning, a tilting of the pelvis is usually present, but 
no bony changes show on the rontgenograph. The 
characteristic appearance is that of the bony shadow 
projecting inward from the pelvic side of the aceta- 
bulum. Later the rontgenograph shows atrophy of 
the epiphvseal line of the femur and acetabulum. 



114 



BOGGS: X RAY IN BONE DISEASE. 



[New York 
Medical Journal. 



which becomes irregular and ill defined. As the dis- 
ease advances the head of the femur is flattened and 
the acetabulum is absorbed, the articular surfaces 
reaching a higher level, but there is no actual dis- 
location. The disease, if left untreated, may pro- 
gress until the head and neck are entirely absorbed, 
and there is great atrophy of the affected bones. 

Tuberculosis of the knee in children is next in 
frequency to that of the spine and hip, and is fre- 
quently followed by disease in the ankle. Attention 
has been called to the fact that the lower extremities 
are more often affected with tuberculosis than the 
upper. In the knee joint it has been stated that the 
origin is more frequent in the bone in children, and 
in the synovial membranes in the adult. The disease 
may start in the femur, tibia, patella, or fibula, but 
the head of the tibia is considered the most frequent 
starting place. It usually begins in the spongy por- 
tion of the epiphyses of the internal condyle. An 
abscess cavity, surrounded by sclerotic osteitis, often 
follows. 

The shoulder is less frequently attacked than other 
joints. It is usually of osseous origin and begins in 
the head or tuberosity of the humerus or neck of 
the scapula. In the shoulder caries sicca often 
occurs. The bony tissue is slowly eroded without 
abscess formation, and the bone and surrounding 
parts show marked atrophy. Abscess formation 
may occur as in other joints. Tuberculosis of the 
shoulder joint is frequently accompanied by pul- 
monary tuberculosis. In the differential diagnosis of 
bone tuberculosis by the Rontgen rays we note the 
following points : In syphilis the bone is porous in- 
stead of translucent, and the periosteum and cortex 
are denser and wavy in outline. In rickets there is 
a flaring out and irregular cup shaped eft'ect of the 
diaphysis, and in scurvy the epiphyses are flattened, 
which is characteristic of the disease. The diagno- 
sis between osteomyelitis and tuberculosis by the 
Rontgen rays is often difficult, but we must take into 
consideration the fact that osteomyelitis does not 
produce bone atrophy and there is a periosteal over- 
growth which is not present in tuberculosis, except 
when the disease involves the shaft. In bone cyst 
there is a clear space, but bone atrophy is lacking. 

Osteomyelitis, in the early stage, usually cannot 
be detected by the Rontgen rays. Very often, at 
the beginning, the course of the disease is rapid, and 
many patients die before a diagnosis is made. 
Therefore in the early cases treatment should not 
be deferred because nothing is shown by the radio- 
graph. The earliest Rontgen ray appearance is a 
slight increase in periosteal shadows at one or more 
places and a definite swelhng of the soft parts. 
After from six to eight weeks' duration, the bony 
changes usually give a very characteristic picture. 
The alternating dark and light areas with rarefac- 
tion, showing a softening and loss of lime salts seen 
at one or both epiphyseal ends of the bone, extend- 
ing to a greater or less length of the shaft, ending 
abruptly at the epiphyseal cartilage associated with 
new bone formation, is a characteristic picture of 
osteomyelitis. Generally, osteomyelitis is confined to 
the shaft of the bone, the epiphyses and joints escap- 
ing. In the hip joint it may be difffcult to differen- 
tiate between osteomyelitis and tuberculosis. Osteo- 
myelitis has a tendency to proliferation of the peri- 



osteum, thickening of bone, and ostcophytic over- 
growth. Bony destruction near a joint, but not in- 
volving it, is seldom caused by tuberculosis. 

Sarcoma is the most common tumor of the bone, 
and in the early stage cannot be diagnosed rontgeno- 
graphically from a simple inflammatory process. En- 
dosteal sarcoma has its origin in the medullary cav- 
ity or cancellous portion. This causes absorption 
of the bone from within, followed by expansion and 
at the same time osseous deposits on the under sur- 
face of the periosteum. Fine trabecute may pass 
through its substance from wall to wall of the cap- 
sule which gives a more or less honeycombed ap- 
pearance on the rontgenograph. The shaft of the 
bone above and below a sarcomatous growth is nor- 
mal and suddenly expands at the tumor. The 
growth generally begins at the ends of one of the 
long bones, but rarely involves the joint. 

Periosteal sarcoma is the most difficult type to 
diagnose by the Rontgen rays, but as soon as the 
periosteum shows thickening dense enough to cast 
a shadow, it can be shown on the plate. The soft 
parts are involved and usually are of sufficient den- 
sity to cast a shadow. 

Myeloid sarcoma must be differentiated from 
bone cyst. It resembles bone cyst in that its growth 
is slow, occurs usually in the long bones, and may 
be followed by fracture. 

The rontgenographs of syphilis of the bone are 
usually characteristic, and changes are shown in the 
bone in several ways. The chief manifestations of 
syphilis of the bones are epiphysitis, periostitis, and 
gumma. There is an irregular epiphyseal line with 
periosteal new bone formation of the shaft side of 
the epiphyseal line. It may be confounded with 
tuberculous epiphysitis, but gives a different picture. 
In tuberculosis we have rarefaction, erosion, or the 
typical fuzzy appearance. In syphilitic epiphysitis 
we sometimes have a separation of the epiphysis, 
but it is to be remembered that thickening of the 
shaft on the epiphyseal side is diagnostic of syphilis. 
This may be confounded with tuberculosis starting 
in the shaft of the bone. Probably the most com- 
mon manifestation of syphilis of the bone is peri- 
ostitis, which presents a typical Rontgen picture. 
There is a lamellation of the periosteum running 
parallel to the cortical line of the bone. When peri- 
osteal bone occurs there may be new endosteal bone 
formation producing a partial obliteration of the 
medullary cavity. Gumma may appear either in the 
form of a circumscribed periostitis causing round 
nodes and sometimes softening and breaking down, 
or may begin in the marrow or in the spongy parts of 
the bone. The mouse-eaten or mosslike appearance 
of the periosteum is very characteristic. The gum- 
matous infection of bones, if localized, shows ero- 
sion and rarefaction of a limited area of the shaft 
of the bone with new periosteal bone formation on 
either side of the affected area. 

Carcinoma of bone is secondary to a growth else- 
where in the body, such as the breast, prostate, etc., 
and usually follows the scirrhous type. It is a late 
manifestation and affects the sternum, ribs, spine, 
and long bones most frequently, but may attack any 
bone. It. is much more common than is generally 
conceded. The disease may invade a large joint, or 
the shaft of the bone or the long bones may be in- 



January 20, 1917.] 



RUDIS-JICINSKY: X RAY IN WAR SURGERY. 



"5 



volved. The changes are shown on the radiograph 
as irregular shadows of varying density, hghter than 
the normal bone. In some cases the disease takes 
the form of necrosis, when the cavities are filled 
with necrotic tissue and appear as lighter areas on 
the plate. 

In connection herewith, let me quote a paragraph 
from an article. Carcinomatosis of the Bone, Secon- 
dary to a Growth in Some Epithelial Organ, which 
I published in the New York jNIedical Journal, 
September 2, 191 1, describing the pathological con- 
ditions: "Von Recklinghausen found that the in- 
vasion began in the marrow, which was usually 
found studded with nodules of cancer tissue. In 
the long bones these occurred most frequently in 
the expanded extremities ; in the vertebras, through- 
out their bodies. This is in accord with the theory 
that the invasion of the bone occurs via the blood 
stream, since Lexer has pointed out that the meta- 
physes are the most vascular parts of bone." 

These cancer nodules (usually found in groups) 
rarely attained any great size. Occasionally they were 
more miliary in character. This invasion of the 
marrow leads to a low grade osteoporosis (called by 
von Recklinghausen, osteomalacia carcinomatosa), 
which often extends from the central canal to the 
periosteum, with nests of cancer cells scattered 
throughout the Haversian canals. Extension to the 
periosteum is productive of a fibroperiostitis with 
formation of new bone. New bone formation also 
occurs in the marrow. These two processes, osteo- 
lytic and osteoplastic, as a rule, are not productive 
of extensive alteration in the architecture of bone. 

E^iPiRE Building. 



THE SURGICAL VALUE OF THE X RAY. 

What We Learned in Our Work in Serbia. 

By J. RxjDis-JiciNSKY, M. D., 

Chicago. 

In the Bohemian-American Mission, or Frothing- 
ham unit, at Uskup, Serbia, military rules and all 
kinds of military orders in regard to the modus op- 
erandi in our procedures in medicine and surgery, 
during our stay there in 1914-1915, had absolutely 
no influence upon our modern means in diagnosis ; 
especially later on, when all prejudice was broken 
down. We could work more independently and ob- 
serve our own results. When we arrived, there was 
an old coil and x ray accessories in the Belgrade hos- 
pital and one apparatus in Nish, both out of order 
after the Balkan war with Turkey. With our expe- 
rience in rontgenology since 1896 we selected a 
portable apparatus for alternating and direct current 
of great efficiency and the best tubes for our work. 
Cases were sent to us for diagnosis or electrical 
treatment from all the other hospitals in the unfor- 
tunate land of constant struggle. 

We used a special fluoroscope and special covered 
screens for observation during operations, especially 
for the extraction of foreign bodies, bullets, resec- 
tions, transplantations of bones, fragments of frac- 
tured bones, deformities, stiff joints, comparison of 
normal and diseased soft tissues, location and 
determination of any abnormality of the organs of 



the body, living and in action, etc. Protecting our 
hands with lead solutions and rubber gloves, we op- 
erated in a dark room, using sometimes just the 
screens, or for photography instead of glass plates, 
special chloride paper or the Eastman films, exhibit- 
ing some wonderful effects in connection with soft 
tissues, such as brain, heart, lungs, diaphragm, stom- 
ach, intestines, liver, bladder, gallbladder, ureters, 
rectum, and in all lesions where there was a con- 
gestion, giving us positive evidence of the site and 
degree of injury, with the shadows even of arteries 
after amputation in stumps of older soldiers. With- 
out regard to our textbooks we could study condi- 
tions, which were guides, not only in diagnosis, but 
also in our decision, whether we should 'operate, 
when and how, observing the individual steps of an 
operation on the screen. If necessary, drainage was 
established and cavities, fistulse, or sinuses were in- 
jected with sterile solutions, or substances opaque 
to the X rays, or we gave the patient a harmless fluid, 
bismuth oxychloride, etc., when the whole alimentary 
tract or the liver and biliary passages could be 
studied, and we injected the bladder, ureters, and 
kidneys for the purpose of diagnosis. 

Knowing that in all practical work with Rdntgen 
rays it is necessary to have a standard of intensity, 
depending on our eyes more than on all kinds of 
mechanical accessories, we could see the effects of 
the modern small calibre bullet on the bones and 
soft tissues, and compare them with the terrible 
laceration and bony destruction in cases of dum-dum 
bullets, of which we have (Fig. i) a whole set taken 
from an Austrian soldier in the field near Shabac. 
who belonged to a Hungarian regiment. For com- 
parison we have (Fig. 2) one set of the absolutely 
clean Serbian bullets, small and jacketed. In many 
aseptic wounds in which the bullet had lodged in 
the tissues and was removed later, we had an oppor 
tunity to study the remoter effects of the injury. In 
all cases the swelling of the tissues at this time had 
almost or entirely obliterated the tubular wound, the 
location of which was indicated by small discolora- 
tion, parenchymatous extravasation, remains of 
fluid, or coagulated blood, and a limited area of 
edema and infiltration. In some cases the wound of 
entrance could hardly be seen at all in the usual 
way. The bullet was found when the diagnosis was 
made by the x rays, in a small cavity filled with 
liquid blood or serum, while a more extensive zone 
of infiltration indicated the primary stage of encap- 
sulation, later perhaps complete closure with no pain 
and symptoms, according to the location. When 
suppuration at the seat of the bullet resulted in the 
formation of a circumscribed abscess, or the bullet 
was between the fragments and pieces of crushed 
bones, we recognized the complication at once, and 
the X rav aided us to locate and remove the missile 
with all the necrotic bony tissues and the debris of 
small fragments, or other foreign bodies and par 
tides carried into the wound. A large proportion 
of the hundreds of bullets extracted under the x ray 
were found deformed, showing that they were de- 
flected by some hard objects or passed through other 
mediums. The firing being usually at long range, 
gave us also many balls in soft tissues without in- 
jurv' to the bones. Such a bullet (Serbian) is shown 
in Figure 3. The bullet is a nickel encased pro- 



Ri'DIS-JlCIXSKV: X RAY IN WAR SURGERY. 



[New York 
Medical Journal. 



jectilc of natural size; tlio jacket is perfect. The 
bullet wa.s reiiio\e(l from behind the fibula, about 
one iiicii above the ankle joint. It entered the calf 
of the leg below the popliteal space and never 




touched the bones. Figure 4 represents the same 
kind of bullet, exhibiting few lines and depressions 
in the body. (Gunshot injury of skull ; primary op- 
eration ; removal of loose fragments of bone ; no 
focal symptoms ; wound healed, leaving a pulsating 
scar.) Figure 5 is an Austrian bullet, slightly bent. 
It was lodged in the deep tissues of the thigh, about 
four inches from the wound of entrance, fracturing 
the femur in the middle, with constantly draining 
sinuses. The fragments of the shaft of the femur 
were put in apposition under the x ray, plaster of 
Paris dressing applied with extension, and windows 
over the sinuses were made for examination and 
treatment. Figure 6 illustrates the brass clad bullet 
removed from the soft tissues of the arm without 
bony injury. Figure 7 shows a round piece of lead 
from a grenade. Figure 8 illustrates a piece of the 
jacket of a cut bullet which lacerated the soft tissues 
of a leg and caused a most repulsive infection, the 
patient's entire body apparently filling with pus with- 
out apparent cause, even when this piece of the bul- 
let was removed. Figure 9 is a piece of iron taken 
from a shrapnel wound of the hip, infected and very 
severe. Figure 10 is a bullet found in a terribly lacer- 
ated wound of a Croatian prisoner of war, shot from 
behind bv his own comrades belonging to an Aus- 
trian regiment. Probing for bullets, etc.. was not 
practised in our hospital at all. We depended on the 
x ray alone, without pain or additional risk to the 
patient ; the existence of fracture, or its absence in 



doubtful cases was positively demonstrated in this 
way. Especially in close proximity to the joints 
the x ray was of the greatest value, even in injury 
to the hollow viscera. Accuracy took the place of 
ignorance and doubt, and painful manipulations 
ceased to be necessary for diagnostic purposes. 
Proper diagnosis and proper treatment followed, and 
the prognosis in injuries with the small calibre bul- 
let, if not fatal from immediate effects, was nearly 
always favorable, unless some vital organ was in- 
jured. Death occurred from acute hemorrhage, or 
if the infection could not be controlled. But some- 
times even the most horrible cases ended in recovery, 
under a most simple dressing soaked in salt solution 
and daily care and observation. 

There was a case with a portion of the frontal 
bone of the skull shot away, the brain exposed; 
another case with entire lower jaw- gone, leaving no 
support for the tongue ; and still another with 
sternum crushed and the heart exposed. But plastic 
surgery did wonders. Other men had been pierced 
bv bullets in every direction. Thus there were cases 
in which the head had been wounded, the bullet en- 
tering above the orbit and passing out of the skull 
in the parietal region on the same side. Others were 
shot through the thorax, while several had been 
wounded in the abdomen, groin, and buttock, in both 
upper and lower limbs, or the bullet traversed lit- 
erally from one end to the other, only particles of 
the jacket of the bullet remaining at certain portions 
of the spine, giving us, later on, symptoms of nerve 
injury, with a certain degree of neuritis or paralysis. 
On the other hand, the majority of original wounds. 




Fig. 2. — A set of Serbian bullets, jacketed, clean and small. 

with the exception of comparatively few, healed and 
left no symptoms whatever behind them. The ten- 
dency to run an aseptic course was marked in such 
cases, deep suppuration or diffuse cellulitis being 



January jo 



KUDIS-JICIXSKV: X RAY JX If. IK SUKOEKY 



rare. The wounded forgotten in the tield for a long 
time suffered most. The asepsis of the bullets was 
clearly demonstrated to us, infection following 
oftener in wounds by hand bombs of Serbian make, 
grenades and shrapnel, portions of clothing being 
carried into the wounds more readily, with dirt, 
mud, and other debris. \'essel wounds gave us many 
cases of traumatic aneurysm with the extension of 
superficial infection to the seat of fracture, showing 
that every change of dressing was attended by risk 
of infection, the fate of the wounded resting in the 
hands of the one who applied the first dressing. 

There is perhaps no better held to prove Mie value 
of X rays in diagnosis than military surgery. There 
the test of diagnosis and deductive reasoning has to 
be done in comparatively short time, with all efTort 
lending to accuracy and completeness. And in 
nearly all cases in actual warfare we had the oppor- 
tunity to prove with our apparatus that of all senses 
which we employ in diagnosis — and we have to em- 
ploy them all — vision usually gives most accurate in- 
formation. However well trained in the interpreta- 
tion of clinical manifestations we may be, we are 
surest of the presence of a lesion when it is demon- 
strated to our eyes. The superiority of the x ray 
over other methods of locating missiles was in our 
practice so great that we used it to the exclusion of 
others, depending on this most distinct aid in con 
servative surgery; as Borden states, "because with 
it obtainable, disturbance of the wound through at- 
tempts to locate missiles was absolutely unneces- 
sar}-." We have seen many times how some col- 
leagues followed, or attempted to follow the traclv 
of the bullet before it had healed with a dangerous 
probe, or some substitute, disregarding one of the 
main tenets of modern surgery, namely, noninter- 
ference. In that way specific infection was made 
possible, even probable. 

With the X ray at hand we located missiles at any 
time when necessity demanded, and their track was 
safely left undisturbed, and even in contraction of 
the tissues, change of position of the patient, with 
all the shifting of the muscles and facial structures 
obstructing the original path made by the projectile, 
had in the end nothing to do with our examination, 
and showed rather the object sought from different 
points of view if necessary. With cleaner bullets, in 
a number of operations, especially in wounds of ex- 
tremities, with all the modern surgical methods, tlie 
mortality was reduced, the x ray playing the most 
important part in our work. We could make out in 
even,- case if there was any deformity of the bul- 
lets, if they were situated at dangerous points, near 
vital organs or not, in bony cavities, or lodged back 
of the bones, the examination being made perfectly 
safe and clean in the dark room or at the bedside 
and through the dressings. We at once distinguished 
the ^fauser bullet from shrapnel, old lead bullets, or 
metallic objects of different forms, their number, 
and the actual material, or could make out the brass 
jacket bullets, which usually had been deformed by 
ricochet, or the jacket entirely stripped oflF and 
thrown some distance from the original bullet, 
having its own track, which could not be traced 
with a probe. Any small missile imbedded in the 
centre of the callus formed at the side of a gunshot 
fracture, or any other place, was found ; fractures 



and their dimensions were made out, the whole 
amount of destruction was diagnosed, and any com- 
miimtion, due to impact against the shaft of the 
bones, could be seen. The conditions of united 
fractures and the actual steps of repair after receipt 
of the traumatism, were observed from time to time, 
and the repair of perforation of the bones was pho 
lographed successfully. We could study also the re- 
lationships of joints, the various movements, fis- 
sures, "green stick" fractures, depressions, marrow 
cavity, separation of splinter or apophysis, the di- 
rection and character of the complete,' transverse, 
obli(|ue, longitudinal, V or T shaped and com- 
minuted fracture, its relations to the neck, head, 
>liaft ; separation of epiphysis, or if extended into a 




xtracted 



3-— Nickel jacketed Serbian projectile, exact 

from leg near ankle joint. 

Fig. 4, — Serbian bullet removed from the skull. 

1-lc. 5.— Austrian bullet, slightly bent, taken from the thigh. 

J^IG. 6. — Brass clad bullet removed from soft tissue of arm. 

i^"'- o"'~?°""'^ ^""^^ °f '<■=»' f™"i ^ "land gcrnade. 

1-lG. 8.— Part of jacket from a cut bullet, which caused extensive 
suppuration. 

Fig. g. — Piece of shrapnel from badly infected wound of the hip 

I'IG. 10.— Bullet found in terribly lacerated wound of back. 

join! multiple, compound, or combined with dislo- 
cation ; fractures of nasal septum, in cavities of the 
head, or near the sutures, sinuses, or grooves, with 
the lesions in the antrum or foreign bodies in the 
eyes. In regard to callus formation, process of re- 
pair, disturbances in this process, small abscess cav- 
ities in the newly formed bone, other peculiarities of 
the wound, perfect or cartilaginous union, caries, 
deposition of earthy salts in the joints, along the 



RUDIS-JICINSKY: X RAY IN WAR SURGERY. 



I New York 
Medical Journal. 



bones or near Ihc opening of the nutrient artery ; de- 
formity, and functional ability — in all the x ray told 
the truth and taught us to do more honest and suc- 
cessful surgery. When the proper conditions and 
positions were known the x ray could not mislead ; 
its revelations being always correct and infallible. 

We usually proceeded in this way : With the help 
of the X ray we made our diagnosis through the pre- 
liminary dressing, not merely looking at the object, 




Fig. II. — Cross-section and sectic 
^. Chamber for powder. 3. Base. 
Chamber for Nos. 4 and ■;. 

but into it, and if from the nature of injury and the 
symptoms presented we judged that the bones were 
crushed, fragments were not in apposition, or the 
bullet was lodged in a part readily and safely ac- 
cessible, we decided to remove it. In the majority 
of cases we worked without general anesthesia, be- 
cause the operation was really of secondary impor- 
tance compared with possible dangers on account of 
the heart, kidneys, etc., and local anesthesia was re- 
sorted to, or none, if the brave patient, usually a 
Serbian, protested, asking rather for a cigarette than 
a stimulant. The x ray tube under or on the side of 
the table, was in action, and when deemed expedient, 
under strict aseptic precautions, we enlarged the 
wound and observed our knife cutting into the tis- 
sues and going deeper step by step toward the mis- 
sile. Finally the bullet was removed, with all the 
bony debris and other particles of foreign bodies 
seen here and there in the wound. If we cut direct 
upon the bullet we wired the fragments of the bones 
together, if necessary, or used plates, set the frag- 
ments properly, and applied a permanent dressing, 
observing thus the whole procedure and the results 
of the same on the screen. We took care of a free 
exposure of the track of the projectiles, and after 
removal of foreign bodies and necrosed or detached 
tissues, we dried the wound and treated the surface 
with tincture of iodine, bringing together the edges 



b)' proxisional sutures with drainage from the most 
dependent part, either by the wound or by a counter- 
opening. Many times we photographed through 
plaster of Paris, and made out on our stereoradio- 
graphic films whether proper approximation of the 
fragments had been accomplished, or why union did 
not or could not take place. Under no circumstances 
could this be demonstrated by any other means of 
diagnosis. If we had a suspected fracture, or dislo- 
cation, or both, where the swelling would not allow 
immediate digital examination on account of pain 
or inflammation which masked the true condition, 
the simple rapid application of the rays at once re- 
vealed the status without danger to the patient and 
with great satisfaction to us. 

We certainly had to remember that the greatest 
diagnostic difficulties were offered by the joints and 
old fractures. The older the fracture, the less con- 
spicuous the line of fracture appeared, being over- 
shadowed by the callus, and the prognosis in such 
cases had to be guarded, if there was a constantly 
discharging wound. Many times the splints and 
plaster of Paris dressings were apphed over the 
original seat of the fracture, especially in fracture 
of the femur, tibia, etc., coming from the field 
hospital. Or, on x ray examination, no bullet would 
be found, it having entered the orbit and passed be- 
hind the eyeball, escaping in front of the external 
meatus on the same side. At other times the official 
record would note penetrating gunshot wound of 
skull, and we found, with the help of the x ray, 
loose fragments of bone, which were removed, but 
the bullet was in the interior of the skull. Such a 
wound healed with a pulsating scar, but no mental 
symptoms. We had only a few amputations in gim- 
shot wounds, as we saw every particle of the 
crushed bone through the preliminary dressing, and 
determined if amputation was necessary. In gan- 
grene, post typhus or from frost bite, we usually ex- 




amined the bones beyond the line of demarcation be- 
fore amputation. In severe cases we shortened the 
exposure from minutes to seconds with the help of 
the tungstate of calcium screens, when skiagraphs 
had to be made, bringing the obiect as close as pos- 
sible to our paper or film, removing our Crook's tube 
to a greater distance from the screen in fluoroscopy. 



Januar>' 20. 1917.] 



SCHULMAN: PAID SERVICE IN HOSPITALS. 



119 



or the paper and the tihn in skiagraphy. In that way 
we could make out some of the rare cases of fissures 
in the clavicle, where there was absolutely no de- 
formity or crepitus, or could see even the most ob- 
scure fracture of the scapula and dislocation of the 
humerus combined with a fracture of the acromion. 
In the elbow joint proper diagnosis was many times 
impossible, but with our x ray we recognized the 
various types of elbow fractures in a second, noting 
all the complications such as a fracture of the olec- 
ranon combined with dislocation of the radius, 
crushed to pieces or not. Study of the wrist joint 
and of the injur)' due to different projectiles was in- 
teresting, as were fractures of the bones of the hand, 
carpal, metacarpal bones, or phalanges. Fractures 
of the pelvis were accurately recognized, and we 
could hardly fail to be impressed with the wonder 
ful results achieved in these cases, differentiating be- 
tween contusion, fracture of the acetabulum or the 
neck, dislocation, or impaction. We had hundreds 
of such cases, viewing the separate fragments of 
the shaft, or particles which had to be removed, not 
to mention the intraarticular complications in the 
knee, or incomplete fracture of the patella. The 
malleolar type of fractures of the leg, which could 
not be diagnosed before, even the so called Pott's 
fracture, were revealed just as well as fractures of 
the lower end of the radius or styloid process. In- 
stead of sprains, many times we found fractures of 
the ankle beside fractures of the tarsal and meta- 
tarsal bones, with injury to the phalanges, called 
usually contusions or "flat foot." In fractures of the 
stemtun and the ribs or vertebrae, we located the 
fragments and decided on operation, if necessary; 
also in fractures of the skull, and of the inferior 
maxilla and larynx. 

We had some remarkable recoveries follow grave 
bullet injuries of the neck, the clinical symptoms be- 
ing confirmed by the x ray; a few wounds of the 
trachea, with fracture of one or more of the spinous 
processes. We had a few gunshot wounds of the 
chest, with fractures of ribs and spinous processes of 
dorsal vertebrae, penetrating wounds of the chest and 
abdomen, drainage being instituted in some cases 
without rib resection, or when empyema and puru- 
lent hemothorax formed, operation being done. In 
peritonitis absolute rest was advised, especially when 
the bullet had passed through ; the chances of life 
were always better, when there was no other com- 
plication. The diagnosis of bronchitis, pneumonia, 
and tuberculosis was made with the help of the x 
ray, also of asthma in the older soldiers, and such 
conditions rendered the lungs more favorable,in the 
eventtial formation of lung abscesses, the aspiration 
of these under the x ray being comparatively easy. 
We also saw the heart in action, the structures about 
the lung root, the aorta, mediastinal shadows, dia- 
phragm, and the esophagus, the increased speed per- 
mitting the best rays in the tube, with absolutely per- 
fect effect as to solidity and perspective of the pic- 
ture. Of bayonet and other stab wounds in the 
chest or abdomen we had only a few, but they were 
never probed either for diagnostic or for therapeutic 
purposes. In the absence of serious visceral lesions, 
penetrating wounds of the abdomen usually healed 
without operation, but under conservative treatment. 
The penetrating wounds of the kidney were bad, if 



complicated, but others ended in recovery. We had 
only two wounds of the urinary bladder and both 
healed, although the bullet penetrated the bony wall 
of the pelvis. 

We have not forgotten either the curative action 
of the X rays in certain cases, and we proved again 
and again that the x ray in reality often not only 
relieved the pain, but caused the disappearance of 
previous fibrous accumulations, being particularly 
useful in enlarged lymphatic, tuberculous lymph 
glands, chronic joint diseases, skin lesions, etc., pos- 
sessing a chemical and even germicidal action, if 
powerful enough. After having worked with the x" 
ray continuously through a fluoroscope and screens, 
under good protection of the body, we were not af- 
fected very painfully during the whole year of our 
stay, although our eyes seemed to suffer a little. 

1900 Blue Island Avenue. 



PAID SERVICE IN HOSPITALS.* 

Its Advantages Over the Present Free System, 

By M. Schulman, M. D., 

New York. 

There are very few men and women among the 
urban population of today who can boast of being 
unacquainted with the doctor. Indeed, men are com- 
ing to realize that a doctor can do something more 
than prescribe a nauseating and expensive medicine 
for a fully developed disease, and are more and 
more seeking periodical examination and advice, 
that possibly unsuspected disease or disease tenden- 
cies may be discovered at the earliest moment and 
their development arrested or averted. This is as 
it should be, for especially in the domain of health 
it is easier to prevent infringement than to remove 
it. An ounce of prevention is fully worth a poimd 
of cure. The modern doctor earnestly begs for an 
opportimity to apply his knowledge in disease pre- 
vention. 

Nevertheless, there still are, and it is to be feared 
for some time will be, sick men and women and chil- 
dren. For such, modern medicine can do something, 
and at times a good deal, but the methods of modern 
medicine and of medicine of one or two generations 
ago are quite different, and of necessity so. This 
important fact is insufficiently realized, not only by 
the people at large, but also by many doctors. Yet 
the reason is close at hand. In the last fifty years 
there has been an enormous increase in the 
knowledge of disease ; there have been im- 
provement and multiplication in measures for 
diagnosis; and there have been very material 
increase and improvement in methods of treat- 
ment. The consequence is, that no one man 
can possibly be master of the entire field of diagno- 
sis and treatment, and clinical medicine has been 
divided into many specialties. While fifty years 
ago there were practically no specialists, today there 
are too many. The already excessive amount of 
specialization is leading to narrowness of view, but 
this matter will shortly adjust itself. 

From the fact that doctors are compelled to de- 

*SuppIementary to "Clinical Medicine and the Public," New York 
Medical Jodbnal, September 4, 1915. 



SCHULMAN: PAID SERVICE IN HOSPITALS. 



[New V'ork 
Medical Journal. 



vote themselves to small parts of the human organ- 
ism so that they may become possessed of complete 
knowledge of those parts, it does not at all follow 
that when that organism becomes diseased, the dis- 
ease limits itself to any given part in order to ac- 
commodate the specialists. The human body, in 
spite of the physician's limitations, remains one com- 
plex whole, so that there is scarcely a disease of 
any one organ that may not make an impression on 
remote parts of the body. It becomes clear that it 
is seldom possibk for any one doctor to give the 
patient the benefit of good modern medical care 
without the cooperation of one or more specialists 
in other branches of the art. Only such cooper- 
ative team work can yield the best results obtain- 
able today. Why should the public be satisfied to 
accept from the medical profession anything less 
than the best? We must also ask. Does the public 
get the best? 

To answer the last question, "the public" must be 
divided into three groups. The first group includes 
the wealthy ; the second, the dependent poor ; the 
third, the intermediate, with moderate incomes. The 
first two groups get the best attention possible ; the 
third, though by no means less deserving, does not. 
The sick rich can employ and pay for any required 
number of specialists. The sick dependent poor 
have excellent provision made for them in hospitals 
and dispensaries, where cooperative team work in 
the practical application of clinical medicine finds 
its highest expression. The sick of the intermedi- 
ate class cannot often aft"ord to pay groups of spe- 
cialists their prevailing fees, and find the hospitals 
and dispensaries, as at present managed, closed to 
them. Manifestly something is wrong with a sys- 
tem of medical practice that neglects to provide for 
so large and worthy a proportion of the population. 
The situation is by no means hopeless, for it merely 
requires that the medical profession come down 
from its lonely pedestal, look about, and adopt meth- 
ods of reorganization, division of labor, and the co- 
operation of effort so freely employed today in all 
other fields of endeavor, that it may become eco- 
nomically, as zcell as professionally, efficient. Busi- 
ness methods as well as business efficiency in the 
medical profession w'ould indeed be an innovation, 
but it will work to the advantage of the general pub- 
lic as well as to that of the medical profession. If 
the changes do not come soon from the voluntary 
efforts of the profession, they will be forced upon 
it bv public demand. 

It was pointed out above that the practical appli- 
cation of clinical medicine finds its highest expres- 
sion in hospitals and dispensaries. This requires 
some modification, to point out that dispensaries do 
not yield the quality of work that they might _a_nd 
should, because of an underrating of their possibili- 
ties and value. They are not given the proportion- 
ate or deserved degree of attention by the managers 
of the hospitals to which they are attached. This 
is an error which is at last coming to be recognized, 
and which will probably in a short time be rectified. 
What these institutions do for the dependent poor 
they, or similar institutions, can just as well do for 
the neglected middle class. There is absolutelv 
no good reason why dispensaries and hospitals 



should not offer medical care for reasonable pay, 
and by u decently paid and properly selected stall 
of physicians and surgeons and specialists in all 
brandies. Similarly, small groups of physicians, 
surgeons, and specialists, may combine and 
cooperate to render medical service in a manner 
comparable to that rendered by hospitals and dis- 
pensaries. They can thus render it far superior in 
(quality and at a cheaper rate than is possible with 
the uncombined, single handed methods that pre- 
vail in private practice today. 

When comparing, from the economic standpoint, 
small groups of cooperating practitioners, and the 
large groups so cooperating in hospital and dispen- 
sar)', the advantage is with the latter. It is a well 
known law of economics, that the larger the produc- 
tion the greater the economy of production. It is 
quite clear that one institution that can handle a 
large number of patients can do so more economic- 
ally than ten small institutions which together han- 
dle only the same number. The saving in incidental 
and overhead expenses must be considerable, and 
might be applied to increase of allowance to physi- 
cians and to decrease of charges to patients. Fur- 
thermore, magnitude commands respect, and, all else 
being equal, a large institution is more attractive to 
patients than a small one. It inspires them with 
greater hope and confidence, and is able to control 
patients better. Practitioners will admit that the 
mipatience of their private patients frequently com- 
pels them to proceed hastily and with insufficient 
studv of the case, while this handicap to accurate 
diagnosis and treatment is practically never encoim- 
tered in hospital work. 

The pay service of a hospital and dispensary 
should be manned bv doctors who receive salaries 
from the institution, in accordance with the amount 
i>f time required of them. The number of patients 
that they may be required to treat within the given 
time must not exceed an established maximum, that 
their work may not be hurried. Thus the income 
of the doctors is assured and is not immediately de- 
pendent on the ipcome of the institution. When. 
however, cooperative offices are owned and man- 
aged for profit by a small group of practitioners, the 
incomes of the doctors are directly proportionate 
and dependent on the total income of their offices. 
It is quite obvious that such small institutions, no 
matter how honestly and conscientiously conducted, 
will be sometimes suspected by their patients, and 
thus sufTer the great handicap of being thwarted in 
their efforts to have a sufficient amount of consulta- 
tion and study brought to bear on a case. This is 
at present also one of the handicaps of the private 
practitioner, from which the hospital is immune. 

Doctors will contend that institutions such as pro- 
posed will compete with them for patients and so 
reduce their clientele and their incomes. Un- 
doubtedlv these institutions would draw many pa- 
tients from private offices of practitioners and re- 
duce the quantitx of their private practice. Their 
incomes, however, would not suflfer. for to man the 
institutions, doctors will be required in number^ 
exactlv proportionate -to the number of patients 
attracted to the institutions. Thus, the greater the 
nimiber of patients, the greater tlie number of doc- 



STEM ART: MERCURIALIZED SERUMS. 



tors, and the greater the number drawing salaries 
from the institutions. These same doctors who are 
to lose private patients will draw salaries from the 
institutions, which will quite compensate them for 
the loss. In addition, they will have an opportunity 
to do better work and render more adeqtiate serv- 
ice than is possible in private practice, becatise they 
will work in cooperation with other doctors, all 
expert in their chosen held. 

We may briefly summarize as follows : 

1. It is impossible nowadays for a doctor to be 
master of the entire field of medicine. 

2. Present day diagnosis and treatment are much 
advanced over those of one and two genera- 
tions ago. 

3. The adequate stud)' of a case by modern 
methods frequently requires the cooperation of 
many specialists. 

4. .At present, for economic reasons, a large pro- 
portion of the population cannot avail itself of the 
best aid that the medical profession is capable of 
rendering. 

5. The situation can be remedied by the estab- 
lishment of cooperative medical offices, or by the 
establishment of pay services in hospitals and dis- 
pensaries. 

6. Hospitals and dispensaries are probably better 
fitted to render the ser\'ice, and can do so on a 
more economical basis. 

/. The establishment of such services would not 
reduce the income of the medical profession. 

8. It is to the interest of the general public to 
stimulate the establishment of such services. 

T845 Seventh Avenue. * 



MERCURIALIZED SERUMS. 

By F. E. Stew.\rt, Ph. G.. M. D.. Ph ar. D., 
Philadelphia. 

The present remarkable interest now being taken 
in mercurialized serums as therapeutic agents is 
largely due to the investigations of Dr. Charles D. 
Byrnes, of Baltimore, ^Id., and Dr. Loyd Thomp- 
son, of Hot Springs, Ark., whose papers f ornT a part 
of the symposium on the subject of immunity we 
are here to discuss. To this symposium my contri- 
bution is the introductory paper. It is to be imme- 
diately followed by a contribution from my associ- 
ate. Dr. Paul S. Pittenger, dealing with the action of 
mercurialized serum on experimental animals. Un- 
der the circumstances, therefore, I am limiting mv 
paper to a general consideration of the subject. 

^lercurialized sertims are prepared by adding cor- 
rosive sublimate to normal serums and dissolving the 
precipitates thus formed in an excess of serums. 

Mercurialized serums mav be prepared from the 
blood serum of the patient (autogenous serum). 
from the blood serum of some other human be- 
ing (homologous serum), or from the blood serum 
of some animal (heterologous serum). These 
preparations may be administered subcutaneously, 
intramuscularly, intravenously, or intraspinally. 
These are all factors that must be taken into account 
.\hen considering the action of mercurialized serum. 

When horse serum is used as a vehicle in the prep- 



aration of mercurialized serum, the product, so far 
as the serum is concerned, must of course be consid- 
ered in the light of our knowledge regarding horse 
serum preparations in general, such as diphtheria 
antitoxin, tetanus antitoxin, and the antibacterial 
serums. This phase of the subject will be consid- 
ered later. 

Corrosive sublimate when injected stibcutaneously 
is irritating. Alerctirializcd serums may be injected 
under the skin, or into the muscles, or intravenously, 
or even intraspinally, and yet produce no irritation 
whatever. How is this change in reaction to be 
explained? 

Referring to Cushny ( i ) we leant that when a "so- 
lution of a metallic salt comes in contact with a living 
tissue, such as the mucotis membrane of the mouth 
or stomach, a metallic albuminate is at once formed, 
and the acid with which the metal is combined is set 
free. The more completely dissociated the ions of 
salt are, the more rapid is the reaction with protein, 
and the more intense the local action. Thus the 
more rapidly ionized organic salts act more strongly 
than the organic ones which are slowly dissociated. 
(Jther factors determining the nature of the local 
action are the character of the precipitate, and the 
activity of the acid formed, the latter again varying 
witli the extent to which it is dissociated into ions." 

The proteins apparently play the role of acids, dis- 
placing the acids of the metallic salts, which are set 
free, and forming insoluble albuminates with the 
salts. These salts are not generally of definite chem- 
ical composition, for the percentage of metals con- 
tained in them usually varies within wide limits ; in 
some cases, however, definite compounds have been 
formed. 

The salts of mercury are more irritating and cor- 
rosive than those of the other metals. Cusluiy says 
the cause of this is probably the fact that the pre- 
cipitate is less continuous and more loose and flaky, 
and also that it is soluble in excess of proteins, and 
therefore allows the unattached molecules to pene- 
trate deeply. Furthermore, mercury itself, unlike 
most of the other heavy metals, is poisonous to the 
protoplasm of the cells. When mercuric chloride 
comes in contact with the tissues it is split up, and 
the mercury ions destroy the cells, not only bv the 
corrosive action of the acid set free, but also by the 
poisonous action of tlie mercury itself. 

The most powerful corrosive salts of any of the 
metals are those which are most rapidly dissociated 
into ions, that is, the chlorides and nitrates, provid- 
ed that thev are soluble. The least corrosive of the 
metals are those formed with a slowly dissociated 
organic acid, such as the acetates, tartrates, and 
citrates. 

Thus when a weak solution of lead acetate is ap- 
plied to the iTiucous membrane, the metal forms an 
albiUTiinate with the protein lying on the surface, 
and in the more superficial part of the cells. This 
albinninate forms a continuous sheet, and the very 
dilute acetic acid set free is incapable of corroding 
the tissues. If a stronger solution is applied the 
tissues are denied this protection bv an insoluble al- 
buminate, and therefore the metallic precipitate ex- 
tends more deeply. The greater the concentration, 
the more rapid and deep the destruction. Thus ace- 



STEWAR'i. MERCUKIAUZED SERUMS. 



t.\EW York 
Medical Jouknal. 



tate of lead may act as an astringent covering the 
mucous surface with a protective pelHcle of insol- 
uble albuminates, or as an irritant on account of the 
more penetrating and corrosive action of the strong- 
er acetic acid set free. No such protection is af- 
forded when a solution of mercuric chloride or ni- 
trate comes into contact with the tissues, and there- 
fore mercuric chloride and nitrate are always corro- 
sive, never astringent. 

The action of mercuric chloride, hke that of all 
the heavy metals, consists of two parts, namely, the 
local effects produced at the point of application, and 
the general effects which follow the absorption into 
the blood and tissues. These two actions are to be 
regarded as entirely independent of each other. 

The heavy metals, as such, do not induce any 
symptoms when swallowed, except by their mechan- 
ical properties. Thus mercurj' may be swallowed 
in large quantities without causing poisoning, and 
silver or copper coins are equally devoid of poison- 
ous effect. However, when mercury is finely di- 
vided, as in blue mass and mercurial ointment, it be- 
comes more or less physiologically active. Saliva- 
tion is readily produced by blue mass. 

The salts of the heavy metals are often only slowly 
absorbed, and in acute poisoning the symptoms arise 
from local irritation and corrosion, and only, to a 
smaller extent, from the general action of the metal. 
Mercury, however, is an exception. Unlike many of 
the other metals it is rapidly absorbed and distribut- 
ed throughout the body, and being fairly toxic in it- 
self, its poisonous effects are largely due to the gen- 
eral action of the metal upon the system. 

Let us consider what happens when mercuric 
chloride is dissolved in a solution of sodium chloride 
not containing albumin, and then note what probably 
occurs when mercuric chloride is dissolved in normal 
serum containing sodium chloride. 

Paul and Kronig (2) investigated the disinfecting 
powers of a solution of bichloride of mercury and 
common salt. Many years ago, Bacelli, when ad- 
vising intravenous injections of mercurial salts in 
cases of syphilis, employed a solution of the bichlor- 
ide mixed with sodium chloride in the proportion 
of one part of bichloride of mercury to three parts 
of sodium chloride, which he stated was more effec- 
tive in actual practice. Paul and Kronig have shown, 
that the actual process is as follows : A soluble salt 
(Na-.HgCl4)is formed which dissociates into positive 
Na ions and negative complex ions of mercury and 
chlorine. The latter are negative from an antiseptic 
point of view, but a certain amount of secondary 
dissociation of the complex negative ion occurs, re- 
sulting in the formation of the active mercury ions, 
though to a smaller extent than when an equimolec- 
ular solution of mercuric chloride alone is employed. 

Corrosive sublimate when dissolved in normal 
serum loses its corrosive character, and the product 
thus formed is bland and nonirritating, and may be 
injected intraspinally, intravenously, intramuscular- 
ly, or subcutaneously without any corrosive or irri- 
tating action whatever, and yet it appears to be just 
as active as mercuric chloride itself. 

The correctness of this statement is clearly dem- 
onstrated bv the investigations of Pittenger, to be 
reported in his contribution to this symposium. 

When the precipitate of albuminate of mercury 



formed by adding a solution of the bichloride to nor- 
mal serum, is dissolved in excess of serum, if any 
dissociation takes place the acid unites with the al- 
bumin of the serum, and therefore mercurialized 
serum when used as a therapeutic agent is incapable 
of corroding the tissues of the patient. 

What is the nature of the compound formed when 
mercuric chloride is added to normal serum and re- 
dissolved in excess of serum? Is it a solution of 
mercury albuminate containing chloride of sodium, 
or is it a solution of the double salt of mercury and 
sodium ? This question cannot be answered without 
further research. 

As far as the relative toxicity and presumably the 
comparative value of the product therapeutically are 
concerned, Pittenger has shown that toxic effects 
may follow the intravenous injection of mercurial- 
ized serum in animals within five minutes when suf- 
ficiently large doses are administered ; also that with- 
in six or eight hours vomiting and bloody stools may 
occur. Cases have been reported where toxic symp- 
toms have promptly followed the intravenous injec- 
tion of one third of a grain in man. 

When heterologous serums are used in preparing 
mercurialized serum, they are to be regarded as het- 
erologous serum preparations the same as diphtheria 
antitoxin, tetanus antitoxin, and antibacterial serums. 

It is of course well known that the subcutaneous 
injection of diphtheria antitoxin may be the cause 
of more or less severe symptoms known as "serum 
sickness," and usually attributed to anaphylaxis. 
These results may follow upon the first or a later 
injection. Recmt studies on animals by Nemm- 
ser (3) and Goodall (4) have demonstrated that 
fatal results from the subcutaneous employment of 
diphtheria antitoxin are exceedingly rare. Weil 
(5) states that phenomena in humans are in ac- 
cord with the results of animal experimentation. 
Even highly sensitized animals can tolerate relative- 
ly large doses of serum when given by the subcu- 
taneous route. 

As pointed out by this author, there has been a 
strong tendency of recent years to substitute the in- 
travenous administration of therapeutic serums for 
the subcutaneous route. This has been recommend- 
ed not only in the case of diphtheria antitoxin, but 
also in tetanus antitoxin. The reasons for this pro- 
cedure are indeed cogent, and have been carefully 
analyzed by Park (6), who reports its use in 200 
cases without a serious accident. As stated by 
Weil (7), on the analogy of animal experimentation 
there can be no doubt that this mode of administra- 
tion, however, is fraught with considerably greater 
danger to the patient from the standpoint of senim 
anaphylaxis. 

In order to obviate serum sickness and anaphy- 
lactic phenomena, Besredka (8) suggested the ap- 
plication in human beings of the method of desensi- 
tization which had been studied by him with great 
elaboration in animals. In a series of experiments 
on guineapigs, he found that the sensitized animal 
could be sufficiently protected against the fatal dose 
of serum given intraspinally if the animal had pre- 
viously received a graded dose of serum under the 
skin, into the peritoneum, intraspinally, or intraven- 
ouslv. 

Weil (q) admits that "as to the results obtained 



January 2c., 



THOMPSON: MERCURIALIZED SERUMS. 



123 



by Besredka in his animal experimentation there can 
indeed be no question." He points out, however, 
the serious difficuhy in applying these results directly 
to the treatment of human bemgs. "In the animal 
experimentations it was known lliat the guineapigs 
had been sensitized by a certain dose of antigen, 
and that a certain definite amount of serum was nec- 
essar}- to produce death; but unfortunately these 
data are not known in human diseases." 

Besredka (10) has recently suggested that desen- 
sitization might be rendered still more certain by the 
use of repeated instead of single preliminar)' doses. 
These are given at comparatively short inter- 
vals, and are graded in such a way that the 
last dose is many times larger than the first. 
He dilutes five c. c. of serum with ten 
times the amount of physiological saline solu- 
tion; one c. c. of this diluted serum is adminis- 
tered intravenously. Four minutes later, three c. c. 
are injected, two minutes later, ten c. c, and two min- 
utes later, twenty-five c. c. Besredka states that the 
curative dose can then be administered without fear 
of anaphylaxis. This is known as the method dc 
doses subintrantes. Weil (11) says there can be no 
question that this method is extremely eft'ective He 
does not consider it to be a reliable guarantee of 
safety, however, in hmiian therapeutics. 

The foregoing brief extract of Weil's important 
contribution to the subject of serum anaphylaxis is 
sufficient to point out the fact that, while mercurial- 
ized serum prepared from horse serum when used 
subcutaneously is apparently safe, certain severe 
symptoms may follow its use, but the danger of 
serious anaphylaxis is very remote. On the other 
hand, when the serum is used intraspinally or in 
travenously the liability of anaphylaxis is increased. 

As already stated, to Byrnes (12) belongs the 
credit of introducing mercurialized serum in the 
treatment of cerebrospinal syphilis. He first used au- 
togenous serum, and afterward homologous serum, 
m its preparation, but after extensive researches to 
ascertain the probable safety of horse serum as a 
base, adopted the latter. The appearance of the 
product on the market prepared in this manner is 
due to his endorsement and approval. So far as 
we know, no cases of anaphylaxis have followed its 
intraspinal injection, and as a large number of pa- 
tients have been treated with the serum, it is safe 
to assume .there is little risk of anaphylactic phe- 
nomena when it is used in this way. 

Referring to the intravenous use of mercurialized 
serum, it will be noted that Thompson, who is large- 
ly responsible for its use in this manner, does not 
recommend this route as a method of choice in all 
cases of syphilis, but finds it a great advantage in 
cases in which quick results are imperative ; and also 
in those cases in which great pain occurs on intra- 
muscular injection of mercuric chloride or other 
mercurial salts. Neither does Thompson favor the 
use of heterologous serum in the preparation of 
mercurialized serum. 

Taking all of these facts into consideration, in- 
cluding the fact that mercurialized serum when in- 
jected subcutaneously or intramuscularly is rapidly 
absorbed and distributed throughout the body, pro- 
ducing characteristic effects upon the svstem in a 



very short period of lime, it seems advisable to ad- 
vocate the use of serum subcutaneously or intramus- 
cularly as a method of choice, except when specially 
indicated intravenously. 

CONCLUSIONS. 

1. Corrosive sublimate becomes noncorrosive and 
nonirritating when dissolved in normal serum. 

2. The compounds thus formed are just as toxic 
and probably therapeutically as efficacious as mer- 
curic bichloride itself. 

3. When prepared from heterologous serums, 
mercurialized serums must be regarded as hetero- 
logous serum preparations, requiring conformity to 
the same rules in their administration as applied to 
other heterologous serums, such an diphtheria anti- 
toxin, and antibacterial serums. 

4. Mercury in the form of mercurialized serums 
is an ideal form for administering mercury subcuta- 
neously, intramuscularly, intravenously, and intra- 
spinally. 

5. Subcutaneous or intramuscular administration 
is the method of choice. Intravenous or intraspinal 
administration should be the method of resort only 
when especially indicated, as outlined in the publica- 
tions of Doctor Byrnes and Doctor Thompson, who 
have made a special study of the subject. 

REFERENCES. 
I. ARTHUR R. CUSHNY: A Textbook of Pharmacology and 
Therapeutics. z. P.\UL and KROMG: The Chemical Basis of 
Pharmacology, p. 14. 3. NEMMSER: Deut. med. IVochenschrift. 
xxxix, i6, p. 740, 1913. 4. GOODALL: Brit. Jour, of Child. Dts., 
ix, p. 433, 1012. 5. RICHARD WEIL: Jour. Med. Research, xxix, 
p. 233-249. 1913- 6. PARK: Boston Med. and Surg. Jour.. January 
16, 1913. 7. RICHARD WEIL: Ibidem. 8. BESREDKA: Ann. 
de Pinst. Pasteur, xxiv, p. 879, 1910. 9. RICHARD WEIL: Ibi- 
dem. 10. Lancet, August 17. 1913, p. 462. 11. RICHARD WEIL: 
Ibidem. 12. C. M. BYRNES: The Intradural Administration of 
Mercurialized Serum in the Treatment of Cerebrospinal Syphilis, 
Journal A. M. A., Ixiii, p. 2182, 1914. 

1 1 Elt.ena Street, Germantown. 



MERCURIALIZED SERUMS. 

By Loyd Thompson, Ph. B., M. D., 

Hot Springs, Arkansas, 

Visiting Urologist, St. Joseph's Hospital. 

The intravenous method of administering mer- 
cury in syphilis was first practised by BaceUi (i), in 
1893, and was soon used by several other investi- 
gators. In this countrj' Bemhart (2), Crume (3), 
Lydston (4), Kingsbury and Bechet (5) Stukes 
(6), and others employed this method with more or 
less success. The bichloride has been the most fre- 
quently used salt and has been given in doses of 
five to forty-five mg. (1/12 to 7/10 grain). The 
cyanide, the biniodide, the benzoate, and sublanime 
have also been used. 

Owing partially to the comparative difficulty of 
the technic, but probably more to the untoward ef- 
fects which sometimes follow, the intravenous in- 
jection of mercury has not come into common use. 
These untoward effects consist of phlebitis and 
periphlebitis, which is sometimes so extensive as to 
cause complete obliteration of the vein. 

Upon reading Byrnes's original article upon the 
intradural injection of mercurialized serum in syph- 
ilis of the central nervous system, the thought sug- 
gested itself to me that if mercurialized serum could 
be injected intradurally without irritation, it could be 



124 



CONTEMPORARY COMMENT. 



[New York 
Medical Journal. 



injected intravenously without causing phlebitis. This 
1 tried with perfect success, and in May, 191 5, re- 
ported sixty-six injections in eight cases (7). 

The method of procedure is as follows : From 
forty to fifty c. c. of blood are collected by vene- 
puncture and placed in a large test tube which has 
been boiled in salt solution. After separation the 
serum is poured ofif and thoroughly centrifugated. 
A watery solution of mercuric chloride is prepared 
so that each c. c. contains twenty-two mg. {Yi 
grain) of salt. 

The serum is now measured and divided into two 
parts, one third of the amount placed in one tube, 
and the remainder in another. The mercury solu- 
tion is added to the first part in the proportion of 
one c. c. to each two c. c. of the serum. A heavy 
precipitate of albuminate of mercury appears, which 
is completely dissolved on the addition of the re- 
mainder of the serum. It will be seen that the mix- 
ture will contain twenty-two mg. {Yi grain) of mer- 
curic chloride in each seven c. c. 

At first great difficulty was encountered in keep- 
ing the albuminate of mercury in solution for any 
length of time, and it was necessary to prepare the 
solution fresh before each injection, but later it was 
discovered that if the mixture is heated in the water 
bath for one half hour at 55" C, it will remain in 
solution indefinitely. 

Mercurialized serum for intravenous injection 
prepared from horse serum has been placed upon 
the market, but owing to the danger of anaphylaxis 
I have not employed this serum and do not recom- 
mend its use. Recently I have used ascitic and 
hydrocele fluids in the preparation of mercurialized 
serum for intravenous injection, with vers' favorable 
results. These fluids, however, vary somewhat in 
their ability to hold the mercury albuminate in solu- 
tion, some of them requiring as much as ten c. c. to 
each twenty-two mg. {Yi grain) of the bichloride. 

It has occurred to me that the use of these fluids 
might present an opportunity for placing mercurial- 
ized serums upon the market from the use of which 
there would be no danger of anaphylaxis. It might 
be well to state parenthetically that ascitic and hy- 
drocele fluids should be tested for the presence of 
tubercle bacilli before using for intravenous injec- 
tions. 

I have not used mercurialized serum intravenous- 
Iv as a routine procedure in the treatment of syphi- 
lis, but have used it mainly in cases in which the 
pain of intramuscular injection was so great that the 
patient would not tolerate it. 

REFERENCES. 
.. BACEIXI: Ca;. med. Roma, xix, 241. 1803. 2. BERNHART: 
New York Medical Journal, igog. 1. CRUME: Journal A. M. A.. 
li, 2135, 1909. 4. LYDSTON: Ibidem. •;. KINGBURY and 
BECHET: Ibidem. Ixiii, 561, 1914. 6. STUKES: Journal Med. 
Assn. Georgia, v, 1915. r- THOMPSONt Journal A. M. A., Ixiv, 
1471, 1915. 

Duoan-Stuart Building. 



Treatment of Heart Block. — D. Danielopohi 
and v. Danulescu (Pressc mcdicale, November 9, 
1916) report experimental researches showing 
that in the symptoms of cerebral anemia occurring 
paroxysmally in heart block subcutaneous adminis- 
tration of adrenaline is indicated. 



Contemporary Comment 

Prevalence of Phimosis. — The New York 
-Medical Journal of October 7th devotes its prize 
essay columns to a series of descriptions from dif- 
ferent surgeons as to the best method of obtaining- 
the most satisfactory results in cases of phimosis. 
That a subject so apparently trifling should occupy 
so large a space, comments the Medical Press, of 
London, for November 15, 1916, is sufticient testi- 
mony to the importance which this common condi- 
tion has acquired in the last few years. The fre- 
quency with which cases of phimosis occur in hos- 
pital outpatient work is always a matter of no little 
surprise to those who have been accustomed to look 
on it as a rarity rather than as an abnormal state. 
But the real fact seems to be that the exception in 
these dispensaries is really the child whose foreskin 
is normal and, with the picture ever before our 
minds of the evil that certainly follows the reten- 
tion of this redundant skin, the question forces it- 
self upon us as to how far should the matter rest 
only with the wishes of a sometimes not over care- 
ful parent. The education of the people in this, as 
in all those matters which involve the future wel- 
fare of the child would certainly effect a notable 
change in the ideas that exist among the poor as 
well as the rich, and if, to crown all, the adoption 
of the early operation in all cases were subsequently 
encouraged by every obstetrician, the many disgust- 
ing infections which often result in total crippling 
of the man or the boy would be a thing unknown. 
"Cardiacs." — The importance of heart diseases 
has not received the full recognition warranted by 
its frequency or effects, says American Medicine for 
December, 1916. There is hope that the newly or- 
ganized New York Association for the Prevention 
and Relief of Heart Diseases will be able to accu- 
mulate a large amount of evidence with reference 
to the causes, method of prevention, facilities fo» 
cure, the types of convalescent institutions most 
worthy, the forms of education to be advised, and 
the vocations best fitted for sufferers from heart 
diseases. In their program, one finds definite lines 
of work which appeal to the reason. From the 
standpoint of industrial effectiveness, the nature of 
the occupation of sufferers from cardiac disease is 
of great moment. To learn during the school age 
those children affected with organic cardiac condi- 
tions and to guide them intelligently into the most 
suitable vocations is a work that promises much. A 
large amount of cooperation will be required, much 
study of individual fitness will be necessary, but the 
trialmust be made in order to determine whether it 
is feasible to develop vocational guidance for chil- 
dren suffering from cardiac disease, with self sup- 
port as the end result. The problem for adults is 
fraught with greater difiiculties because there is in- 
volved the adaptation of the patient to his environ- 
ment and the alteration of long established habits 
of living in the patient himself. Changes of occu- 
pation, teaching new occupations, the provision for 
new trade training, the underwriting of self sup- 
porting businesses where larger amounts of rest 
may be possible are by no means simple measures to 
carrv out on a large scale. 



Editorial Notes and Comments 



NEW YORK MEDICAL JOURNAL 



IXCORPORATINC THE 



Philadelphia Medical Journal 
and The Medical News 

A Weekly Re'vie^M of Medicine 



CHARLES E. de M. SAJOUS, M.D., LL. D., Sc. D. 

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Cable Address, Medjour, New York. 



NEW YORK, SATURDAY, JANUARY 20, 1917 

STATISTICS AND HEALTH. 

Among the more significant recent indications of 
progress in the preventive medical world must be 
noted the first joint session of the sociological and 
statistical sections of the American Public Health 
.\ssociation at its recent meeting in Cincinnati, a 
session devoted to the consideration of errors in 
sanitary research. The field of health work has 
been flooded with streams of investigations, of sur- 
veys, and of reports. The freely flowing pens at 
the source of these streams have often been held by 
social workers who have not a vestige of medical 
training. The resulting false emphasis is under- 
standable ; but even when medical men are in charge 
of sociosanitarj' investigations, they, too, often lack 
the specific training in statistical method on which 
often depends the scientific value of such work. In 
spite of energj' and good intentions, many investi- 
gators have not been taught to differentiate between 
material which is and that which is not suitable for 
statistical analysis ; nor do they know the methods 
and limitations of mathematical presentation. Hence 
exaggerated statements, absurd deductions, and logi- 
cal fallacies pour forth, and are presented as statis- 
tical summaries of scientific study. 

Such work brings discredit on statistics, and on 
social and health reports. The general public grows 



skeptical of the conflicting conclusions of various 
investigators as to the extreme importance of their 
pet evil. This incredulity is the result, no doubt, 
of the presentation of propaganda as if they were 
scientific data, as was pointed out at Cincinnati by 
Doctor Armstrong, vice-chairman of the sociological 
section, and organizer of the symposium. 

A valuable paper by Doctor Dublin, a much need- 
ed contribution to the question of standards and for- 
mulas in the application of statistical methods to 
health work, was happily illustrated by the many in- 
stances of hazardous generalities and flimsily based 
deductions as presented by Doctor Schneider in a 
discussion at once searching and amusing. The 
amazing correlations on cause and effect in the hous- 
ing and other studies cited, serve to call to our at- 
tention many similar instances in current reports. It 
seems that the average investigator often starts work 
without stating his problem, proceeds planlessly, ac- 
cording to developments, "adopting the principle of 
the shotgun rather than the rifle," and hastily trans- 
forms into dogma generalizations based on insuffi- 
cient or inaccurately observed data. 

One of SchneideT's instances of this tendency was 
the report of a young lady who, finding that diph- 
theria and overflowing privies coexisted in the same 
house, stated that the recent epidemic of diphtheria 
in her town was probably caused by privies. Fur- 
ther, in a statement regarding the Liverpool rehous- 
ing work, it is pointed out that the tuberculosis 
death rate in the district affected was "more than 
cut in half" by the improvement in housing alone. 
This grotesque conclusion entirely disregards as 
possible other causes of the decreased death rate, the 
fact that the rate for the whole city fell markedly 
during the years in which the rehousing was 
done; that only a carefully selected sixty-five per 
cent, of the original population of the district was 
rehoused in it; and that a large number of social 
service measures were instituted, such as the reduc- 
tion of the number of saloons, the provision of in- 
fant welfare work, the establishment of recreational 
facilities and medical school inspection, an elaborate 
antituberculosis campaign, etc. 

Exactly such confusion of association with causa- 
tion will continue to exist until our statisticians put 
themselves at the service of our investigators as ex- 
pert advisors; and until the investigators turn, as 
pupils in this important matter, to the statisticians. 
Then we shall have "less assertion and more evi- 
dence, less emotionalism and more reason, less faith 
and more science." 

That the .American Public Health Association de- 



126 



EDITORIAL ARTICLES. 



[New York 
Medical Journal. 



voted an entire session to the furtherance of such 
cooperation augurs well for the future of statistics, 
sociology, and sanitation. 



SING SING'S REBIRTH. 

Conditions existing today at Sing Sing, both as a 
result of the innovations of the former warden, Mr. 
Osborne, and the introduction of a psychiatric clinic, 
as set forth by its director, Dr. Bernard Glueck, at 
a recent meeting of the New York Psychiatric 
Society, show such marked advances over the past 
that we wish to call attention to the results obtained. 

In the first place, the formation of the Mutual 
Welfare League by Mr. Osborne was an experiment 
which has proved successful in group psychology. 
The league, as is pretty well known now through 
the notoriety it has received, is a body of men com- 
posed of prisoners through whom the prisoners be- 
come self governing. Infractions of discipline and 
the law are dealt with in a court of the league, and 
the prisoners themselves designate the disposition of 
the cases. This is the application to prison life of 
a principle well understood by men of afifairs, name- 
ly, that responsibility and authority must be com- 
mensurate. The league is a success because the 
men, by succeeding in governing themselves through 
it, derive therefrom a much larger measure of indi- 
vidual freedom. It is a solution along the lines in 
.which every social problem must be solved, a solu- 
tion that brings benefits both to the individual and 
to the group. 

The special work of the Psychiatric Clinic is more 
particularly interesting from the medical point of 
view. Already in the study of successive admis- 
sions it has become evident that a very large per- 
centage of those sent to Sing Sing — considerably 
over fifty per cent. — are sufifering from definable 
diseases of the central nervous system, and are 
therefore fundamentally not only cases for the doc- 
tor, but for the psychiatrist. To such a state has the 
ideal of the law brought us ! The ideal that consid- 
ers the crime and not the criminal. 

It is of exceeding interest to learn that the pris- 
oners themselves are beginning to appreciate, and to 
value very highly the existence of the Psychiatric 
Clinic. The clinic is there to help them, and they 
know it, and therefore they are constantly applying 
for help in person, and not only that but doing what 
very few judges on the criminal bench would think 
of doing — applying to the Psychiatric Clinic for in- 
formation about those who come before their own 
Mutual Welfare court so that they can deal with 
them more intelligently. 

And finally, a matter of the utmost importance in 
prison administration, as well as in all institutional 



management, it is being found more and more as the 
days go by that the serious difiiculties which result 
in disorder and highly aberrant forms of conduct 
which in the average prison demand disciplinary 
measures of more or less severity, are almost all 
artificial products. In other words, a more intelli- 
gent understanding of the person and his immediate 
prison environment and the relation of the two will 
enable the management, in at least nine cases out of 
ten, to readjust the situation so as either to prevent 
these outbreaks or to cure them after they have oc- 
curred. 

The advent of the psychiatrist in the prison will 
undoubtedly prove a revolutionary measure in prison 
management. It is the beginning of sanity in deal- 
ing with the criminal. 



PITUITARY "TETHELIN" AS GROWTH 
PROMOTER 

The daily press has announced the discovery by 
scientists of the University of California of a sub- 
stance in the pituitary body supposed to account for 
the gigantic development of the body in acrome- 
galy, and deemed capable therefore of promoting 
growth of the human frame. We shall await with 
interest the reports of the California scientists. 
In the meantime, however, we cannot but express 
the opinion based on similar etiforts in the past, that 
pituitary products of any kind will fail to accomplish 
the feat expected of them. 

Because tumors of the pituitary body are known 
to cause acromegaly, which includes remarkable de- 
velopment of the body, many have thought that this 
overgrowth was due to a secretion produced by that 
organ. i3ut repeated trials with extracts of the lat- 
ter have failed to cause ovcrgTOv\'th, and there is 
not the least evidence to show that these extracts 
represent at all the so called secretion. Thus, as 
stated by Biedl, in his work on the Internal Secre- 
tory Glands (p. 340), "vve possess no proof of any 
kind that the active substance present in pituitary 
extract is formed in the organ during life and by 
it passed on into the bloodstream." The assump- 
tion of such a performance on the part of pituitary 
organic products he attributes to analogy. But this 
analogy is not even close when carefully scrutinized, 
and if we realize that, as recently demonstrated, the 
pituitary contains a substance corresponding with 
adrenal substance — found throughout the chromaf- 
fine system — we can readily account for any effects 
pituitarv glandular products may have on the blood- 
pressure, though modified by the presence of nucle- 
ins and other organic constituents with which the 
adrenallike substance is combined. On the whole, 
evidence is accumulating that, as long ago urged 



EDITORIAL ARTICLES. 



127 



by Lewandowsky, we are only dealing, in so far as 
pituitary products are concerned, with useful phar- 
macological agents, but not with the homologues 
of a secretion. Indeed, so far, nothing, not even 
Cushing's work, has demonstrated that such a se- 
cretion exists. 

The failure to promote growth by means of pitu- 
itarj' extracts is but one of many clinical facts which 
point in the same direction. Thus, acromegaly may 
affect one side of the body only, and, in fact, only 
a small portion of it. This suggests a nervous in- 
fluence. How could a general secretion affect but 
one side, or a few segments, of the body? A 
nervous connection of the pituitary with the body at 
large explains it, however. Again, during the active 
stage of acromegaly the symptoms are derived from 
a combination of diseases of the thyroid (Graves's 
disease) and adrenals (hypernephroma), while in 
its late or passive stage, they are those of tliese same 
organs, but when they have been exhausted (m}'xe- 
dema and hypothyroidia or even Addison's disease). 

It is very doubtful, therefore, whether "tethelin" 
will ever meet the claims of its discoverers. Growth 
and mentality can, however, be developed in chil- 
dren that are deficient in these respects by extracts 
of other ductless glands — those whose functions the 
pituitary coordinates. 



WHAT IS AN EPIDEMIC? 

The health officer of a city which has had fifty 
cases of infantile paralysis to 100,000 population 
makes the official statement that there has been no 
epidemic of the disease, although the average citizen 
of that community is of a different opinion. 

The definition of an epidemic as furnished by the 
lexicographers is not a help in this instance. It is 
evidently a relative term, since fewer cases of a dis- 
ease like poliomyelitis deserve the term, than of an- 
other disease, hke scarlet fever. No number of 
cases to the population is set for an epidemic of any 
disease. The word does not have a pleasant sound, 
especially in the ears of a department of health, 
which must feel itself, to a certain extent, responsi- 
ble for the rise and progress of an epidemic, but the 
health department does not do well when it attempts 
to diminish its responsibility or improve the appear- 
ance it makes by changing the usual meaning of the 
word to suit the occasion. 

The fewer cases of all kinds of disease that health 
authorities come to look upon as an epidemic, the 
sooner will the public come to look upon infectious 
disease as something we need not and ought not to 
have with us to a large extent year after year. It 
is the business of boards of health to sharpen the 
dulled public conscience in such matters rather than 



to help lull it into deeper lethargy. A city is made 
none the more healthful, nor more attractive, by 
covering up its health conditions by a juggling of 
terms. 



POSTURE. 

The profession is indebted to Doctor Goldthwaite 
and others for their recent enthusiastic endeavors 
in behalf of good posture, and for pointing out the 
important and often surprising relation between 
bad posture and many chronic disorders such as aU- 
buminuria, persistent vomiting, partial paralysis, and 
insanities. History repeats itself, and the preaching 
about the importance of good posture for health is 
not at all a new propaganda. History needs to re- 
peat itself, for, although we ought to expect a ma- 
chine which is abnormally caved in here and bent 
out there, which has its boiler crowded, its water 
pipes pinched, and its battery wires interfered with, 
to go wrong, we are of such slow understanding 
that we have to have these selfevident things forced 
upon our consciousness by repetition. 

Bad posture means more than an abnormal rela- 
tionship of organs in the body, and, conversely, get- 
ting a man or a woman into good posture means 
much more than is indicated by the phrase. Bad 
posture is a sign of something (usually a good deal) 
back of it, and the restoration of parts to their nor- 
mal relations means a correction of the physiolog- 
ical faults and a removal of the etiological fac- 
tors which brought about the bad posture. Bad 
posture is never assumed for bad posture's sake, 
and while there are certain types which tend 
to such posture it is because the type is easily af- 
fected by the conditions which bring on bad posture. 
The robust child and the adult who takes an ade- 
quate (not an excessive) amount of recreation from 
work does not usually fall into bad habits in sitting 
or standing, in fact he is able to combat the condi- 
tions of study and work which make for bad 
posture. The less robust child and the overworked 
or too sedentary adult cannot, on the other hand, be 
made to maintain a good posture merely by being 
told to sit up or stand up straight. The work which 
is commonly done along these lines in the schools 
and gymnasiums is practically always of this type, 
and shows by its lack of results how superficial is the 
method of most "physical education." One may give 
an undernourished, hothouse child gymnastics all 
day long with no effect on his wilting physique un- 
less something more is attempted. Gymnastics, 
even for a few minutes a day, may help, but alone 
they seldom cure bad posture. In the curing of 
bad posture associated with an aggravating chronic 
disease, the patient must be made over in more than 
relation of parts, though the getting him into bodily 



uS 



NIllVS ITEMS. 



[New York 
Medical Journa 



good shape is tlie first step, and an important part 
of the process. 

That in the robust bad posture means Httle is well 
evidenced. We have in mind a circuit judge and a 
college president, both men of remarkable physical 
and mental powers, both of unusual height and de- 
cidedly stooped by study, with projecting chins, and 
therefore (if we may trust some teachers) a mis- 
placed diaphragm and stomach. Abraham Lincoln 
stooped, but he was very powerful and never sick. 
Such men can compensate for bad posture, while in 
the more delicately balanced, of whom so many now 
survive, this will undoubtedly add to the trend to- 
ward weakness and chronic disease. 

As put by Doctor Goldthwaite, we need to look upon 
the patient, especially the chronic patient, as a 
whole. We need to examine him stripped, and not 
only lying upon his back (in which position his ail- 
ments cften disappear), but standing and sitting. 
Moreover, we need to know a man's whole anatomy 
for comparison with his whole pathology, as well 
as the anatomy of his separate organs 



IN MEMORY OF DOCTOR WHEELER. 

The death of Dr. Claude Lamont Wheeler has 
brought to this office many expressions of sorrow 
and regret. One of the most graceful of these was 
a poem by W. J. Lampton, which was read at the 
meeting of the Fendsophs, a dining club of profes- 
sional and literary men of which Doctor Wheeler 
was the dean. This poem is reproduced below : 

Cl.\'jdf L.mmon't Wheeler. 
Who said 

Th,it he was dead ? 
If hreath 

Were hfe, or death. 
It might be so, 

But there is spirit which we know 
Lives always, and we feel its cheer 
Today and here. 
As though he had not gone. 
But still sat on 
In his accustomed place 
.And with his easy, kindly grace, 
Brought to the board that welcome which 
Gives humblest fare the savor of the rich. 
His hands are cold today. 
But their last clasp will be 
A ch?ery warmth in memory 
That cannot pass away. 
Who said 

That he was dead? 
Who dares to say 
He is not with us here today? 



News Items 

A Dinner to Dr. Chevalier Jackson. — The Philadel- 
phia Laryngological Society will give a testimonial dinner 
to Dr. Chevalier Jackson on Tuesday evening, January 
2.';rd, at the Hotel Rittenhouse. Philadelphia. Dr. j. Solis- 
Cohen will deliver the address of welcome and Dr. Hobart 
Amory Hare will act as loastmaster. Addresses will be 
delivered by Dr. J. Chalmers Da Costa, representing Jef- 
ferson Medical, Dr. Edward Alartin, representing the Uni- 
versity of Pennsylvania, and Dr. Judson Daland. represent- 
ing the Medico-Chirurgical College. 



Personal. — Dr. William S. Stone has been appointed 
assistant director of cancer research at the Memorial 
Hospital, New York. 

The Henry S. Wellcome Prize Competition. — The 

Associ.ilion of Military Surgeons of the United States has 
announced the result of this competition. A gold medal, 
with $.300, was awarded to Dr. Mahlon Ashford, Captain, 
Medical Corps. United States Army, whose essay was en- 
titled The Organization of Medical Officers. Dr. William 
C. Rucker. assistant surgeon general of the United States 
Public Health Service, received a silver medal and $200 
for his essay on 'J"bc Influence of the European War on 
the Transmission of tlie Infectious Diseases. 

Pneumonia and Grippe in New York. — During the 
week ending January ij, 1917, there were reported to the 
Department of Health of the City of New York 60 deaths 
from grippe, 142 from bronchopneumonia, and 366 from lo- 
bar pneumonia. During the preceding week there were 4Q 
deaths from grippe, 146 frotu bronchopneumonia, and 276 
from lobar pneumonia. The total number of deaths from 
all causes reported to the department last week was 2,076, 
corresponding to an annual death rate of nearly 19 in a 
thousand of population ; the death rate for the preceding 
week was T/--,^- 

Meetings of Medical Societies to Be Held in Phila- 
delphia during the Coming Week. — Monday, January 
22nd, North Branch of the County Medical Society, Sec- 
tion in General Medicine of the College of Physicians ; 
Tuesday, January 2.3rd, West Philadelphia Medical Asso- 
ciation. Academy of Stomatology; Wednesday, January 
24th, County Medical Society ; Thursday, January 25th, 
Pathological Society, Northwest Branch of the County 
Medical Society ; Friday, January 26th. Neurological So- 
ciety. South Branch of the County Medical Society, North- 
ern Medical Association, Medical Club (directors). 

Low Death Rate in the Army. — In an army of more 
than 150.000 national guardsmen and regulars, only 274 
deaths occurred during the last seven months, according 
to the annual report of the chief surgeon of the Southern 
Department. Of the deaths 108 were classified as caused 
by violence, while 166 were caused by disease. Of the 
total deaths, 47 were caused by gunshot wounds. This in- 
cludes the II men who were killed at Carrizal June 21, and 
others in the San Ignatio raid. June 15, Parral, and other 
minor clashes. These men were regulars. There have 
been 29 accidental deaths, ig suicides, 10 drownings, and 
3 fatal sunstrokes. Out of the 166 deaths from dis- 
ease, 44 were due to pneumonia, 31 were from abdominal 
disease, appendicitis and internal troubles of that nature. 
Dysentery killed 11 men, but only one death from typhoid 
fever occurred during the seven months. 

Gifts and Bequests to Hospitals. — Among the gifts 
made to charitable institutions by Mr. Jacob H. Schiff on 
his seventieth Inrthday are the following : To the Monte- 
fiore Home and Hospital. $100,000 to be used for research 
work : to the American Red Cross Society, for war relief 
in Europe, $100,000; to the Henry Street Settlement. 
$25,000. 

The will of the late Martha L. Binder, of Philadelphia, 
includes the following bequests to Philadelphia institutions : 
To the Presbyterian Hospital, $2,000 ; Methodist Hospital, 
$1,000; Episcopal Hospital, $500. 

The Medical Society of the County of New York, — 
A stated meeting of this society will be held in Hosack 
Hall, New York .Academy of Medicine, Monday even- 
ing, January 22nd, under the presidency of Dr. J. Bent- 
ley Squier. The program will consist of a svmposium 
on Compulsory Health Insurance. Papers will be read 
as follows: The Needs and Possibilities, by Professor 
Irving Fisher, of Yale University; The Economic Dis- 
advantages, by Mr. William Gale Curtis, Chairman of 
the Educational Committee; The Tentative Draft, by 
Dr. Samuel J. Kopetzky. chairman of Committee on 
Medical Economics: Criticism of the Tentative Draft, 
by Dr. Eben V. Delphey. Among those who will take 
part in the discussion of the subject will be: Dr. Alex- 
ander Lambert, Dr. Edward D. Fischer, Dr. William 
S. Gottheil, Dr. Sigismund S. Goldwater, Dr. Louis I. 
Harris. Dr. Walter Lester Carr, Dr. Israel Strauss, Dr. 
I. M. Rubinow, and Dr. Henry W. Berg. The program 
for the February meeting of this society will consist of 
a symposium on Infantile Paralysis. 



January 20, 1017.] 



NEWS ITEMS. 



129 



Bronx County Medical Society. — The January meeting 
of this society has been postponed to Wednesday evening, 
January 31st. At this meeting, which will be held in Eb- 
ling's Casino, St. Ann's Avenue and 156th Street, Dr. John 
B. Deaver, of Philadelphia, will read a paper on Gastric 
and Duodenal Ulcer, with lantern slide demonstrations. 
.■\t the annual meeting of the society, held on the evening 
of December 20th, the following officers were elected: 
President. Dr. J. Lewis Amster ; first vice-president. Dr. 
John J. Decker ; second vice-president. Dr. Maximilian 
Zigler ; treasurer. Dr. Philip Eichler ; secretary, Dr. Isidore 
J. Landsman ; board of censors. Dr. John E. Virden, Dr. 
John F. Holmes, Dr. Jacob A. Keller, and Dr. John 
Riegelman ; delegates, Dr. Cornelius J. Egan and Dr. Na- 
than V. Van Etten ; alternates, Dr. Paul Dolan and Dr. 
Edward Corbett. 

A New Monthly Journal Devoted to Tuberculosis. — 
The National Association for the Study and Prevention of 
Tuberculosis announces that its plans are complete for the 
publication of a monthly journal for physicians and re- 
search workers in tuberculosis, to be known as the Ameri- 
can Reviczv of Tuberculosis. The Transactions of the an- 
nual meeting of the association will be discontinued and the 
papers presented at these meetings will be published in the 
Reznew. 

The first issue of the new journal will appear in March, 
and will contain approximately sixty-four pages of reading 
matter. It will be of standard magazine size. Dr. Allen 
K. Krause, of Baltimore, has been appointed managing 
editor of the Rez'ieu', and its editorial policy will be de- 
termined by an editorial staff of seven members to be 
appointed by the board of directors of the association. 

The Department of Health Loses Two Capable Offi- 
cials. — The retirement on pension of Dr. John S. Billings, 
deputy commissioner, and Mr. George A. Roberts, chief 
clerk constitutes a distinct loss to the community. 
Doctor Billings entered the department of health 
as bacteriologist in 1895, and four years later was placed 
in charge of the department laboratory of diagnosis, then 
occupying quarters in the Criminal Courts building on 
Center street. In 1905 he became chief of the newly cre- 
ated division of communicable diseases and as such had 
an important share in shaping the activities directed to- 
wards the administrative control of tuberculosis. His work 
in the organization and administration was so successful 
that a reorganization of the depattment placed him in 
charge of the bureau of infectious diseases (later, bureau 
of preventable diseases) made by consolidating the di- 
vision of contagious diseases with the division of communi- 
cable diseases. Doctor Billings has been acting deputy 
commissioner since the appointment of Doctor Emerson 
as commissioner. He was forceful, well versed in the serv- 
ice and practice of health administration, a tireless worker, 
and devoted to the Department of Health. 

Child Labor Day. — The National Child Labor Com- 
mittee, with headquarters at 105 East Twenty-second 
Street, New York, announces that Child Labor Day 
will be observed by churches on January 28th, by syna- 
gogues on January 27th, and by schools on January 
29th. The recent passage of the Federal child labor 
law has made the regulation of child employment in 
factories, mills, canneries, mines, and quarries uniform 
throughout the country, but children working in stores 
and offices, on the streets, as telegraph messengers, 
and in other industries not engaged in interstate com- 
merce, are outside the field of Federal legislation and 
must be protected by the States. It is to the children 
in these perfectly familiar but more or less unregulated 
industries that the National Child Labor Committee 
calls attention this year. To facilitate the study of 
local child labor conditions the National Child Labor 
Committee has issued a stud}' outline giving the main 
facts as to the industries in which children may be at 
work, an analysis of the child labor and school laws 
that should protect them, and suggestions for improv- 
ing educational conditions and making school, mothers' 
pensions, and child labor laws coordinate. The pam- 
phlet also contains a program for a child labor meet- 
ing which will be of great help to all who plan to ob- 
serve Child Labor Day. Copies of the pamphlet to- 
gether with other special printed matter and informa- 
tion may be obtained from the National Child Labor 
Committee. 



State Hospitals for the Insane Overcrowded. — In an 

effort to secure more adequate provision for the care of the 
constantly increasing number of insane persons in New 
York State, the State Hospital Commission has sent a 
message to the State legislature describing the deplorably 
overcrowded condition of the thirteen State hospitals for 
the insane. The message states that exclusive of parole 
cases there are 33,988 patients in the State hospitals and 
that their capacity is only 27,890. The percentage of over- 
crowding is 29.9. The upstate hospitals are overcrowded 
from 8 to 25 per cent., while the metropolitan institutions 
as a whole are overcrowded 29.1 per cent., the most serious 
condition e.xisting at the Manhattan State Hospital on 
Ward's Island, where the overcrowding is 38 per cent. At 
Centra! Islip. Kings Park, and Brooklyn State Hospital 
equally unsatisfactory conditions prevail. The commission ' 
suggests a definite programme, extending over a period of 
several years, which will provide for the gradual reduction 
of tlie present excessive overcrowding. 

Society of Medical Jurisprudence Condemns Health 
Insurance. — The Committee on Industrial Insurance of 
the Society of Medical Jurisprudence, of New' York, after 
several months of investigation, presented a report of their 
findings at a recent meeting of the society. The conclu- 
sions arrived at by the committee show that industrial or 
health insurance laws have not proved a success in either 
Germany or England where such acts have been passed by 
the national legislatures. The committee also reported 
that they had found that persons who would be directly 
affected by the law were not interested in it, and it was 
their belief that the subject had been agitated primarily by 
the American Association for Labor Legislation. Organ- 
ized labor was either opposed or indifferent to any com- 
pulsory health insurance laws. 

Tissue Examinations for Diagnosis. — The Department 
of Health has just completed and put into operation a plan 
by which the physicians of New York city are invited to 
submit specimens of tissue for microscopic diagnosis. 
Specimen blanks with instructions to physicians, and bot- 
tles containing tissue preservatives are being distributed 
to the various call stations throughout Greater New York, 
and physicians are requested to use them when forwarding 
specimens. Specimens in which an immediate diagnosis is 
desired should be sent directly to the Research Laborato- 
ries, foot of East Sixteenth Street, New York, and a re- 
port based upon examination of frozen sections will be sent 
by letter or telephone within twenty-four or thirty-six 
hours. Otherwise specimens may be left at the nearest call 
station, and will be reported upon within two or three 
days. 

The responsibility for the diagnosis of tissue lesions will 
be assumed by Dr. Douglas Symmers, consulting patholo- 
gist to the Department of Health and professor of pa- 
thology in Bellevue Hospital Medical College. Dr. Sym- 
mers will head a stafif of pathologists specially trained in 
the methods of tissue diagnosis. 

The Widal Test for Milk Dealers. — The commissioner 
of public safety and the health officer of the city of 
Rochester, N. Y., required that all applicants for licenses to 
sell milk should submit to a blood test to determine 
whether or not they were possible carriers of the typhoid 
bacillus. An applicant for renewal of such a license re- 
fused to permit the test to be made and applied to the 
courts for a mandamus to compel the commissioner of 
public safety to renew his license. The court refused to 
compel the renewal of the license. In the opinion Judge 
Rodenbeck said : 

It is important ... to the whole community that the supply 
of milk and cream should be kept clean, pure, and wholesome and 
should not be contaminated with impurities or infected with disease; 
and it is the duty of the health authoriles to see that this is 
accomplished by the establishment of such reasonable regulations 
as may be necessary to meet existing conditions or to ward off 
impending dangers to the public health, and in imposing a blood 
test as a condition to a license to sell milk and cream in the city 
the commissioner of public safety and the health officer acted within 
the scope of their authority, and applicants for such a license 
should cooperate with the public authorities and assist rather than 
oppose reasonable efforts to provide pure and wholesome milk and 
cream for the people of the city. The requirement of a blood test 
of an applicant for a license is just a step, and a small one, in the 
direction of the protection of the public health, but every reason- 
able effort made in this direction should be encouraged so long as 
it does not unreasonably infringe upon the rights of the individual. 

The opinion is published in full in Public Health Reports 
for January 12. IQ17. 



Modern Treatment and Preventive Medicine 

A Compendium of Therapeutics and Prophylaxis, Original and Adapted 



SODIUM BICARBONATE IN GASTROIN- 
TESTINAL DISORDERS. 
By Louis T. de M. Sajous, B. S., M. D., 
Philadelphia. 
(Continued from page 85.) 
A feature of the action of sodium bicarbonate 
also requiring consideration is its influence on the 
motihty of the stomach. As Cushny states, "dilute 
solutions of the alkalies may act as slight irritants 
to the stomach wall and thus improve its circula- 
tion, and lessen pain, eructation, and distention, 
very much in the same way as other slight gastric 
irritants, such as the volatile oils." The liberation 
of carbon dioxide through reaction with hydro- 
chloric acid is, moreover, generally credited with 
distinctly augmenting gastric movement. Again, the 
influence of the drug on the potency of the pyloric 
opening is to be considered. While low acidity of 
the gastric contents constitutes a reason for slow 
evacuation of the stomach, owing to reduction in 
the amount of hydrochloric acid, which normally 
acts as a stimulant to the propulsive contractions of 
the pyloric portion of the organ, and is the physio- 
logical cause for relaxation of the pylorus, markedly 
excessive acidity, especially in a sensitive, eroded, or 
actually ulcerated stomach, tends to cause pyloro- 
spasm and consequent delayed evacuation — a con- 
dition which sodium bicarbonate, administered at a 
suitable time, will relieve. 

A related question is that regarding the effect of 
sodium bicarbonate on the gastric functions where 
some of it passes into the duodenum unneutralized. 
From experimental work published in 1906, Lonn- 
quist ascertained that a solution of sodium bicarbon- 
ate artificially introduced directly into the duodenum 
tends to reduce gastric secretion. This effect he 
ascribes to a reflex arising in the duodenal wall and 
reacting upon the mucous membrane of the stomach. 
In relation to the pyloric sphincter action, more- 
over, it is well known that, while an acid reaction 
on the duodenal side of the pylorus causes contrac- 
tion of the sphincter, an alkaline reaction, such as 
would result from direct entrance of unneutralized 
sodium bicarbonate into the duodenum, tends to in- 
duce relaxation of the pylorus. From the practical 
standpoint, the secretion depressing action of the 
alkali when- in the duodenum has been shown by 
Linossier and Lemoine to be, as a rule, negligible. 
Not only is it highly improbable that any consider- 
able portion of the bicarbonate taken into the stom- 
ach will enter the duodenum as such, the alkali com- 
bining with the hydrochloric acid, which itself favors 
pyloric relaxation, but, according to their experi- 
ments, the secretion depressing effect of the alkali 
when in the duodenum is much more than counter- 
balanced by its action in augmenting gastric secretion 
while still in the stomach. In the same way, the 
effect of sodium bicarbonate in the stomach in inter- 
fering with relaxation of the pyloric sphincter by 
neutralizing the acid which excites it should normally 



prevail over the pylorus relaxing effect of alkali en- 
tering the duodenum. Hyperchlorhydria, however, 
constitutes an exception to this, the pylorospasm due 
to excess of acid and reversed pyloric reflex being 
relaxed by sodium bicarbonate. 

Likewise of interest and significance in connection 
herewith are the recently published researches of 
Hamburger and Halpern on the effects of various 
salts and alkalies on the activity of pepsin. These 
investigations clearly prove, as Langley had pre- 
viously maintained, that pepsin is extremely sensi- 
tive to alkalies, especially when digesting in vitro in 
the form of aqueous pepsin to which the hydro- 
chloric acid necessary for its activity has been added 
after admixture with the alkali. In experiments 
more closely simulating clinical conditions in that 
actual gastric juice was used instead of aqueous 
pepsin, addition of alkali sufiicient to neutralize the 
free hydrochloric acid caused an arrest of pepsin 
activity which could be overcome by addition of 
more acid ; on the other hand, when enough alkali 
was used to neutralize both free and combined 
(total) acidity, the arrest of pepsin activity was per- 
manent, subsequent addition of acid failing to reac- 
tivate the pepsin. Complete and continuous neutral- 
ization of the gastric juice by adequate doses of 
alkalies is, therefore, advised by Hamburger in the 
curative treatment and prevention of gastric ulcer, 
with the object of inhibiting peptic digestion, "which, 
next to mechanical trauma, is probably the chief 
factor in promoting gastric ulcer." Such a proce- 
dure would doubtless not be without disadvantages, 
important among which would be the cessation of 
the bactericidal function of the stomach through ab- 
sence of free hydrochloric acid. This objection 
might, however, be overcome by aseptic feeding or 
the ingestion of antiseptics. That the feasibility of 
continuous, complete neutralization by the use of 
certain alkalies, with certain foods and methods of 
feeding, has already been demonstrated is asserted 
by Hamburger. Therapeutic demonstrations in 
connection herewith are promised. 

Among the various clinical applications of the ac- 
tions of sodium bicarbonate above discussed, the 
most important, from the immediate symptomatic 
viewpoint, is that of relieving gastric pain. For this 
purpose sodium bicarbonate is by many considered 
one of the best of the alkalies. According to 
Huchard, it is far more efficient in this direction than 
magnesium oxide or prepared chalk, owing to the 
large amount of carbon dioxide liberated from it. 

The use of sodium bicarbonate before meals to 
augment the flow of gastric juice in the stomach for 
the digestion of the subsequent meal has already 
been touched upon. According to some, such use 
of the drug will relieve the pain or discomfort aris- 
ing from delayed digestion in cases of hypochlor- 
hydria. For indigestion manifested in discomfort 
at the cardia, with eructations, somnolence, low 
spirits, and irritability of temper, the following mix- 
ture has been recommended : 



January 20, 1917.] 



MODERN TREATMENT AND PREVENTIVE MEDICINE. 



131 



5 Sodii bicarbonatis, 5iss ; 

Infusi gentianae compositi (N. F.) 3vi 

M. et Sig. One tablespoonful an hour before meals. 
E. Binet, in similar cases, orders the following 
powders taken one hour and one-half hour before 
the meal, and if necessary, also one-half hour and 
one hour after the meal : 

5 Sodii bicarbonatis gr. xii ; 

Magnesii oxidi ponderosi, gr- iv ; 

Belladonnse folioruni pulveris S^-Ve- 

Pone in chartulam No. I. 

With each of the above formulas, in the type of 
case referred to, acceleration of gastric motility 
through carbon dioxide liberation, promoting better 
admixture of the gastric juice with the food, and 
hastening evacuation of the stomach, is doubtless an 
important factor in the relief procured. 
(To be continued.) 



X Ray Therapy in Muscular Sclerosis Follow- 
ing Contxacture. — M. Mercier {Paris medical, De- 
cember 2, 1916) points out that in military practice, 
sclerotic muscular conditions following persistent 
contracture or myositis have given considerable 
trouble. Four cases presenting retraction of the 
biceps, the result of wounds of this muscle or of 
its tendon by shell fragments, were recently treated 
by the x rays, with promising results. None of 
these patients had been able to extend the forearm 
more than 90°. Converging rays to the extent of 
two H. units were used upon the muscle tissue of 
the biceps, first on one side, then on the other. A 
filter of one to 1.5 mm. of aluminium was used, and 
weekly treatments were given. After eight or ten 
sittings these patients were all able to extend the 
forearm up to 150° and even 160° — a gain of 60° 
to 70°. 

Carrel's Method in the Treatment of Infected 
Wounds. — P. Desfosses {Prcsse mcdicale, Novem- 
ber 30, 1916) describes, with illustrations, the use 
of Dakin's solution as used with success in French 
military practice. In surface wounds the tube car- 
rj-ing the solution to the part is perforated with 
many small holes and laid over the injured surface. 
In horizontal through and through wounds a simi- 
lar tube is tied. shut at one end and passed through 
the wound track ; in vertical wounds it is, in addi- 
tion, surrounded with sponge tissue to keep the solu- 
tion from immediately running out below. In deep 
wounds with a single opening above, a tube with a 
few holes near the tip is merely passed down to the 
bottom of it. Where the opening is below, and the 
patient cannot be turned on his face, the tube is 
surrounded with sponge tissue where it enters the 
wound or, if the orifice of the wound is too broad, 
several tuljes with small holes are used and the fluid 
injected with considerable pressure. Intermittent in- 
stillation, employed for most wounds, is accom- 
plished by releasing a clip on the tubing every two 
hours for a few seconds, about twenty to 100 c.c. of 
the fluid thus passing through the wound. When 
the wound has been rendered sterile — usually in 
eight to eleven days — the number of bacteria in the 
discharge having progressively decreased to nil and 
this condition having been maintained two or three 
days, the wound is closed with adhesive strips or 
sutures. 



Therapy of Bronchial Asthma. — Wolff Freu- 
denthal {Neiv York State Journal of Medicine, De- 
cember, 1916) states that the proper treatment of 
bronchial asthma should be based upon the probable 
cause of the condition and its removal where possi- 
ble. In the form due to nasal conditions much re- 
lief can often be obtained by correction of the con- 
ditions. Nasal obstructions should be removed sur- 
gically, infected sinuses, including the ethmoid, 
should be drained, and chronic nasal catarrh should 
be cured by proper methods of treatment. In cases 
of true bronchial asthma there is usually a thicken- 
ing and local disease of the lining of the bronchial 
tubes, which should be treated by direct applications. 
These should be made with the aid of the broncho- 
scope and a modified Ephraim's flexible spray. 
Chloride of zinc in one-half to one percent, solution, 
or hammamelis, or tannic acid, containing some oil 
of peppermint, are the most useful agents to employ 
as sprays. The endobronchial application of gal- 
vanic and faradic currents is of value in delaying 
or arresting the onset of hyperirritability of the 
bronchi. Asthma resulting from sexual neuroses 
and the form which is of purely neurasthenic origin 
are both difficult to treat and most intractable to 
cure, usually undergoing relapses as soon as any line 
of satisfactory treatment is stopped. 

The Streptococcus as a Factor in the Treat- 
ment of Tuberculosis. — K. M. Ferguson (Vir- 
ginia Medical Semi-monthly, December 8, 1916) 
points out that whereas under absolute rest, fresh 
air, and increased nutrition many cases recover, after 
the stage of softening and excavation has been 
reached, when organisms other than the tubercle 
bacillus are found in the sputum, chiefly the strepto- 
coccus, tuberculosis is curable only with great diffi- 
culty. Elimination of the streptococcus has, there- 
fore, seemed to him an important feature of the 
treatment of the disease, and he has tried autosero- 
therapy in a tuberculous woman of thirty years, with 
temperature ranging from 102° to 105° F., pulse 
rate of 135, loss of weight from 125 to eighty 
pounds, nightsweats, bedsores, and daily expectora- 
tion of a half pint of thick sputum. A piece of 
canthos plaster about one inch and a half square 
was covered with petrolatum or olive oil, carefully 
wiped off, and placed on the chest at bedtime. From 
the blister formed by morning one c. c. of 
serum was withdrawn with a hypodermic syringe 
and injected into the muscles of the arm, or else- 
where. This procedure was repeated every four 
days, and soon improvement was noticed. After 
six months of the treatment the patient had gained 
more than twenty pounds, expectoration was reduced 
to two or three drams, and the temperature ranged 
from normal to 100° F., with a maximum of only 
99° F. on days in which the patient remained quiet. 
Attempts at discontinuance of the injections early 
in the treatment were soon followed by aggravation 
of the symptoms, and with noticeable improvement 
when the injections were resumed. Two years after 
the beginning of her symptoms, and about a year 
after the beginning of the treatment, the patient's 
menstruation returned, she ate and slept well, and 
her weight was stationary. The sputum still showed 
tubercle bacilli. Autoserum injections were still be- 
ing administered every week or ten days. 



132 



MODERN TREATMENT AND I'REVENTIVE MEDICINE. 



[New York 
Medical Jouknal. 



Treatment of Infected Gunshot Wounds. — 

Joseph Rilus Iiastmaii {Surgery, Gynecology, and 
Obstetrics, January, 1917) states that in treating in- 
fected wounds, the following resources are em- 
ployed in the American Hospital in \'ienna : i. Re- 
moval of infected bits of clothing, or other infected 
foreign matter. 2. Wide incision and drainage. 3. 
Immobilization. 4. Continuous irrigation by the 
drop method with Dakin's solution of sodium hypo- 
chlorite, or continuous immersion in hot antiseptic 
solutions, as acetate of aluminum. 5. Stimulation 
of lymph drainage with Wright's solution of sodium 
citrate one part, sodium chloride four parts, and 
water ninety-five parts. 6. Regular and prolonged 
daily exposure to the rays of the sun. 7. Continu- 
ous exposure of all wounds to the air without 
dressings whenever possible to avoid foreign body 
reaction. 

The Heart of the Recruit and Soldier. — E. Kil- 
bourne Tullidge (Military Surgeon. January, 1917) 
is of the opinion that the treatment of that condition 
now generally known as the irritable heart of sol- 
diers should be devoted not only to the mental side 
of the condition, but to the increase in the health of 
the body as a whole, in such a manner as will in- 
crease assimilation, natural resistance to infection, 
and elimination of detrimental toxic influences, by 
building up the man both physically and mentally. 
Open air and graduated exercises are needed, regu- 
lar hours for sleep and rest, wholesome easily di- 
gested food, and a daily talk, all of which are con- 
ducive to a recuperative termination that will enable 
the soldier to resume his duty at the front. Digi- 
talis is in reality useless in the nervous forms of 
these disorders. Sleep, combined with psychother- 
apy, are the chief factors in the cure, extending over 
a maximum period of from two to three weeks. 

Removal of Stones from the Kidney. — William 
J. Mayo (Surgery, Gynecology, and Obstetrics, Jan- 
uary, 1917) says that pelviolithotomy is the most 
generally useful operation for stone in the kidney. 
As shown by Brodel, the anterior row of calyces 
and the anterior half of the posterior row in about 
ninety-five per cent, of the cases are supplied by the 
anterior renal arteries and the kidney is notched on 
the posterior surface. In the small remainder the 
contrary is true. The kidney is separated from its 
fatty capsule and brought well up into the wound 
so as to expose the pelvis in the notch. If the stone 
is felt, it is removed by direct incision, and a search 
is made with the finger within the pelvis for others. 
The pelvis is then sutured with catgut, the kidney 
dropped back into position, carefully surrounded by 
its fatty covering, which should not have been lacer- 
ated in the separation, and two or three rolls of 
nibber tissue are introduced into the kidney space 
to provide temporary drainage. If the stone cannot 
be felt, needling or pummeling in an efifort to con- 
firm the X ray diagnosis injures the kidney and 
serves no good purpose. The pelvis of the kidney 
should be exposed by dissecting tbe fatty tissues 
back from it in a fiaplike manner, and the stone 
located by the finger introduced through an incision 
into the pelvic cavity and removed. The capsule 
should then be sutured and the fascial flap sutured 



in position. The kidney should then be dropped 
back within the fatty capsule and the rubber tissue 
drains introduced. Drainage of the pelvis of the 
kidney is rarely required after pelviolithotomy for 
uncomplicated stones in the pelvis. If necessary, it 
should be done not through the pelvis, but by coun- 
ter puncture through one of the calyces, preferably 
the posterior inferior calyx. 

Salvarsan in the Treatment of Syphilis. — 
H. N. Cole (Ohio State Medical Journal, January, 
1917) states that he uses as a routine initial dose 
0.2 gram salvarsan intravenously in a female and 
0.3 gram in a male. The injections are given at 
intervals of from four to seven days and are in- 
creased by 0.1 gram each week up to a maximum 
dose of 0.4 gram in a female and 0.5 gram in 
a male. Five or six injections constitute a course 
of treatment. The number of injections necessan, 
in a given case varies — the most he has given has 
been twenty-eight. He does not use salvarsan alone, 
but combines it with gray oil, which is administered 
intramuscularly. The Canadian preparation, diarse- 
nol, dissolves readily, but the Philadelphia product, 
arsenobenzol, requires more violent shaking with 
glass beads and heated water. They are all neu- 
tralized by the addition of fifteen per cent, sodium 
hydrate solution. He does not approve of using a 
syringe and injecting it into the arm, but prefers 
the cylinders. Neosalvarsan is not employed except 
for intramuscular injections in children. The un- 
toward symptoms are usually not severe. With the 
Canadian product they are about two or three times 
as frequent as with salvarsan. Arsenobenzol is 
recommended as being superior to diarsenol. 

Treatment of Trichinosis with Thymol. — Brad- 
ford A Booth, William N. Goehring and Max 
Kahn (Journal A. M. A., December 30, 1916) state 
that thymol has been advocated in the treatment of 
trichinosis for the removal of the parasites from 
the intestine, but cases are seldom seen or diag- 
nosed before lodgment of the parasite in the tis- 
sues has taken place. The oral administration of 
thvmol for the destruction of the parasite after 
lodgment is futile since the drug, when thus given, 
has its antiparasitic powers neutralized by the liver. 
If introduced parenterally a large portion of the 
drug might be expected to be taken into the blood 
stream and be carried to the muscles before pas- 
sage through the liver. This was accomplished in 
a case, reported in detail, by the subcutaneous or 
intramuscular injection of the drug, with the result 
that recovery from the symptoms of muscular in- 
vasion was very prompt. Some of the thymol was 
recovered from the urine as such, the remainder ap- 
pearing in the combined form in which it is found 
after absorption from the gastrointestinal tract. The 
administration of the drug was shown to destroy 
the parasites in the muscles by the production of 
an immediate and enormous rise in the number of 
eosinophiles in the blood. The drug was given in 
solution in olive oil of such strength that each mil 
represented sixty-five milligrams of the drug. This 
oily solution was carefully autoclaved before and 
after the addition of the thymol. The dose used 
was two to three mils daily for a week. No toxic 
effects were produced. 



Januarj'^>^. '9i~-] 



MODERN TREATMENT AND PREVENTIVE MEDICINE. 



133 



Treatment of Anorectal Hemorrhage. — Samuel 
Goodwin Gant {Xczi' York State Journal of Medi- 
cine, December, 1916) asserts that bleeding from 
the stomach, small intestine, or colon associated with 
rectal hemorrhage should be treated by placing the 
patient in bed, withholding all solid food, and giving 
morphine to relieve pain and diminish peristalsis, a 
mild laxative to secure soft stools, and calcium 
chloride, gelatine, or bismuth. Normal horse serum 
may be administered for very severe intractable 
bleeding. Styptics should not be depended upon and 
heart stimulants should be avoided. When the hem- 
orrhage comes from recurrent coloproctitis, irriga- 
tions rectally or through an appendicostomy should 
be given. These should consist of four per cent. 
boric acid ; ichthyol, three to five per cent. ; balsam 
peru, four per cent. ; or of two per cent, potassium 
permanganate. A high enema of warm silver ni- 
trate solution is also valuable. In the rectum bleed- 
ing lesions are healed by adding to the irrigations 
the topical application of eight per cent, balsam 
of peru, twenty per cent, argyrol, or by touching the 
spots with a cautery. Active bleeding can be con- 
trolled by packing the rectum with gauze soaked 
with perchloride of iron, alum, tannic acid, or epine- 
phrin. Ligature of the bleeding vessels, clamping 
them, or the application of the actual cautery may 
be necessary, and the use of a Gant pyramidal com- 
press over the anus is also of great service in some 
cases. 

Comparative Study of Salvarsan and Neosal- 
varsan. — William B. Trimble and John J. Roth- 
well {Journal A. M. A., December 30, 1916) state 
that the conflicting statements made in the literature 
and heard among medical men induced them to carry 
out a comparative study of the effectiveness of these 
two preparations and of their advantages in the 
treatment of syphilis. The drugs were given in- 
travenously, the doses for each arbitrarily fixed, the 
patients unselected, and the remaining treatment 
made nearly uniform. Salvarsan was given in an 
initial dose of 0.3 gram and in subsequent doses 
of 0.6 gram ; neosalvarsan was given in an initial 
dose of 0.45 gram and in subsequent doses of 
0.9 gram. The effects of the treatment were 
carefully recorded and compared when the work- 
was completed. Clinically no difference could be de- 
tected between the two preparations so far as their 
therapeutic value was concerned. The disappear- 
ance of the lesions was as rapid and complete after 
the one as after the other. The reactions produced 
by salvarsan were much more frequent than those 
occurring from neosalvarsan. and several severe re- 
actions followed the former drug, while none oc- 
curred after the latter. Serologically, neosalvarsan 
seemed decidedly the better drug, for in patients re- 
ceiving the same number of doses of each of the 
drugs, there were forty per cent, of negative react- 
tions produced by neosalvarsan as against about 
seven per cent, by salvarsan. The former drug had 
the further advantage of easier administration. In 
the course of this studv the fact was also brought 
out that a course of four injections of either of 
these arsenicals alone is insufficient treatment, and 
should alwavs be followed by mercurial treatment. 
More than four doses of the arsenical should also 
be given to most patients. 



Treatment of Filariasis and Elephantoid Con- 
ditions by Intramuscular Injections of Salvarsan. 

— J. G. ^IcNauglUon {Journal of Tropical Medi- 
cine and Hygiene, November i, 1916) reports 
from the Ellice Islands good results with 0.3 
gram intramuscular injections. The conditions 
benefited included both elephantoid fever and 
the tissue enlargements characteristic of ele- 
phantiasis. The fever was at times overcome 
within a few hours of the injection, and the 
filariffi disappeared from the blood under the in- 
fluence of the remedy. Enlargements of at least 
ten years' standing in the extremities seemed to 
diminish in size after the treatment. He is enthusi- 
astic about the remedy, believing the disease should 
be completely wiped out through its use. 

The Influence of Acidosis on Hyperglycemia 
in Diabetes Mellitus. — Albert A. Epstein and 
Joseph Felsen iy American Journal of Medical Sci- 
ences, January, 191 7) draw the following conclusions 
from their observations : i. The withdrawal of food 
from certain cases of diabetes provokes or aggra- 
vates the acidosis. 2. The acidosis causes an in- 
crease in the blood sugar content in two ways : by 
augmenting the mobilization of sugar, and by affect- 
ing the sugar secreting function of the kidneys. 3. 
Liberal, but judicious administration of carbohydrate 
may control the acidosis provoked by the withdrawal 
of carbohydrates or complete fasting, thus leading 
to a general amelioration of the diabetes. 4. A pro- 
gressive rise in the blood sugar content, associated 
with a gradual fall in the alveolar carbon dioxide, is 
indicative of impending coma. 

Treatment of Circulatory Failure in Acute In- 
fections. — Malcolm Goodridge {American Journal 
of Medical Sciences, January, 1917) reaches the fol- 
lowing conclusions: i. There is neither clinical nor 
experimental evidence to support the belief that fail- 
ure of the vasomotor centre is the cause of the symp- 
toms of circulatory failure which occur in acute 
infectious disease. 2. While it has been shown ex- 
perimentally that the heart is not exhausted in ani- 
mals dying of acute infectious diseases, there is no 
positive proof that the myocardium is wholly effi- 
cient in its effort to maintain the circulation in the 
body of the living animal under such circumstances. 
3. The hypothesis which suggests the existence of 
a third centre controlling the flow of blood is im- 
portant, even though it is not yet proved. 4. Al- 
cohol and strychnine are absolutely worthless drugs 
in the treatment of circulatory failure. 5. Epine- 
phrin and pituitary extract are useful in the treat- 
ment of sudden circulatory collapse, but their action 
is not a sustained one. 6. The nitrites are valu- 
able additions to our therapeutic armamentarium in 
the treatment of pulmonary edema under certain 
circumstances, because of their selective action in 
constricting the pulmonary arteries. 7. Caffeine in- 
creases the flow of blood when the supply to the 
heart is inadequate, probably by an action on some 
mechanism outside of the heart. 8. One of the 
most important contributions of recent times on the 
action of digitalis is the proof electrocardiographi- 
cally that it exerts precisely the same effect on the 
heart in febrile conditions that it exercises in non- 
febrile states, and whether the rhythm is initiated 
in the normal pacemaker or not. 



134 



MODERX TREATMENT AND PREVENTIVE MEDICINE. 



INew York 
Medical Journal. 



Localized Hyperhidrosis. — Arthur William 
Stillians {Journal A. M. A., December 30, 19J6) 
states that the most efficient remedy for this very 
annoying condition is aluminum chloride. It should 
be used in the form of a twenty-five per cent, solu- 
tion in water and gently mopped upon ihe affected 
part every second or third day for three applica- 
tions. After each application the skin should be 
allowed to dry thoroughly. This course will usu- 
ally control the symptoms, but it may be repeated 
if there is a return of symptoms. One application 
may be used weekly if desirable to prevent further 
recurrence. Excessive use of the drug will cause 
itching or stinging sensations and carelessness of 
application or subsequent scratching may induce a 
dermatitis. These occurrences can be controlled by 
stopping the use of the application and employing 
cold cream containing twelve per cent, of boric 
acid or of calamine lotion with or without half of 
one per cent, of phenol. The aluminum chloride 
applications should never be made to portions which 
have become irritated from scratching or other ap- 
plications until the skirt has been treated and has re- 
turned to normal. 

Treatment of Fracture of the Nose. — J. Molinie 
{Presse mcdkale. November 20. 1916) lays stress 
on a vertical position of the ;iasal setrtuni as a sine 
qua lion of successful treatment of fracture of the 
nose ; failure to secure this condition interfering 
both with the permeability of tlie nasal cavities, and 
external symmetry of the nose. Applying this prin- 
ciple in the treatment of cases occurring in militarj 
practice, he has constructed a flat jawed forceps 
with parallel motion which permits seizing the 
septum in its entire altitude, straightening it, and 
bringing the whole of it back into the vertical me- 
dian plane. To maintain it in position during the pe- 
riod of consolidation he uses an apparatus compris- 
ing bilateral and jointed internal splints that can be 
folded and opened at will. These are introduced 
through the nostrils in the folded position, then 
spread and applied on each side of the septum. Ex- 
clusively external treatment of nasal fractures is 
thus done away with. Such external treatment 
leads almost always to nasal stenosis, especially when 
fracture has resulted from the passage of a projec- 
tile through the face. 

Electrical Treatment of the Wounded. — W. J. 
Turrell {Lancet, December 16, 1916) states that the 
methods of electrical treatment of various disabili- 
ties, including those resulting from military wounds, 
are not appreciated at their real worth. Ionization 
with two per cent, sodium chloride solution gives ex- 
cellent results in a variety of conditions, such as 
subacute and chronic rheumatism, neuritis, sciatica, 
impetigo, sycosis, stiff joints, and septic and idolent 
wounds. The applications should be made with 
large pads and strong currents and they should be 
of as long duration as possible. .Such ionization 
followed by massage and maniijulation gives good 
results also in cases with fibrous bands and adhesions 
restricting motility of a joint. In the case of indo- 
lent wounds, zinc may well be substituted for the 
common salt, and after a few applications change 
may profitably be made to the use of ultraviolet ra- 
diation. In foul, sloughing wounds sodium chloride 



ionization quickly checks the odor and promotes 
prompt healing with soft scars. In cases of nerve 
injury rhythmically reversed faradism is applied if 
the nerve reacts to the faradic current ; if not rhyth- 
mically reversed galvanism is applied. Tone may 
be restored and maintained in damaged muscles by 
the use of Bergonie's apparatus. Cases with ver\' 
severe pain can be relieved promptly by the use of 
diathermy, which also reduces the congestion and 
promotes the removal of stasis. Diathermy is also 
very serviceable in the alleviation of the pain of 
sciatica, neuritis, lumbago and allied conditions, and 
in overcoming muscular spasm. In the use of dia- 
thermy the current should be applied slowly and in 
the right direction, should be continued for a mini- 
mum of fifteen to twenty minutes, as great a heat- 
ing effect as is consistent with safety should be se- 
cured, and the size of the pad and electrode should 
be selected to fit the part. Both high frequency 
vacuum tube application and ultraviolet radiation 
are useful for the pain of trench feet and other 
similar conditions. For the breaking down of ad- 
hesions the Morton static wave current is very effi- 
cacious. It also hastens the absorption of fluid from 
inflamed joints, diminishes stasis, and reduces local 
congestion. 

Removal of Foreign Bodies from the Media- 
stinum. — Rene Le Fort {Bulletin de I'Academie 
dc mcdecine, November 28, 1916) states that in- 
stances of foreign bodies, such as a rifle bullet, 
shrapnel, or shell fragment, in the mediastinum are 
by no means rare. Operative removal, however, is 
seldom undertaken. This is due chiefly to deficien- 
cies in the classical methods of exposing the medias- 
tinum. Experience has convinced Le Fort that the 
best route of extraction is, in the majority of cases, 
both for the anterior and the posterior mediastinum, 
through the pleura anteriorly. A flap with external 
base is made, comprising generally three ribs — the 
second, third, and fourtli above, the third, fourth, 
and fifth below, and the sixth in the case of bodies 
behind the heart in contact with the diaphragm. Ex- 
tensive resection of the sixth rib alone also proved 
serviceable for exploration of the interior medias- 
tinal region. Through the costal flap, inspection and 
palpation of the heart, ascending, horizontal, and de- 
scending aorta, from heart to diaphragm, all the 
great vessels, and, in a word, of the whole medias- 
tinum from sternum to spinal column, are easily 
feasible. The resulting pneumothorax is easily 
withstood by the patient. Pleural adhesions do not 
contraindicate the transpleural procedure ; in a case 
with complete adherence, the lung was simply 
stripped from the surrounding tissues with a com- 
press, as in the procedure followed in hernia cases 
in loosening the sac. Various foreign bodies were 
thus removed from behind the heart and in contact 
with the great vessels in a series of twelve cases, 
all of which recovered. In a single instance, the for- 
eign body had to be left in — a shrapnel ball situated 
behind the left pulmonary veins near their points of 
origin, the tearing of tissues necessary to free the 
projectile causing alarming periods of cardiac ar- 
rest. Removal of foreign bodies from the medias- 
tinum should alwavs be preceded by a complete x 
rav examination. 



MODERN TREATMENT AND PREVENTIVE- MEDICINE. 



135 



Treatment of Pellagra. — L. H. Howard {Char- 
lotte Medical Journal, December, 1916), as the re- 
sult of treating hundreds of cases, asserts that over 
eighty-five per cent, of cases are curable ; that diet 
alone will not cure; that the true cause of pellagra 
has not yet been found, and that it is transmissible. 
In the treatment he has found arsenic in the form 
of cacodylate of sodium, gold in the form of solu- 
tio aurii et sodii chloridi, nuclein and protonu- 
clein in tablet form, and Cooper's well water of great 
value. The following foods are recommended in 
the order of their importance : Fresh beef, milk, 
eggs, fresh fish, oysters, game or wild fowls, vege- 
tables, nuts, fruits, bread, and cereals. 

Treatment of Strictures with the Pneumatic 
Sound. — C. E. Woods (Urological and Cutaneous 
Revieiv, January, 1917) uses a pneumatic sound 
which is made of rubber, tubular in shape, and closed 
at one end only. Its walls have a greater resistance 
than the walls of the stricture. The pneumatic 
sound is lubricated and introduced in the same man- 
ner as a soft rubber catheter. If the stricture is a 
20 F., then an 18 F. pneumatic sound can be com- 
fortably inserted. The nozzle of the pump is lubri- 
cated and inserted firmly into the opening of the 
sound, and then pressure is exerted until the patient 
begins to feel that the stricture is comfortably 
stretched. Then the sound is clamped and a reading 
is made. When the maximum distention is reached 
the tube is clamped and allowed to remain in place 
for from ten to twenty minutes. The air is then 
slowly withdrawn and the sound removed. Treat- 
ments can be given every second day, in some cases 
daily. As a result of his experience he concludes 
that: I. The resistance of strictures has been 
greatly overestimated ; 2, this method produces more 
dilatation and better drainage without trauma than 
either the steel sound or dilator; 3, the pressure is 
exerted uniformly on the stricture and the diameter 
of the stricture increases in direct proportion to the 
diameter of the pneumatic sound ; 4, the stricture 
can be treated without pa:in and the time required 
for a cure is twentj^-five per cent, to fifty per cent. 
less than the time consumed in treating by steel 
sounds or dilators. 

The Heat or Percy Treatment of Cancer of the 
Uterus. — J. D. Rogers {Virginia Medical Semi- 
monthly, November 24, 1916) writes very favorably 
of this method, which is based on experimental 
work showing that a temperature of 115° F. ap- 
plied for fifteen minutes will kill cancer cells and 
can be made to penetrate two and a half inches, 
while normal tissue withstands 130° F. In applying 
the method, the abdomen is first opened and the 
extent of pelvic and abdominal metastases, if such 
exist, ascertained. The intestines are packed ofif 
in the usual manner and, if possible, the internal 
iliac and ovarian arteries ligated to prevent second- 
ary hemorrhage. Tincture of iodine or Harring- 
ton's solution is applied to the entire vaginal sur- 
face, a water cooled vaginal speculum inserted, the 
cervix grasped with a vulsella, and a small tip 
Percy cautery inserted. Grasping the uterus, the 
hand in the abdomen directs the cautery' and deter- 
mines the degree of heat applied. Heat is applied 
to different parts of the growth, larger sizes being 



used as one proceeds, care being taken never to em- 
ploy such a degree of heat that the uterus cannot be 
held in the gloved hand. The procedure lasts one 
hour, or until all tissues that were at first fixed in 
the pelvis have become freely movable. The opera- 
tion requires experience and good team work in the 
operating room, but unlike radium and x ray treat- 
ment, its cost is not prohibitive. Many of the pa- 
tients show marked improvement, both locally 
and constitutionally, after the treatment. Many cases 
otherwise considered inoperable on account of ex- 
tension into the parametrium are converted by it 
into good surgical risks for simple or radical hyster- 
ectomy. It should be resorted to as a preliminary 
step in most hysterectomies for carcinoma, especially 
of the cervix. In very early cases the application of 
heat and hysterectomy might be done at one sitting. 
An advantage of the heat treatment is the lessened 
virulence of metastasis if the latter occurs in an ad- 
vanced case. 

Surgical Treatment of Exophthalmic Goitre. — 

George W. Crile {Ohio State Medical Journal, Jan- 
uary, 1917) summarizes the treatment of exophthal- 
mic goitre, based on the results of 1,477 operations 
for goitre performed by himself and his associates. 
Of these, 674 were for exophthalmic goitre. He 
asserts that the treatment comprises: i. A period 
in which nonsurgical treatment has been tried. If 
this has been done without avail then ; 2, surgical 
procedures to break the force of the disease are indi- 
cated ; and 3, a period in which the greatest possible 
degree of restoration for those organs which may 
have been damaged by the disease is accomplished 
by rest, and by dietetic and hygienic management. 

Fecal Incontinence. — Samuel G. Gant {Penn- 
sylvania Medical Journal, December, 1916) describes 
the prophylactic treatment of this condition, consist- 
ing in preserving the nerves and not nipping the 
anus muscle in anorectal operations. A fistula should 
be divided once and at a right angle. Rectal wounds 
should be drained and not packed, and the fingers 
should be used in place of a mechanical dilator when 
divulsing the sphincter. Nonoperative treatment is 
not reliable, but tonics, cold astringent solutions, 
massage, vibration, and galvanism may strengthen 
the sphincter. The preparation for fecal incontin- 
ence operations consists in thoroughly emptying the 
bowels with laxatives and enemata and then inhibit- 
ing it with morphine, flushing the rectum with 
twenty-five per cent, hydroxid just before the opera- 
tion, swabbing the bowel with an antiseptic, and 
painting the perianal skin with iodine before work 
is begun. Where elaborate perineorrhaphy is per- 
formed chromicized catgut is used for buried su- 
tures, and plain catgut for superficial sutures. He 
has devised an operation which can be done under 
local anesthesia, and which requires only about ten 
minutes. In seventeen cases reported it was com- 
pletely or partially cured in sixteen. In deplorable 
cases where plastic operations fail an artificial anus 
is established. The best operative treatment consists 
in restricting the diet to fluids, regulating the stools, 
cleansing and protecting the wound, and prescrib- 
ing morphine and belladonna hypodermically to ease 
pain and quiet the muscles until the wound is healed. 



Miscellany from Home and Foreign Journals 



Fraud and Skin Eruptions. — John Collie {Lan- 
cet, December lo, 1916) states that the characteris- 
tics of artiiically produced skin eruptions may be 
summarized as follows: i. The condition is unlike 
that found in any of the usual skin diseases. 2. The 
eruption or lesions appear in situations easily 
reached by the right hand in right handed persons 
and the left in le'ft handed persons. Favorite sites 
are the fronts of the arm and forearm, and of the 
leg and thigh. 3. The regions about the mouth, 
nose, ear, scalp, knees, hands, and genitalia usually 
are not affected and between the shoulder blades the 
skin is almost always found to be normal. The 
soles of the feet are also seldom affected. 4. The 
lesions are often characteristic, running longitudin- 
ally along the limb, or having curious shapes, such 
as perfectly circular ulcers ; parallel scratches, run- 
ning in straight lines ; having straight margins or 
presenting evidences of a drop of irritating fluid 
having run down from the point of application. 5. 
The surrounding skin is healthy. 6. Sensation of 
the part is usually abnormal, being either excessive- 
ly painful or almost anesthetic. 7. The lesions may 
appear to order, as following an incidental sugges- 
tion by the examiner. Finally much help in diag- 
nosis can be obtained in many cases by smelling the 
lesion to detect irritants, by applying an efficient 
permanent occlusive dressing, and by examining for 
stigmata of hysteria, such as anesthesias and pares- 
thesias and loss of sensation in the palate. In other 
cases the deception may be more difficult to detect 
than in the purely artificial skin lesions through the 
willful maintenance of a preexisting skin disease. 
Finally, some of the forms of trade or occupational 
dermatitis may be kept up by the victim in order to 
secure the rewards for illness without having to 
work. 

Clinical Diagnosis of Luetic Aortitis. — I. J. 
Levy {Archives of Diagnosis, October, 1916), hav- 
ing in mind the early diagnosis of this condition, 
before the anatomical destruction is beyond repair, 
divides the course of the disease into three clinical 
periods, based upon the different pathological stages. 
In the primary stage, transient pains in the chest 
may be the only complaint. Physical examination 
and the x rays are negative. A positive Wasser- 
mann reaction, however, in a subject in the early 
forties with indefinite chest pains, is strong pre- 
sumptive evidence of a beginning luetic aortitis. In- 
deed, ninety per cent, of individuals with positive 
Wassermann show evidence of luetic changes in the 
aorta, providing the disease has been present fifteen 
years; and sixty per cent, of these patients die of 
their aortitis. In the second, or advanced, stage, 
few if any s}mptoms may similarly exist, the de- 
creased aortic elasticity being usually compensated 
for by concentric cardiac hypertrophy. Anginalike 
pains, or true angina, may be the only warning sig- 
nal. Dyspnea on exertion and palpation are also 
early symptoms, and there may be general physical 
w-eakness or neurasthenic manifestations. Probably 
late in this stage the aortic valve becomes diseased, 
and the x ravs mav reveal diffuse aortic dilatation ; 



but a positive Wassermann is practically obligatory 
for a reliable diagnosis. Only in the third, or final, 
stage is the classical clinical picture of luetic aortitis 
observed, with frequent and severe anginal pains, 
dyspnea, and edema of the lower extremities, and 
nocturnal asthmatic attacks. Diffuse aortic dilata- 
tion is an important factor in the diagnosis, and 
there is a characteristic ringing quality to the second 
aortic soimd. A positive Wassermann, if the spe- 
cific infection is not of recent origin, is practically 
conclusive evidence. The cases with aortic insuf- 
ficiency are much more easily diagnosed. In these 
the diastolic murmur is often more distinctly audi- 
ble over the mitral area. When the heart has broken 
under the strain, one sees little response to rest and 
digitalis. The patient may, however, be left par- 
alyzed before cardiac decompensation supervenes, 
and undoubtedly general paresis or tabes sometimes 
closes the scene in a latent aortitis. 

Bronchial, Pulmonary, and Pleural Disease. — 

Frederick T. Lord {Journal A. M. A., December 30, 
1916) lays great emphasis upon the value of a 
proper history and of physical examination in the 
diagnosis of disease of the respiratory tract. The 
evolution and progress of individual symptoms and 
their order of appearance are of very great diagnos- 
tic value. These points are of especial importance 
in such conditions as lobar pneumonia, pulmonary 
infarction, aspirated foreign bodies, bronchial and 
cardiac asthma, in the detection of the cause of an 
apparent chronic bronchitis, and in the determina- 
tion of the etiology of hemoptysis and of pleurisy. 
Physical signs may be divided into two classes: i. 
Dullness, bronchial breathing, and increase of voice, 
whisper, and of tactile fremitus ; all of which are 
common to lobar pneumonia, bronchopneumonia, 
pulmonary infarction, and retraction or compression 
of the lung. 2. Dullness, diminished or absent 
breathing, voice, whisper, and fremitus ; which are 
common to massive pneumonia, tumors of the pleura 
or lung, pulmonary cysts, and atelectatic areas from 
bronchostenosis. Resonance replacing the dullness 
of the second group is indicative of pneumothorax. 
Certain other points of value are brought out by 
him. For example, in a case of aspirated foreign 
body immediate effort should be made to remove it 
through the bronchoscope; the usual therapeutic 
procedures such as shaking, the use of emetics, etc.. 
should not be tried ; and finally the chance of 
spontaneous expulsion does not justify delay in 
treatment. Postoperative pulmonary conditions 
occur in not less than two per cent, of cases of gen- 
eral anesthesia and constitute one-fourth of all 
deaths following operations under general anesthe- 
sia. Pulmonary abscess is not at all uncommon as 
a postoperative complication of operations in the 
nasal or pharyngeal tract. The etiology of chronic 
bronchitis was found to be some form of cardiac 
failure, arteriosclerosis, or nephritis in sixty-three 
per cent, of the cases coming to autopsy. Pulmon- 
ary tuberculosis was the cause of the next largest 
group of cases thus diagnosed. 



January 20, tgi^.] 



MISCELLANY FROM HOME AXD FOREIGN JOURNALS. 



137 



Second Primary Cancers. — Douglas Drew 
{British Medical Joiinial, December i6, 1916) re- 
ports two cases of what seemed to be second 
primary carcinomatous growths in the remaining 
breast after the removal of the other at an earlier 
date for carcinoma. In one case the second growth 
appeared in the remaining breast thirty-nine months 
after the removal of the other breast; in the second 
case the interval was twenty-one months. He re- 
gards the cancers in the remaining breasts in these 
two cases as instances of second primary cancers 
because there were no evidences in either case of 
any recurrences of the original growth during the 
interval following the removrd of the breast first 
affected. 

Meningococcal Infection Without Meningitis. 
— W. M. Elliott (La)tcct. December 16, 1916) re- 
ports the case of a soldier, nineteen years old, hav- 
ing symptoms strongly suggestive of typhus fever. 
There were general malaise, general pains in the 
back and extremities, shivering and high fever. A 
rash consisting of erythematous blotches, petechial 
spots, and very shallow vesicles was present. The 
mental condition of the patient was perfectly clear. 
There was a critical fall of fever on the sixth day. 
I'hysical examination showed no definite signs and 
there were no evidences of meningitis, even the 
spinal fluid being normal. Specimens of the pa- 
tient's blood showed agglutination of the meningo- 
coccus and very marked complement deviation when 
tested against emulsions of this organism. 

Milk Borne Infection. — Eugene R. Kelley 
Uounml A. M. A., December 30, 1916) states that, 
taking diphtheria, septic sore throat, scarlet fever, 
and typhoid as the commonest epidemic diseases 
which may be spread through milk contamination, 
all outbreaks of these were carefully studied for a 
period of five years to determine the frequency with 
which milk was to be regarded as the actual means 
of their dissemination. The results showed that 
the transmission of the disease could be definitely 
assigned to milk in seventy-nine per cent, of the 
cases of septic sore throat, in six per cent, of the 
cases of typhoid fever, in 1.6 per cent, of scarlet 
fever, and in 0.19 per cent, of cases of diphtheria. 
Taking all of the diseases together milk was the 
agent of spread in only four per cent, of the cases 
which occurred in the state of Massachusetts dur- 
ing the five year period under examination. From 
the point of view of the deaths caused, milk was re- 
sponsible for three per cent, of typhoid deaths, 0.08 
per cent, of diphtheria deaths, 0.8 per cent, of scar- 
let fever and ninety-eight per cent, of septic sore 
throat deaths. This gives an average for the entire 
group of only two per cent, of the total deaths from 
these diseases as due to milk. From these figures 
it is evident that milk is of great importance in the 
transmission of septic sore throat, which, however, 
is of relatively rare occurrence; that it is negligible 
as a factor in the cases of diphtheria and scarlet 
fever; and that it is of minor importance in the 
spread of typhoid. The menace of tuberculosis 
would seem to be the best justification for the prop- 
aganda for the supervision and control of our milk 
supplies, in so far as this seeks to suppress com- 
municable diseases. 



Demography and Its Relation to the Vital Statis- 
tics of Armies. — Weston P. Chamberlain {Mili- 
tary Surgeon, January, 1917) states that in the ten 
year period, 1890-1899, diseases of the digestive sys- 
tem were a little more common among whites, the 
proportion being 355.98 to 243.29. For the last 
decade in the United States, digestive disturbances 
were considerably more prevalent among white 
troops than among the colored, while in the Philip- 
pines the reverse condition was found. As regards 
one of the most serious of the tropical digestive 
diseases, viz., dysentery, Johnson points out that a 
race out of its own habitat is a greater prey to 
dysentery, owing to the adoption of a mode of life 
and diet unsuited to the necessities of the climate. 
He asserts that the mortality is usually greater 
among the native populations. In our own service 
during the past decade, it is shown that the relative 
number of admissions for dysentery in the Philip- 
pines varied greatly from year to year, but aver- 
aged over twenty per cent, lower for negro than for 
white troops. They were less than half as great 
for Filipinos. Death rates averaged per thousand 
for whites 0.4, for negroes 0.2, and for Filipinos 
0.1, but the total number of deaths are too few to 
give these figures a great deal of value. • 

Exophthalmic Goitre and the War. — Leon 
Berard {Bulletin dc l' Academic dc nicdecinc, No- 
vember 28, 1916) states that since the beginning of 
the war he has met with a relatively large number 
of cases of exophthalmic goitre in men from 
twenty to forty-five years of age. Some of these 
subjects had previously had small stationary goitres 
for a more or less prolonged period. The exoph- 
thalmic symptoms developed from physical or men- 
tal overwork, intoxication from poor food or water, 
or microbic infections — dysentery, typhoid, or para- 
tyj)hoi(l — in the form of light attacks of thyroiditis. 
In three cases, however, exophthalmic goitre ap- 
peared suddenly, following violent emotions, re- 
peated anxiety, or strenuous physical exertions. In 
a few days these three subjects found their necks 
growing larger, eyes protruding, pulse rate increas- 
ing, and mental state exhibiting restlessness and anx- 
iety. All three had diarrhea and lost considerable 
weight. Nervous shock, manifested essentially in 
vasomotor disturbances and transient or permanent 
changes in the ductless glands and central nerve 
cells, is held to be the starting point of such cases. 
The therapeutic indications in all varieties, whether 
due to fatigue, mental shock, or infections attending 
war, include prompt isolation of the patient in calm 
and comfortable quarters, where he may feel him- 
self completely safe. I-Iydrotherapy with tepid 
water should be utilized and one gram of quinine 
sulphate and two grams of sodium salicylate given 
on alternate days. Ingestion of fresh thymus 
and subcutaneous injection of the serum of thy- 
roidectomized animals may also cause notable im- 
provement. Where, after five or si.x months of such 
treatment, systematically carried out, the disturb- 
ance is only slightly reduced, surgical treatment 
should be resorted to, the more boldly since these 
subjects are, as a rule, young and resistant, with less 
serious cardiac impairment than prevails in the more 
chronic or older cases encountered during peace. 



138 



MISCELLAXV FROM HOME ,1.\D FOREIGN JOURNALS. 



I.N'lw Vork 
Medical Journal. 



The Toxemias of Pregnancy. — J. R. Losee and 
Donald D. \'an Slyke (^A)iicrican Journal of 
Medical Sciences, January, 1917) say that 
the toxemias of pregnancy can be attributed 
neither to faihire in diaminization of the 
aminoacids nor to the moderate degree of 
acidosis observed. The nature of the toxin 
or toxins remains unknown. The same is 
true of the nature of the functional disturbances 
which cause the abnormal nitrogen metabolism, yet 
the constancy of the low urea ratios in the urine 
in eclampsia, and of high ammonia in pernicious 
vomiting, lends support to the opinion that the nitro- 
gen distribution of the urine, in connection with all 
the data in the case, should assist in diagnosing the 
toxemias of pregnancy, and in differentiating them 
from such conditions as nephritis and transitory 
gastric disorders. 

Primary Tumors of the Fasciae. — G. Bolognesi 
{Rez'uc dc chirurgic. June, 1916) reports three 
cases of this type. Little on the subject was found 
in the literature. Leaving aside apparently fascial 
growths of the abdominal wall, the precise origin 
of which is, as a rule, doubtful, primary tumors of 
the fascise are commonest in the lower extremities, 
the next point of frequency being the back of the 
neck. Differentiation from tumors of muscles by 
palpation during contraction of the muscles of the 
part is a difficult and uncertain matter. The vari- 
ous types of tumor, including the two main varieties 
of connective tissue tumors — fibroma and sarcoma 
— and mixed forms, are all represented in these 
growths. One of the three cases was of giant cell 
sarcoma, another of hard fibroma, and the third of 
ossifying fibroma. The treatment is wholly sur- 
gical. In rlift'use neoplastic forms, however, the 
fascial focus is inoperable. Dift'erentiation of the 
fascial growth from involvement of the adjoining 
soft tissues is, in fact, an impossibility in the ma- 
jority of cases. 

Glucose Formation from Protein in Diabetes. — 
N. W. Janney (Archives of Internal Medicine, No- 
vember, 1916) states that he became convinced, from 
a critical study of diabetes mellitus and phloridzin 
diabetes, that glucose formation from protein is 
essentially the same in these two conditions, and 
deemed it justifiable to apply in the study of human 
diabetes the much more accurate results obtainable 
in phloridzin experiments. With a certain technic he 
found it possible thus to determine quantitatively 
the amount of glucose formed in the organism from 
ingested proteins. Isolated proteins were found to 
yield large amounts of glucose in metabolism, vary- 
ing from forty-eight to eighty per cent, according to 
the protein examined. The prevailing view that the 
animal or vegetable origin of a protein bears a rela- 
tionship to its ability to yield glucose in the system 
proved erroneous : the amovmts of sugar yielding 
aminoacids contained in the various proteins consti- 
tute the chief determining factor in this connection. 
.\s for the formation of glucose from body proteins 
themselves, these proteins were shown to yield 
about fifty-eight per cent, of glucose in metabolism. 
Cases showing a urinary glucose nitrogen ratio of 
3.4 to one or higher are to be regarded as grave; 
the lower the ratio, the better the prognosis. As 
the glucose excreted by the fasting diabetic is of 



protein origin, sugar formation from fat does not 
take place to any great extent in this disease. In 
food tables for diabetics, glucose formation from 
protein must henceforth be taken into account. Pro- 
prietary protein foods were found to present no ad- 
vantages over equal amounts of bread in diabetes, 
the large amount of protein present leading to the 
formation of considerable glucose in the system. 
Only by exclusion of all food, as in the Allen treat- 
ment, can a complete rest be given the sugar utihz- 
ing function of the organism. A diet containing 
moderate amounts of protein and fat and low in 
carbohydrates is, after all, the most judicious one 
for diabetics. 

Experimental Studies on the Relation of the 
Pituitary Body to the Renal Functions. — Motz- 
feldt [Journal of Experimental Medicine, January, 
1 91 7) holds that e-xtracts of the pituitary body exert 
a constant, physiological influence on the functional 
activity of the kidneys in human beings. This ac- 
tion consists in a checking of the flow of urine, it 
being most noticeable when there is a marked flow 
of urine. The results of his experiments upon rab- 
bits confirm his belief. He states, also, that during 
the past three years a number of cases of diabetes 
insipidus have been reported in which pituitary ex- 
tracts have checked diuresis to a considerable extent. 

The Production of Arteriosclerosis and Glomer- 
ulonephritis in the Rabbit. — Bailey (Journal of 
Experimental Medicine, January, 191 7) calls atten- 
tion to vascular lesions that occur in man following 
infectious diseases and reports a series of experi- 
ments made upon rabbits. Some of these were in- 
jected with diphtheria toxins alone, a second series 
with the toxins and pituitrin, and a number with 
pituitrin, and a number with pituitrin alone. The 
results showed that by the intravenous injections of 
large amounts of diphtheria toxin one can produce 
a vascular degeneration in rabbits of the entire aorta, 
the carotids to the base of the skull, the subclavians, 
the iliacs, and, for a varying distance distally, the 
brachials, femorals, and large abdominal vessels. 
There is also produced in the kidneys a marked vas- 
cular and parenchymatous degeneration. The pit- 
uitrin by itself did not produce any vascular degen- 
eration in the rabbits used. 

Experimental Purpura and Resistance of Ery- 
throcytes. — John H. Musser and E. B. Krumb- 
haar (Journal A. M. A., December 23, 1916) states 
that purpura was produced by the injection of an 
antiplatelet serum, but it was not possible to pre- 
pare a serum from pure platelets, there always be- 
ing some red cells included with them. The mech- 
anism by which the purpura was produced, there- 
fore, might have been due in part to the hemolytic 
property of the serum, conferred by the presence 
of the er}'throcytes. It was believed, however, that 
the hemolysis was due to that property common to 
all cytolytic sera, rather than to a specific hemolytic 
factor. These observations suggested that purpura 
might be due to a substance which simultaneously 
destroyed platelets and decreased the resistance of 
red ceils. In the experimental animals, as in human 
]nirpura, there was noticed both a prolongation of 
coagulation time and an increased ffagility of the 
red cells. 



Proceedings of National and Local Societies 



AMERICAN ASSOCIATION OF OBSTETRIC- 
IANS AND GYNECOLOGISTS. 

Tiventy-ninth Annual Meeting, Held at Indian- 
apolis, Indiana, September 25, 26, and 27, 1^16. 

The President, Dr. Hri.n O. Paxtzer. of Indianapolis. 
in the Cliair 

Appendicular Abscess Complicated by Hemor- 
rhage and Death. — Dr. Magnus A. Tate, of Cin- 
cinnati, Ohio, spoke of this condition as rare. The 
patient was a young woman who had her first attack. 
Her abdomen was opened through the right rectus, 
and drainage was profuse for six days. At the end 
of the tenth and eleventh days her condition was 
good ; on the twelfth day she complained of pain 
and nausea; on the morning of the thirteenth day 
there was hemorrhage from the wound, and on the 
fourteenth day her condition was alarming, death 
occurring the saine evening. Autopsy revealed a 
gangrenous sac, the size of a silver dollar, which 
was found in the mesentery, probably the site of 
hemorrhage. 

Dr. Albert Goldspohn. of Chicago, said that 
this case reminded him of an experience he had 
after a vaginal hysterectomy in a septic case a num- 
ber of years ago where, after a normal course fol- 
lowing operation, the patient began to bleed about 
two weeks after the wound had nearly closed. Af- 
ter futile attempts to stop the hemorrhage by local 
tamponing and the use of clamps, he saved the pa- 
tient's life by doing an abdominal section and ligat- 
ing the internal iliac arteries. 

Drainage for Pus Conditions in the Pelvis dur- 
ing Pregnancy. — Dr. Fr.\ncis Reder, of St. Louis. 
Missouri, stated that the most frequent cause of a 
pus accumulation in the pelvis during pregnancy 
must be attributed to a diseased appendix. A pel- 
vic abscess was the most insidious, with the excep- 
tion perhaps of a subphrenic abscess. The reason 
for this was that the diagnosis of appendicitis was 
often obscured by pregnancy. If the pains and fre- 
quent indispositions, which usually accompanied the 
pregnant state, were not scrutinized correctly and 
promptly interpreted by the physician, the primary 
clinical picture of an attack of appendicitis might 
be readily overlooked, and only recognized when the 
more serious phases of the disease had manifested 
themselves. 

Pregnancy did not in any way predispose to ap- 
pendicitis. On account of the anatomical changes 
which took place in the pelvis during pregnancy, ap- 
pendicitis might terminate in a pus formation more 
rapidly than in the nonpregnant state. A close 
study of the symptoms of an appendicular lesion 
during pregnancy might bring out some clinical 
points which diiTered from the usual clinical pic- 
ture as it was found in women who were not preg- 
nant. For instance, before any pus formation had 
taken place, the pulse and temperature might show 
little or no change. The pain was usually located 
in the epigastric region and remained there until the 
disease had reached the stage when all pain ceased. 

The triad douloureuse of Dieulafoy over the 



lower abdomen was so obscured by other conditions 
that it was usually blurred, and its presence there- 
fore lost. Even in an advanced pregnancy a read- 
ily recognizable rigidity of the right rectus was sel- 
dom encountered, and only exceptionally did palpa- 
tion reveal a tender spot over McBurney's point. 
Nausea and vomiting, two alarming symptoms in 
an attack of appendicitis, counted for naught dur- 
ing pregnancy because they were frequently associ- 
ated with the toxemia of the latter condition. 

Pregnancy favored the rapid development of the 
pathological stages of appendicitis, and a pus collec- 
tion might be found in the pelvis in a very short 
time. In one patient, pregnant five months, a dis- 
tinct fluctuation could be detected in Douglas's 
pouch by rectal palpation on the fourth day after 
a severe attack of so called indigestion. This pa- 
tient felt indisposed for only two days. On the 
third day she became very sick. No physician had 
been consulted before the third day. Operative 
treatment of pus accumulations in the pelvis during 
pregnancy was very important. The danger in- 
volved two lives, and prompt intervention was de- 
manded as soon as a diagnosis had been made. 

The most satisfactory and convincing evidence as 
to the presence of pus in the pouch of Douglas 
could be obtained by a rectal exaiuination. If the 
accumulation was considerable, no difficulty should 
be experienced in promptly detecting a fluctuating 
mass, even if the examining finger was inexperi- 
enced. In the treatment of a pelvic abscess com- 
plicating pregnancy two factors became' absolutely 
axiomatic ; first, prompt recognition of the collec- 
tion of pus and, second, the simplest surgical meas- 
ure for relief. 

Surger}' during the pregnant state must have its 
limitations, and they must be more respected in the 
latter stage of gestation. An abdominal operation, 
for example, could be done with less risk of inter- 
rupting pregnancy before the fourth month than 
after. Furthermore, the thoroughness with which 
an operative measure during early pregnancy could 
be carried out was fraught with less danger than in 
the latter stages. Great antipathy still existed to 
attacking a pelvic abscess through the rectum, large- 
ly because of the likelihood of infecting the abscess 
cavity. This was doubtful, inasmuch as it was one 
of nature's ways in relieving the organism of a pus 
accumulation in the pelvis. Patients relieved in 
this manner had usually suffered no untoward re- 
sults and their recoveries had been satisfactory. 

Dr. Herman E. Heyd. of Bufifalo, New York, 
said that in cases of appendicitis complicated with 
pregnancy miscarriage was apt to take place. Mis- 
carriage was likely to occur in typhoid fever com- 
plicating pregnancy. Undoubtedly a bacteriemia 
was established, and the fetus was injured by rea- 
son of the infected blood, and as a result the woman 
had a miscarriage. 

Dr. W. A. P). Sellman, of Baltimore, stated that 
he had had experience with two cases of appendicu- 
lar abscess complicating pregnancy, in a woman 
pregnant four months and the other in a woman 



I40 



PROCEEDINGS OF SOCIETIES. 



(New York 
Medical Journal. 



pregnant six months. One method of clcahng with 
these abscesses was opening through the vagina pos- 
teriorly into the cul de sac and by that means reach- 
ing the abscess, as suggested by Doctor Reder. The 
second method was opening the abscess through the 
rectum. He selected the abdominal route, made an 
incision, drained the cavity, leaving the drainage 
tubes in. His experience was that in appendicular 
abscesses it was necessary to drain the cavity for a 
longer period than that suggested by Doctor Reder. 

Dr. Roland E. Skeel, of Cleveland, Ohio, said 
that as regards making a puncture through the rec- 
tum in these abscesses he had used that procedure 
for ten years, but he would emphasize the fact that 
there must be an abscess cavity. If there was no 
abscess cavity with a thin wall, it would be danger- 
ous on account of peritonitis or rectal infection. He 
could recall cases of appendicular abscess which 
opened and drained through the rectum spontane- 
ously. 

Doctor Reder, in closing, said that in these cases 
he contented himself with draining and did not care 
to use a split tube for fear some irritation by pres- 
sure might e.xcite infection. 

Rupture of the Uterus; Recovery. — Dr. Rufus 
B. Hall, of Cincinnati, Ohio, reported a case of 
rupture of the uterus, followed by sepsis, with a 
walled off abscess, which was operated in thirty- 
seven days after delivery. The patient made a slow- 
but satisfactory convalescence and is now perfectly 
well. Rupture of the uterus during labor was a 
rare and dangerous accident. It was so dangerous 
that it was our duty to report every case in detail, 
whether the patient recovered or not, that the pro- 
fession might profit by the facts revealed in each 
individual case. From the history of the case and 
the subsequent findings at the time of the operation, 
the question was asked if it was possible that the 
unrecognized small rupture, causing leakage into the 
abdomen, might not be more frequent than was gen- 
erally believed. The case reported would suggest 
that as a possibility, because there were no symp- 
toms connected with the case that would suggest 
rupture of the uterus, and it was not suspected until 
revealed at the time of the operation. 

Dr. Henry Schwarz, of St. Louis, Missouri, said 
that there should be some, history accounting for 
cicatricial tissue or some weakening in the uterine 
wall. Without such a history, and without the symp- 
toms of scar, tallying with the symptoms of rupture 
of the uterus during delivery, he would hesitate to 
accept this case as one of rupture of the uterus oc- 
curring at the time of delivery. 

Dr. Edward J. III. of Newark, New Jersey, said 
he did not think Doctor Hall's patient had a rupture 
of the uterus. Rupture of the uterus always oc- 
curred in the lower and hardly ever or never in the 
upper segment. He spoke of no blood being in 
the abscess. There must have been some blood 
there if the woman had a rupture of the uterus. 
He had seen many cases of chronic suppurative 
metritis following labor in which abscess occurred 
near the anterior horn and after being opened and 
drained the patient got well, provided it was a single 
abscess. 

Dr. J. Henry Carstens, of Detroit, asked if this 
case might not have been one. of embolism of the 



uterus, where the muscle tissue degenerated, broke 
lose, and finally resulted in an infection of the ab- 
dominal cavity. 

Dr. Roland E. Skeel, of Cleveland, stated that 
rupture of the uterus belonged to one of two 
categories ; first, those cases in which there was a 
disproportion and after a prolonged labor there was 
a thinning out of the lower uterine segment and 
rupture occurred in the uterine cavity ; second, 
where degeneration of the uterine muscle took place, 
rupture might occur early in labor anywhere in the 
body of the uterus. 

Dr. Sylvester J. Goodman, of Columbus, said 
he wished to report two cases of rupture of the 
uterus which occurred in his service in the last few 
months. In the first case the diagnosis was not 
made until a week after the rupture occurred. In- 
fection took place with general peritonitis and pus 
everywhere. The abdomen was opened, and a dead, 
macerated fetus removed, hysterectomy done, and 
abdominovaginal drainage instituted ; the woman 
recovered. The other one was a case in which the 
diagnosis was made promptly by the attending 
physician. Appendicectomy was done by Doctor 
BaldwMu, abdominovaginal drainage instituted, and 
the patient made an uneventful recovery. 

Dr. O. H. Elerecht, of St. Louis, stated that if 
we recalled the dfiferent types of bicornate uteri and 
the different types of double uteri, occasionally we 
would see one that was open or very thin, and there 
was a disproportion between the one uterus and 
the other, the one being parasitic on the other, the 
tubes and ovaries being two in number only. There 
was a possibility that Doctor Hall's case was one 
of this type inasmuch as the patient did not mani- 
fest any of the classical symptoms which were 
found in a typical rupture of the uterus. 

Dr. James E. Davis, of Detroit, stated that 
Cullen some years ago repotted a hundred and fifty 
cases of cysts occurring from the Wolffian duct re- 
mains, between the anterior part of the uterus and 
bladder. Last year he had such a case. The cyst 
had become infected, in fact, most of these cysts 
became infected and were recognized following ob- 
stetric deliveries. In his case the woman mani- 
fested a septic temperature, beginning on the fourth 
day which continued for some eight weeks. When 
she came to operation an abdominal section was 
done and nothing was found to account for the 
conditions until he began to separate the bladder 
from the anterior portion of the uterus, and then 
he opened into a cystic cavity, which was infected, 
and which he diagnosed as belonging to this type 
of cyst. Doctor Hall's case might belong to this 
class of cases. 

Dr. Van Amber Brown, of Detroit, said there 
luight be something in the history of Doctor Hall's 
case that might throw light on the question. 

Dr. E. GusT.w Zinke, of Cincinnati, said there 
was an absence of injury to the organ, and if a 
rupture had taken place it was probably sponta- 
neous, due to some disturbance in the uterine wall. 
What was it that could disturb the uterine wall 
so as to result in a rupture of the uterus during 
delivery? Nearly everything was mentioned except 
one thing, and that was, there was a possibility that 
the placenta in some of its parts had undergone 



PROCEEDINGS OF SOCIETIES. 



141 



chorionic epitheliomatous degeneration and had de- 
stroyed the uterine musculature of that region. It 
might have been very hmited in extent. We could 
never tell when these malignant changes took place. 
There must have been a pathological process which 
produced tlie rupture of the uterus. 

Dr. Charles L. Bonifield, of Cincinnati, said 
that the woman might have received some injury to 
the uterus through the abdominal wall which might 
have caused a Hmited thrombosis. 

Rupture of the Uterus in Caesareanized Women. 
— Dr. John Nokval Bell, of Detroit, drew the fol- 
lowing conclusions: i. A Caesareanized woman was 
always in danger of uterine rupture in subsequent 
pregnancies and should be under careful observation 
for the last half of her gestation. 2. In case her 
puerperium following the first section was afebrile 
she might be allowed to go to term if she could be 
in the hospital for the last month of gestation ; oth- 
erwise the labor should be anticipated and opera- 
tion done at least two weeks prior to term. 3. That 
implantation of the placenta over the scar area un- 
doubtedly increased the danger of rupture, as did 
also afebrile puerperium following operation. 

Rupture of the Caesarean Scar. — Dr. Abraha.m 
J. RoXGY, of New York, drew the following conclu- 
sions: I. Spontaneous rupture of the Caesarean scar 
occurred in about three per cent, of cases. In most 
instances rupture took place during labor. Infre- 
quently it took place during the latter half of preg- 
nancy, especially in the last six weeks. 2. We had 
no means by which we could judge the strength of 
the scar. Rupture would occur in cases which ran 
an afebrile course and in which union of the wound 
was apparently by first intention. 3. One third of 
all cases that were operated for reoperated section 
showed evidence of inflaminatory reaction in and 
about the uterine wound. The result in such cases 
was a weakened scar. 4. Proper suturing of the 
uterine wound and exact approximation of the 
edges would not always prevent subsequent rupture 
of the scar. 5. The mortality rate of repeated sec- 
tion was smaller than that of primary Caesarean sec- 
tion, because these patients were more carefully 
watched by competent men. 6. A patient who had 
had a Caesarean section should not be allowed to go 
through a tedious or severe labor. If labor did not 
progress rapidly, repeated section should be per- 
formed. 7. When advising a patient to have a 
Caesarean section the management of subsequent 
pregnancies should be taken into consideration and 
discussed with one of the members of the family. 
8. As a general rule, it might be stated that fully 
seventy-five per cent, of women who had had a Cae- 
sarean section were delivered by repeated section 
during their subsequent labors. 9. The obstetrician 
should always bear in mind that Cjesarean section 
created a new problem for the woman, and there- 
fore he must carefully weigh the indications before 
he decided upon the abdominal route. He must re- 
member that the dictum, "once a Caesarean section, 
always a Cfesarean section," held true in fully seven- 
ty-five per cent, of cases. 

Dr. Palmer Findley, of Omaha, said that if 
ninety-seven women out of a hundred went through 
labor with a Caesarean scar successfully without in- 
tervention, the thing to do was to put the woman 



in a hospital, if possible, and be ready to interfere, 
but we should not adopt the method of Cjesareaniz- 
ing every woman who had had a previous Caesarean 
scar in the uterus. He did not think we should be 
guided by any three per cent, of chances except this : 
we should take every precaution to safeguard the 
woman in the event of imminent rupture of the scar. 

Dr. J. Henry C.\rstens, of Detroit, said he had 
had about fifteen patients upon whom he had per- 
formed Ca;sarean section a second time. In all of 
the cases there was pelvic deformity. There was 
not one of them that was Caesareanized for placenta 
praevia or eclampsia. He made it a point to have_ 
these patients go to .the hospital early, if possible," 
and operated on them two weeks before the expect- 
ed time of labor. He hesitated twice before he 
would sterilize a woman who had had no children. 

Dr. Henry' Schwarz, of St. Louis, said that he en- 
dorsed every word Doctor Findley had said. Within 
the last year he had delivered two women through 
the natural passages. One was a woman on whom 
Doctor Webster, of Chicago, had performed a Cae- 
sarean section on account of obstrtiction to delivery 
by an ovarian tumor. He had a Caesarean section on 
the other ]5atient years ago. The woman was 
brought to the hospital with a temperature of 104° ; 
she was intensely sapremic ; there was an ofifensive 
discharge from the uterus, with a dead, macerated 
fetus in the uterus. He removed the fetus. She 
was a young woman, and this was her first preg- 
nancy. After emptying the uterus and removing a 
subserous fibroid, which was situated on the left side 
of the uterus, close to the external os and blocking 
the pelvis, and after removing a smaller fibroid near 
the fundus, he closed the uterus, because the woman 
was young and had had no children. He delivered 
this woman about seven months ago through the 
natural passages. 

Dr. James E. Davis, of Detroit, stated that the 
problem from a pathological standpoint was this : 
First, we had a reduction of muscle tissue, and a 
degradation of normal tissue ; then we had a deg- 
radation of the connective tissue by the interposition 
within the cotniective tissue cells of syncytial cells. 
The connective tissue, while it might be in certain 
instances as strong as the muscle tissue, yet was not 
as resistant to the syncytiolysins which were formed 
from the syncytial cells, and wherever we had syn- 
cytial cells we had a tissue of very low resistance so 
far as its ability to withstand pressure was con- 
cerned. 

Dr. Irving W. Potter, of Bufifalo, said that he 
iiad done Caesarean section on a number of patients 
a second time without any trouble. One could not 
see the scar in the majority of cases from the out- 
side, but if he felt from below up, he would find a 
thinning in many of the cases, although it was not 
enough to make any special difference. 

Dr. A. Rongy, of New York, said that he had 
never sterilized a woman, unless she had had two 
children. He did not do a hysterectomy in these 
cases, but resected the tubes on either side and then 
embedded the cut ends of the tubes in the wall of 
the uterus. That was a safe procedure. 

Gunshot Wounds of the Abdomen in Pregnant 
Women. — Dr. Lewis F. Smead, of Toledo, Ohio, 
reported the case of a woman shot through the 



142 



PROCEEDINGS OF SOCIETIES. 



[New Vorc 
Medical Journal. 



abdomen, with the recovery of both mother and 
child. The bullet perforated the colon and the 
uterus of the mother, the placenta, and the hand 
of the child. Gunshot wounds of the abdomen were 
more dangerous during pregnancy than at other 
times. The abdomen should be opened in all cases 
if possible. The uterus at full term should be emp- 
tied by C;esarean section and at earlier periods if 
the organ was badly injured. A uterus during labor 
was likely to spread any infection which was free 
in the abdomen and a pregnant uterus was there- 
fore a menace to the patient if peritonitis developed. 

The uterus would usually be emptied by Csesarean 
section or hysterotomy because the abdomen was 
open. Hysterectomy was usually not indicated in 
gunshot wounds of the abdomen unless the uterus 
was badly lacerated. Drainage should always be 
used in these cases and irrigation very rarely. He 
gave an abstract of about thirty cases of gunshot 
wounds of the abdomen in pregnant women. 

Dr. John D. S. Davis, of Birmingham, Ala., 
reported a case of gunshot injury in a woman preg- 
nant three and a half months. She was handling a 
small rifle when it went off and shot her through 
the abdomen, producing twenty-five perforations, 
six through the transverse colon, and nineteen 
through the small intestines. She was brought a 
distance of eighty-five miles. He saw her twelve 
hours after the reception of the injury. There were 
five perforations on the mesenteric border of the 
small intestine, and two perforations on the mesen- 
teric border of the transverse colon. He closed 
back the serosa and turned in the musculature and 
put the serosa over that. Instead of doing two 
resections of the gut, he took out five feet of the 
intestine between the nineteen perforations. She 
recovered and gave birth to a hving child at the 
ninth month. 

Version with Report of Five Hundred Cases. — 
Dr. Irving W. Potter, of Buffalo, N. Y., stated 
that in the advocation of all procedures we should 
have a clear idea as to the results. In these 500 
cases there was not a maternal death, and there 
were no injuries to the mother's soft parts that re- 
quired repair. In other words, there were no tears 
of the cervix or the perineum that necessitated su- 
turing. There were no alarming hemorrhages, and 
the period of involution in these cases was shorter 
than ordinary with less flow during the puerperium. 
The convalescence was more rapid, due to the elim- 
ination of the shock that was experienced by pa- 
tients going through a long second stage of labor. 
There was also apparent greater strength of the 
patient at the end of the puerperium. In reference 
to the fetus, there were fifty-seven stillbirths, the 
greatest cause being prolapse of the cord ; in thirty 
cases alone death was due to this cause. 

Conclusions. Version should be more often done 
to shorten the time of labor, lessen the shock to 
the mother, and eliminate undue pressure to the 
child's head. 

That the majority of occipitoposterior positions 
were best treated by version. That version can 
readily be accomplished in primiparae and should 
he more often done. 

That the fetal mortality in version should not be 
as great as in prolonged instrumental delivery. 



That head injuries to the child were lessened by 
a properly performed version. 

Lymph Gland Extract, Its Preparation and 
Therapeutic Action. — Dr. D.wid Hauden, of Oak- 
land, Cal, stated that he had used in several cases 
of streptococcemia the magnesium sulphate solution 
advocated by Harrar. The magnesium sulphate 
solution alone produced no leucocytosis, but used 
in conjunction with leuc(?cytic extract, a marked 
leucocytosis resulted of a more profound character 
than the extract alone produced. These patients 
recovered. Two cases of easy bleeders, one with 
hemorrhage from the abdominal incision, the other 
with free oozing from the mucous membrane had 
a complete and permanent cessation of the bleeding 
almost immediately following the one dose. His 
associates had been using this lymph gland extract 
in cases of hemophilia, pulmonary hemorrhage, and 
tonsillar bleeding with very favorable results. He had 
used, during the last two years, lymph gland extract, 
in all inoperable cases of carcinoma, and discounting 
fully the possibilities of spontaneous improvement, 
he believed he was justified in the conclusion that 
the eft'ects had warranted the use of the extract. 
He probably would never use body extracts in 
operable cases of malignancy as a substitution for 
operation, but if proved of value in animal work, 
they would have their place from a prophylactic 
standpoint. In inoperable cases, it gave one method 
that undoubtedly prolonged the patient's life and 
relieved many of the distressing symptoms, so that 
the amount of opiates necessary was lessened, but 
above all it put in our hands a means to make 
the patients really feel something was being done 
for them. 

The present important field for the lymph gland 
extract was. however, undoubtedly in cases of hem- 
orrhage and especially so in patients whose blood 
changes resulted in lowered coagulability. 

Doctor Archibald and Doctor Moore were anxious 
to see the extract tested more extensively in tubercu- 
losis and other chonic infections for they felt that 
their laboratory experimental work had demon- 
strated its effect in these cases. 

Dr. James E. Davis, of Detroit, said he would 
like to ask Doctor Hadden if in using the lympho- 
cytic extract he knew how the platelets were pro- 
duced. Some believed that the platelets had nothing 
whatever to do with the coagulation ; others had 
raised the question as to just what the platelets 
were, whether they were fragmentary portions of 
the lymphocytes, and he wondered whether light 
had come to Doctor Hadden in the particular in- 
stance of the platelets. 

Doctor Hadden, in closing, said that personally he 
could not express any opinion with reference to 
the function of the blood platelets. He knew they 
markedly increased. After a series of injections 
in lower animals Doctor Moore had proven conclu- 
sively, although he was not willing to give the evi- 
dence publicity, that we were dealing with an en- 
zyme and the presence of the enzyme produced 
these changes. 

Observations on Blood Pressure during Opera- 
tions. — Dr. Charles W. Moots, of Toledo, Ohio, 
said, that having made observations and records of 



BOOK REVIEWS. 



143 



the pressures in ninety-eight per cent, of his cases 
for the past eight years, he had, as a result of his 
experience alone, come to certain conclusions which 
he wished to offer at this time. i. The systolic 
pressure alone was of very slight, if of any value. 
2. The diastolic pressure alone was of much more 
value than the systolic alone. 3. The pressure 
ratio was the essential factor, and ottered the earli- 
est danger signal. 4. There were certain elements 
in technic which had markd and constant effect upon 
the pressures. These were as follows : a. The psy- 
chical or emotional state of the patient, b. The 
position of the patient upon the table, the extreme 
Trendelenburg being the worst, c. Overdosing by 
the anesthetist, d. The amount of traumatism in- 
flicted by the actual operation, such as cutting and 
tearing the tissues with scissors, the hands, and 
other dull instruments ;^ the packing of large gauze 
packs instead of rubber tissue into the abdominal 
cavity. e. The preservation of the fluids in the 
body up to the hour of the operation, this being ab- 
solutely necessary to maintain the usual pressures. 

Dr. R. R. HuGGiNs. of Pittsburgh, said that if 
anyone cared to take the blood pressures of pa- 
tients previous to operation when he was suspicious 
of any weakness on the part of the circulatory appa- 
ratus of the patient, he should take the pulse pres- 
sure with the patient in the lying position and if he 
then found that it went down, as the speaker 
had described, that patient was a bad risk. A pa- 
tient with a blood pressure of 170 or 180, with low 
diastolic pressure, should always be watched. The 
same thing was true of low blood pressure. 

Dr. J. H. Carstens, of Detroit, said that he had 
for some time insisted on taking the blood pressure 
of patients a day or two before operation, and in the 
case of a patient with a blood pressure of 170 it was 
dangerous to operate before adopting some meas- 
ures to reduce it. 

The Diagnosis of Pelvic Troubles. — Dr. J. 
Henry C.xrstens, of Detroit, said that these pa- 
tients had pains when moving the uterus and the 
» pelvic organs in certain directions. If you pulled 
the uterus to the right, they complained of severe 
pain in the left side, or vice versa. When you pulled 
the uterus away from the bladder no complaint 
seemed to be made, but when you pulled the uterus 
forward or away from the rectum, severe pain was 
complained of, often also in the back. These cases 
were due to adhesions, and he believed that the ad- 
hesions were caused by an infection from the rectum 
and sigmoid, as these patients were often suffering 
from chronic constipation. He was convinced that 
where the histor}^ was perfectly clear of the ex- 
istence of any trouble previously, with a gradual on- 
set of pain and distress, it was very much increased 
when moving the uterus and the pelvic organs. 

Conclusions: First, naturally all pelvic troubles of- 
fered difficulties in diagnosis ; second, pain on mov- 
ing the uterus or pelvic organs indicated adhesions ; 
third, these adhesions were probably caused by in- 
fection from the bowels : fourth, these obscure cases 
required exploratory celiotomy for perfect diagno- 
sis and treatment. 

{To be concluded.) 



Book Reviews 



[We publish full lists of books received, but ■ujc acknoiul- 
edge no obligation to review them all. Nevertheless, so 
far as space permits, tee review those in which we think 
our readers are likely to be interested.] 



A Practical Medical Dictionary of Words Used in Medicine 
i^'ith Their Derivation and Pronunciation, Including 
Dental. Veterinary, Chemical, Botanical, Electrical. Life 
Insurance, and Other Special Terms ; Anatomical Tables 
of the Titles in General Use, and Those Sanctioned by 
the Basle Anatomical Convention ; Pharmaceutical 
Preparations, Official in the United States and British 
Pharmacopoeias and Contained in the National For- 
mulary; Chemical and Therapeutic Information as to 
Mineral Spring's of America and Europe, and Compre- 
hensive Lists of Synonyms. By Thomas L.\throp 
Stedman, A. M., M. D. Editor of the Twentieth Cen- 
tury Practice of Medicine, of the Reference Handbook 
of the Medical Sciences, and of the Medical Record. 
Fourth, Revised Edition. Illustrated. New York : 
William Wood & Co., 1916. Pp. 1102. (Price, $5.00.) 
This edition of Stedman's Medical Dictionary is the fourth 
that has been published within a comparatively short 
space of time. This fact shows that its usefulness is ap- 
preciated by the medical profession. It is essentially a 
comprehensive dictionary, that is to say, it comprehends 
within its pages all or, at any rate, almost all the in- 
formation with regard to medicine and surgery that falls 
within the scope of a medical dictionary. The present 
edition has been brought thoroughly up to date and this 
is saying a good* deal for the industry and painstaking 
care of the author, when the rate at which medicine and 
surgery advance and terms multiply are borne in mind. 
It is pointed out in the preface that in former editions 
the terms of the Basle .Anatomical Nomenclature vere 
indicated only when they differed from those in common 
use; in the present edition it has been found best to mark 
all these terms even when they do not differ from the 
vernacular. The author gracefully acknowledges that he 
has taken to heart and benefited by criticism of former 
editions, that is presumably when such criticism appeared 
justified. The result is a complete and valuable book of 
reference for all medical men. 

Outlines of Physiology. By Edward Gro\'es Jones. A.B.. 
M.D., F..'\.C.S.. Professor of Surgery, Emory Univer- 
sity (Atlanta Medical College), and Allen H. Bun'ce, 
.'\.B., M.D., Associate in Medicine, Emory University 
(Atlanta Medical College"). Fourth Edition. Revised. 
Ill illustrations. Philadelphia: P. Blakiston's Son & 
Co., 1916. Pp. xvi-.^73. (Price, $1.50.) 
This convenient handbook of physiology, now in its fourth 
edition, has be«?n brought up-to-date. The majoritj' of 
changes are of details, the chapters and general arrange- 
ment of the book being kept as in the third edition. A 
number of new illustrations are added, many others are 
reengraved, and the authors and publishers have ex- 
pended no little effort to keep the book up to the highest 
standard. Wliile the book is not a quizz compend, never- 
theless it presents the essentials of physiology in a clear 
cut form to the student. The busy practitioner can profit- 
ably spend a few hours in reviewing his knowledge of 
physiology by means of the clear cut presentation of this 
convenient handbook. 

The Mentally Defective Child. Written specially for 
school teachers and others interested in the educational 
treatment and aftercare of mentally defective school 
children. By Meredith Young, M. D.. D. P. H., D.S.Sc. 
of Lincoln's Inn, Barrister-at-law'. Chief school med- 
ical officer, Cheshire Education Committee; Lecturer 
on School Hygiene, Victoria University of Manchester ; 
Certifying Medical Officer to the Local Authority 
(Mental Deficiency act) for the County of Cheshire, 
etc. With illustrations. New York: Paul B. Hoeber, 
1916. Pp. 140. (Price, Si.so.) 
The present volume is an effort to describe mental de- 
ficiency in children in such a manner as easily to be 
grasped 'by the lay reader, especially the school teacher, 



144 



SOCIHTIHS.—OfflCIAL NEWS.— BIRTHS, MARRIAGES, AND DEATHS. 



[New York 
Medical Jouhnal. 



and seems to be on ihc whole u sviccessful one. Doctor 
Young has presented his subject in simple language and 
has been concise, sometimes sacrificing complete descrip- 
tion to brevity. The English view of mental deficiency 
is the one taken throughout, and is at times at variance 
with the American one, particularly in the classification 
of these cases. The inevitable Binet-Simon tests are of 
course presented with some discussion of them. A few 
case histories are quoted and a chapter is given to treat- 
ment. A large part of ihe book is given up to the quota- 
tion of English legislation on the subject. The writer 
is handicapped throughout by the very small compass of 
the volume; it is much too small to contain a proper 
presentation of mental deficiency to a lay audience. Many 
more case histories should be quoted, and much more 
Sipace should be given to tests, including the Yerkes- 
Bridges, the Healy, Fernald, etc. 



Meetings of Local Medical Societies 

Monday, January 2ind. — Medical Society of the County 
of New York. 

TuESD.\Y, January 33rd. — New York Academy of Medi- 
cine (Section in Obstetrics and Gynecology) ; New 
York Psychoanalytic Society ; New York Derinato- 
logical Society; Metropolitan Medical Society of New 
York; Buffalo Academy of Medicine (Section in Pa- 
thology) ; New York Medical Union ; New York 
Otological Society ; Onondaga Medical Society, New 
York; New York City Riverside Practitioners' So- 
ciety (annual) ; Valentine Mott Medical Society, New 
York; Washington Heights Medical Society, New 
York; Woman's Hospital Society, New York; Ther- 
apeutic Club (annual). 

We nesday. January J^th. — New York Academy of Med- 
icine (Section in Laryngology and Rhinology) ; New 
York Surgical Society: New York Society of Internal 
Medicine; Schenectady Academy of Medicine. 

Thursday, /aKi/orj) 35th. — Ex-Intern Society of Seney Hos- 
pital, Brooklyn; Medical Union. Bultalo (annual); 
Hospital Graduates' Club, New York (annual) ; New 
York Physicians' Association. 

Friday, January 26th. — Society of New York German 
Physicians; New York Clinical Society; Manhattan 
Medical Society; Society of Alumni of Sloane Hos- 
pital for Women : Brooklyn Society of Internal Med- 
icine; Italian Medical Society of New York. 

Saturday, January ijth. — New York Medical and Sur- 
gical Society (annual); West End Medical Society; 
Harvard Medical Society ; Lenox Medical and Sur- 
gical Society. 



Official Ne-ws 



United States Public Health Service : 

Official list of changes in the stations and duties of 

commissioned and other officers of the United States 

Public Health Service for the seven days ending January 

TO, 1917: 

AsHFORD, F. A., Passed Assistant Surgeon. Relieved 
from duty at Montreal, Canada, and directed to pro- 
ceed to Ellis Island, New York, and report to the 
chairman of a board at the bureau, Washington, 
D. C, January 11, 1917, for examination to determine 
his fitness for promotion to the grade of surgeon. 

Clark, T., Surgi'on. Directed to proceed to the National 
Junior Republic, Annapolis Junction, Md., to make a 
mental examination of the boy inmates of that in- 
stitution. 

Frost, E. H. Passed Assistant Surgeon, Ordered to re- 
port to the chairman of a board at the bureau, Wash- 
ington, D. C, January II, 1917. for examination to 
determine his fitness for promotion to the grade of 
surgeon. 

Kempf, G. a.. Passed Assistant Surgeon. Directed to 
proceed to Wilmington, Del., to carry out studies of 
school and mental hygiene in Newcastle County. 



MuLLAN, E. H., Passed Assistant Surgeon. Ordered to 
report to the chairman of a board at the bureau, 
Washington, D. C, January 11, 1917, for examination 
to determine his fitness for promotion to the grade 
of surgeon. 
KoiiKRTS, Norman, Surgeon. Detailed to supervise the 
cyanide fumigation of vessels at the New York 
Quarantine Station. 
Smith, F. C., Surgeon. Relieved from duty at the Cape 
Charles Quarantine Station and directed to proceed 
to Ellis Island, N. Y., for duty. 
Stoner, J. B., Surgeon. Relieved from duty at Ellis 
Island, New York, and directed to proceed to Mon- 
treal, Canada, for duty in the medical examination of 
immigrants. 
Sydenstricker, E., Public Health Statistician. Directed 
to proceed to Washington, D. C, to assist in studies 
relating to industrial hygiene. 
WiLDON, L. O., Assistant Surgeon. Directed to proceed 
to Wilmington, Del., to carry out studies of school 
and mental hygiene in Newcastle County. 
WiLDMAN, H. v., Assistant Surgeon. Directed to pro- 
ceed to Wilmington, Del., to carry out studies of 
school and mental hygiene in Newcastle County. 
Witte, W. C, Assistant Surgeon. Directed to deliver a 
lecture on diseases caused by insects before the 
School of Civics and Philanthropy, Dallas, Texas. 
.Boards Convened. 
Board of which Assistant Surgeon General W. G. 
Stimpson is chairman reconvened at bureau January 11, 
1917, for the examination of certain passed assistant sur- 
geons for promotion. Also convened January 30, 1917, 
for the examination of certain assistant surgeons for 
promotion. 

Board of medical officers convened at Marine Hospital, 
San Francisco, Cal., January 15, 1017, for the examina- 
tion of certain officers of the Coast Guard for promo- 
tion. Detail for board : Senior Surgeon L. L. Williams, 
chairman; Assistant Surgeon D. S. Baughman, recorder. 

Births, Marriages, and Deaths 

Died. 

Campbell. — In Williamsport, Pa., on Sunday, January 
7th, Dr. Eugene Boyd Campbell, aged sixty-six years. 

Clary. — In New Britain, Conn., on Friday, January 
5th, Dr. George Clary, aged eighty-seven years. 

Damrell. — In Tulsa, Okla., on Sunday, December 17th. 
Dr. Carter Edmund Damrell, aged forty-two years. 

Feacin.— In Mobile, Ala., on Saturday, December 23rd. 
Dr. Ernest Samuel Feagin. aged thirty-five years. 

FouARTV. — In Brooklyn, N. Y., on Friday, Janxiary 5th. 
Dr. William Ralph Fogarty, aged twenty-eight years. 

Galer. — In DeGraff, Ohio, on Monday, January 1st. 
Dr. Frank M. Galer, aged seventy-three years. 

Grabenstatter. — In BulTalo, N. Y., on Wednesday, 
January 3rd, Dr. George W. Grabenstatter, aged forty- 
eight years. 

Grabber. — In Meriden, Conn., on Monday, January ist. 
Dr. Charles Augustus Graeber. aged seventy-five years. 

Harris. — In Norwich. N. Y., on Sunday, December 
J4th, Dr. Blinn A. Harris, aged fifty-four years. 

Kimball. — In Los Angeles, Cal., on Wednesday, Jan- 
uary 3rd, Dr. James H. Kimball, aged seventy-two years. 

Kornema.\n. — In Newark, N. J., on Monday, January 
8th, Dr. Henry A. Kornemann, aged eighty-four years. 

McLaughlin. — In Greencastle. Pa., on Saturday, Jan- 
uary 6th, Dr. Charles Michael McLaughlin, aged fifty-iive 
years. 

Myers.— In York, Pa., on Friday, January 5th, Dr. Al- 
fred My^rs, aged sixty-two years. 

Phenix. — In Colorado, Texas, on Sunday, December 
31st. Dr. Newton J. Phenix, aged fifty-five years. 

Reed.— In Lancaster, Pa., on Wednesday, January 3rd. 
Dr. Joseph A. E. Reed, aged eighty-five years. 

Rogers. — In Cleveland, Tenn., on Wednesday, January 
3rd. Dr. Karl E. Rogers, aged thirty- four years. 

Weidman. — In Jacksonville, 111., on Tuesday, January 
-'nd. Dr. Peter S. Weidman, aged ninety-one years. 

Williams. — In Summerfield, Ohio, on Saturday, Jan- 
uary 6th, Dr. John H. Williams, aged sixty year.s. 



New York Medical Journal 

INCORPORATING THE 

Philadelphia Medical Journal th' Medical News 

A Weekly Review of Medicine, Established 1843. 



Vol. CV, No. 4. 



NEW YORK, SATURDAY JANUARY 27, 1917. 



Whole No. 1991. 



Original Communications 



THE PREVENTION AND RETARDATION 

OF CARDIOVASCULAR DISEASE.* 

By Charles Lyman Greene, M. D., 

St. Paul. 

.\niong physicians and laymen alike we recognize 
a certain pessimism and passive acceptance with re- 
lation to heart disease strikingly similar to that 
which prevailed with respect to pulmonary tubercu- 
losis fifty years ago, when enforced late recognition 
and an aimless and impotent therapeutics created 
universal hopelessness and fatal neglect. Both con- 
ditions represent infection and hence are meas- 
urably preventable. Both tend to chronicity, and 
once firmly seated as a chronic process each exhib- 
its an inexorable tendency to a slow progression 
greatly accelerated if allowed to take its own 
course. Each inflicts enormous losses upon civil- 
ized races, and constitutes one of the chief causes of 
disability, suffering, and untimely death. 

Only within the past few years has it become pos- 
sible for the medical man measurably to retard and, 
to a considerable degree, prevent cardiovascular dis- 
ease. Hitherto, depending solely upon the classical 
clinical expressions of impaired reserve, often so 
gross and frank as to be almost as manifest to the 
layman as to the physician, and recognizing in and 
through them his sole justification for active thera- 
peutic interference, he naturally has failed to real- 
ize the prophylactic and remedial possibilities grad- 
ually developed during the past decade. 

In the light of modern knowledge a campaign 
might be waged on behalf of the cardiopath with 
what might prove to be astonishing results, not only 
with respect to lengthening the average term of life 
of those actually afflicted, but, in no inconsiderable 
measure, with relation to the prevention of the dis- 
ease itself. 

The great advance of the past few years has 
yielded isolated facts of the utmost clinical value 
when set in their proper order and perspective, the 
chief of which may be summarized as follows : 

First, definite proof of the bacterial origin of acute 
rheumatism and syphilis, the two diseases chiefly responsi- 
ble respectively for the juvenile and for the elder groups 
of cardiovascular diseases. 

Second, the nature and the extreme value of the sub- 
jective symptoms of cardiovascular insufficiency. 

Third, the establishment of maximal dimensions for 

•Read at the seventeenth annual meeting of the American Thera- 
peutic Society, at Detroit, Michigan, June lo, lgl6. 

Copyright, 1917, by A. R. 



the heart and the placing of proper emphasis upon the 
relationship existing between structural type and the size 
of the heart normal for the individual. 

Fourth, the development of better and more accurate 
methods of percussion applied to the determination of the 
true cardiac profile. 

Fifth, the great advance represented by the routine use 
of the Rontgen ray in determining the size of the heart, 
its tj-pe, and the nature and degree of modifications of its 
contour, associated with the various forms of impairment. 

Sixth, the fact that therapeutic doses of an active 
preparation of digitalis do not affect the normal heart, the 
fully compensating diseased heart, or such subjective symp- 
toms as are unrelated to cardiovascular inadequacy. 

The author will venture to add one specific con- 
tribution of his own, which he believes to be of 
considerable value both in the extraordinary char- 
acter of its clinical relationships and in the fact that 
its recognition serves to clarify many clinical pic- 
tures otherwise blurred and obscured. He refers to: 

Seventh, the dilatations or chronic overstrains of the so 
called "drop heart'' — cor pendulum — a type long recognized 
as an anatomical entity, but almost wholly disregarded with 
respect to the importance of its clinical manifestations. 

Only the briefest consideration of these factors 
which promise much for the future welfare of 
the cardiopath is possible. Let us consider : 

/. Prevention. — The two infections largely respon- 
sible for cardiovascular disease are acute rheuma- 
tism and syphilis, the former producing chiefly j^ri- 
mary mitral valvulitis of the acute endocarditic 
type, and the more active primary types of myocar- 
ditis and pericarditis, in infancy, childhood, and the 
early decades of adult life; the latter afYecting for 
the most part the older groups and exerting its ef- 
fect chiefly upon the aortic valves, arteries, and my- 
ocardium. To the patient and persistent work of 
Frederick Poynton, of London, we owe our present 
ability to place acute rheumatism with the acute in- 
fections and attribute it to a pleomorphic organism 
which, as E. C. Rosenow has shown, represents a 
strain, and probably a transmutation form of the 
ordinary hemolytic streptococcus, almost constantly 
present in diseased tonsils and frequentlv found in 
the many other septic foci now justly held accounta- 
ble for the genesis of a large number of hitherto 
obscure ailinents. Furthermore, it has been shown 
that certain streptococcic strains active in acute 
rhemnatism give evidence of a selective affinity for 
the endocardium or myocardium. The opinion has 
gained ground steadily during the past few years 
that myocardial toxemia is seldom or never lacking 

Elliott Publishing Company. 



146 



GREENE: CARDIOVASCULAR DISEASE. 



[New York 
Medical Journal. 



in this and many other acute prostrating infections, 
and that endocardial damage also occurs far more 
frequently than at present is recognized or believed, 
though in neither case need permanent degenerative 
or inflammatory residual changes result. If this 
view is correct, in many instances the question of 
permanence or impermanence of damage must be 
detennined in great measure by the management of 
the case. More and more fully medical men are 
coming to realize the absolute necessity of safe- 
guarding the heart in acute prostrating infections, 
especially in acute rheumatism, not only during the 
illness itself, but throughout a prolonged con- 
valescence. The writer would emphasize the ne- 
cessity of following such cases further in oriler 
that lesions undetectable during the illness, but be- 
coming manifest later, may not in the future be so 
generally overlooked as at present. Mitral stenosis, 
for example, is seldom recognizable until several 
weeks after apparent recovery from the attack of 
acute rheumatism usually responsible. 

In connection herewith attention may be called to 
the great value of the work done by D. J- Davis, 
Rosenow, and many others at home and abroad with 
respect to the bacterial flora of the chronically dis- 
eased tonsils, and to these structures, natural in- 
cubators, commissaries, and transformers, we must 
attribute nearly all the cases of acute rheumatism 
which arise and, therefore, a large proportion of 
the cardiac cases of the juvenile type. Rational and 
radical treatment of these prime generators of heart 
disease must greatly diminish its prevalence in the 
future. The almost invariable occurrence of ante- 
cedent tonsillitis in cases of acute rheumatism has 
been obscured hitherto by the fact that the disease 
develops as a slow sepsis and in many, if not in most, 
instances, shows arthritic symptoms only after the 
lapse of a period varying from several days to two 
or even three weeks, during which time the primary 
tonsillar infection, often slight, will usually have 
disappeared. In the rheumatism of very young 
children, articular symptoms may be wholly lacking 
or so slight as to escape notice or be accepted by the 
parent as "growing pains." 

The prevention of permanent heart disease is also 
in no small measure dependent upon the ability of 
the physician to recognize during an illness the less 
obvious signs of cardiac involvement. Both in 
teaching and in practice, more emphasis should be 
placed upon the question of integrity of the heart 
muscle, absence of minor dilatation, and the [jres- 
ence of normal sounds, and less upon the relatively 
unimportant differential diagnosis of valvular le- 
sions and the mere recognition of heart murmurs. 
The student or physician who auscultates the heart 
with the conscious primary purpose of determiinng 
the presence or absence of normal heart sounds, by 
his very attitude of insistence upon the normal, is 
placed in the best position to detect and appreciate 
the abnormal both in quality and accentuation. The 
usual opposite method is responsible doubtless for 
an immense number of missed diagnoses. 

The etiological role of syphilis is far greater than 
was thought possible prior to the introduction of the 
Wassermann and luetin tests. In most instances the 
initial effect is produced early in the secondary 
stage, the degenerative processes progress with ex- 



traordinary deliberation but inexorable persistence, 
and the disease frankly declares itself in the late 
tertiary period when the basic infection may be rec- 
ognizable only by the results of the luetin test. 

Two points of especial importance might be men- 
tioned : One, the now fully proved worthlessness of 
a denial of syphilitic infection, whatever the ap- 
parent impeccability of the patient; the other, the 
untrustworthiness and inconclusiveness of the Was- 
sermann test when performed by any but thorough- 
ly trained and up to date serologists. The effect of 
the revelations relating to syphilis in the cardio- 
vascular field has been such as to emphasize greatly 
the prophylactic and retarding value and importance 
of early, efficient, long continued, and, if necessary, 
frequently repeated antiluetic treatment. 

?. The value of subjective symptoms in diagnosis. 
— We owe a debt of gratitudeto Dr. James Mackenzie 
and Dr. Henry Head for having drawn the atten- 
tion of the medical profession to the character and 
clinical value of certain of the many subjective clin- 
ical expressions of cardiovascular disease. .\t in- 
tervals, for years before the grosser signs of de- 
compensation occur in cardiovascular disease, peri- 
ods of minor insufficiency arise, such as must in- 
evitably tend, by their persistence over considerable 
periods, to accelerate any existing degenerative pro- 
cess and thereby shorten further the impaired life 
of the sufferer. These demand attention precisely 
as would a case of pulmonary tuberculosis during 
an accession of the infection, and it is through sub- 
jective symptoms with or without demonstrable 
minor dilatations that we must detect them. At 
present such patients are safeguarded almost wholly 
through their own subjective discomfort, which by 
enforced limitation of activity, most strenuously re- 
sisted by the unaware victim, inadequately and im- 
perfectly acts as an automatic brake. 

These subjective symptoms are of the most varied 
description and their localization is often most mis- 
leading in its remoteness until the therapeutic test 
is applied. To an astonishing extent, moreover, 
both the minor and the major discomforts and pains 
of cardiovascular insufficiency are referred partially, 
maximally, or even wholly to the upper abdomen 
and especially to the region of the epigastrium. In 
the light of his own experience, the author would 
most emphatically reverse the old rule which said 
that when a patient complained of his heart his 
stomach should be looked to, for not only do we 
know that cardiac pain and discomfort may be and 
often is actually referred along physiological path- 
ways to the upper abdomen, but we also know that 
with an overstrained heart and myocardium, even 
a moderately distended stomach may produce vary- 
ing degrees of discomfort and actual pain. The 
author has known of many instances of operation 
proposed or actually performed upon patients under 
conditions of great hazard and with futile or even 
fatal results, where a careful interrogation of the 
cardiovascular field would have revealed the actual 
source of the localized pain and, occasionally, ten- 
derness as well. Anyone who has studied carefully 
the distribution of pain and tenderness in angina 
pectoris, in the light of Dr. Henry Head's re- 
searches, will readily understand how such errors 
arise. 



GREEXE: CARDIOVASCULAR DISEASE. 



H7 



Pain of cardiovascular origin may be most in- 
tense or be represented by a mere sense of discom- 
fort, griping oppression, clutching, or a feeling of 
crowding or constriction of the heart. A rather 
common and much misinterpreted associated sign 
is that of tenderness over the region of the apex and 
inferior left border of the heart, usually regarded 
as an hysterical zone, because of its relation to the 
breast and its not infrequent appearance bilaterally. 
In many instances of subsiding acute dilatation it 
will be foimd to move inward as the heart border 
recedes. Another symptom, readily misinterpreted 
as globus hystericus, is the very common discomfort 
experienced ov^r the upper sternum or in the throat 
in cases of minor insufficiency, especially such as 
occur in the drop heart. It usually disappears 
with significant promptness under rest and digitalis. 
We can but mention the various disturbances of 
sleep, laying particular emphasis upon the not un- 
common occurrence of persistent day drowsiness in 
certain cases of myocardial degeneration and mitral 
lesions, changes of disposition, loss of the power of 
concentration and sustained application, mental con- 
fusion, easily induced physical fatigue, nimibness 
and tingling, increased susceptibility to cold, a host 
of symptoms of gastric localization, and many 
other clinical expressions usually placed convenient- 
ly under the ample cloak of so called "neurasthe- 
nia." Dyspnea is a not uncommon symptom and 
may take any one of many forms. A mere sense of 
respiratory inadequacy or discomfort ; inabilitj' to 
sit in a close room ; a tendency to unconscious sigh- 
ing or the taking of deep breaths, or inability to hold 
the breath. Dyspnea on exertion may, of course, 
occtir, and be of the utmost significance. 

The most important of the primary and cardinal 
single symptoms of minor decompensation is the 
limitation of cardiac reserve evidenced in the nar- 
rowing of the patient's field of symptomless or rela- 
tively effortless activity, manifest only when the 
neuromuscular units involved are other than those 
brought into constant use in the patient's daily ac- 
tivities. This accords with the well known fact that 
an actual breakdown of a compensating, frai'kly 
diseased heart may occur in a person performing 
daily and without distress, hard manual labor, when 
he undertakes some other strenuous physical exer- 
cise. 

J a)id 4. The sice of the normal heart. — Until 
Moritz. von Tabora, and \''eith gave us their care- 
fully worked out orthodiagraphic measurements 
representing, when combined, the dimensions of 
normal hearts at all ages and for all heights and 
weights, we lacked any proper standard. The nor- 
mal heart even in an athletic subject seldom ex- 
ceeds 13.5 cm. in total transverse diameter and, as 
the author has stated on many previous occa- 
sions, the drop heart, normal and undilated, may 
measure transversely only 7.5 cm. Anyone who 
marks the maximal area of 13.5 or 14 cm. upon a 
large series of chests will realize that formerly he 
has passed as normal a great number of pathologi- 
cally enlarged hearts. If he reduces these measure- 
ments to nine, ten, or 10.5 cm., common figures for 
the undilated drop heart, he will be impressed still 
more strongly. 

For determining the cardiac outline modern per- 



cussion should absolutely displace the old flat finger 
method, and strict adherence should be given to the 
rule that all strokes should be made at right angles 
to the anterior plane of the heart. For this purpose 
the writer personally prefers his own method of 
percussion. 

One great advantage derived from the establish- 
ment of a normal maximum dimension has been the 
aid given with respect to the detection of the dilated 
and hypertrophied silent hearts, a host of which 
daily escape detection. Such hearts account for 
most of the sudden deaths, generally attribtited to 
"acute indigestion" or "acute dilatation of the stom- 
ach," because of the attendant nausea, vomiting, and 
discomfort, or the intense angina of epigastric local- 
ization. 

5. With respect to the routine use of the Rontgen 
ray, the author can only say that he finds it in- 
valuable and indispensable to the work of the spe- 
cialist. As a check upon percussion it seldom re- 
veals serious errors, but when errors do occtir they 
are likely to be so gross as to emphasize the need of 
such special methods. 

6. The diagnostic value of therapeutic doses of 
digitalis. — Cloetta, Hanson, and others have estab- 
lished the fact that the normal or fully compensat- 
ing diseased heart is wholly unaffected by the ordi- 
nary therapeutic doses of digitalis, and this knowl- 
edge yields us an invaluable diagnostic measure in 
the form of test doses of an active preparation of 
the drug. 

We note the effect exercised primarily, upon sub- 
jective symptoms, and secondarily, upon the heart 
outline itself. The latter is often strikingly af- 
fected, but in other instances the amelioration or 
removal of symptoms seems to be due largely to 
the direct efl'ect of the drug in rehabilitating an 
impaired myocardial tonus. It is of peculiar use- 
fulness in connection with the overstrained or 
dilated drop heart whose true dimensions caii usu- 
ally be determined only through the use of digitalis, 
often necessarily combined with physical rest. 
Under such conditions the shrinkage in outline may 
be extraordinary, though by no means always well 
retained unless the general nutrition can likewise be 
improved. 

7. The drop heart. — The correct descriptive term 
would be undoubtedly "the heart of universal con- 
genital asthenia," for it is distinctly a part, and only a 
part, of that constitutional state so characterized by 
Berthold Stiller and now very generally accepted 
by the most prominent European authorities. It is 
really a ptotic heart, and the condition is associated 
invariably with a greater or less degree of general 
visceroptosis in individuals presenting outwardly 
the peculiarities of body conformation and struc- 
ture which we have associated in the past with the 
so called tuberculous predisposition and general 
visceroptosis. Such patients are unusually suscep- 
tible to infection, laggard convalescents with respect 
to actual full recovery of flesh and strength, fur- 
nish an ideal soil for the development of tubercu- 
losis, and doubtless are for the most part victims 
of past infection, fortunately obsolete in most in- 
stances. Insufficiency of structure, a tendency to 
subnutrition. and instability of function charac- 
terize these cases. The presence or at least, the 



MYLES AND SMITH: SECONDARY MASTOIDITIS. 



[New York 
Medical Journal. 



activity of their symptoms usually corresponds 
more or less directly with their state of nutrition 
and varies with it. These patients compose the 
greater part of that great body, conveniently but 
inaccurately classified as passive or depressed 
neurasthenics and nervous dyspeptics, who in the 
past have been a constant lure and temptation to 
our surgeons, with mutual disappointment in most 
instances. 

The drop heart or heart of congenital asthenia 
is peculiar, both when normal for the individual, 
and when dilated or actually diseased. It is long, 
attenuated, and narrow, seems to be suspended by 
its great vessels and their fascial attachments above, 
presents as its right border, not the corresponding 
auricle as in the case of a normal heart, but the 
right ventricle, the auricle lying above. As seen 
fiuoroscopically, it presents the appearance of a 
pulsating bag, rotating to the front with each cycle 
in the direction of the moving hands of a watch, 
usually causing a sharp impact against the chest 
wall and a somewhat diffuse apex beat. 

Such a heart seems to be peculiarly susceptible to 
myocardial toxemia, overstrain, and dilatation, and 
correspondingly productive of symptoms whenever 
the nutrition of its possessor falls below a certain 
point. Its chief interest to the clinician lies in the 
fact that even when widely dilated it is not likely 
to yield a percussion outline greater than normal. 
Only by a knowledge of the condition itself, there- 
fore, and of the inherent tendency to dilatation and 
recourse to the therapeutic test can we avoid miss- 
ing one of the important sources of obscure symp- 
toms of most varied nature and localization. In 
some instances, indeed, and for the same reason, 
we may overlook a decidedly dangerous dilatation. 

Such hearts, though less frequent in men than in 
women, must inevitably cause much temporary dis- 
ability among the soldiers now engaged in the Eu- 
ropean 'War, for they are of exactly the type and 
possessed of just the possibilities of abnormal re- 
sponse to psychic shock, on the one hand, and limi- 
tation of cardiac reserve, on the other, most likely 
to constitute a source of genuine discomfort to such 
of their possessors as are exposed to the shocks 
and strains of war. 

CONCLUSIONS. 

It would appear that the foregoing statements 
justify the following conclusions: 

1. It has now become possible measurably to re- 
tard and, to a considerable degree, prevent cardio- 
vascular diseases. 

2. It is imperatively necessary in the interests of 
the cardiopath and of the race that a justifiable 
optimism should replace the almost universal pes- 
simism now existing. 

3. A knowledge of the specific bacterial origin 
of diseases of the heart should be promulgated, 
together with the means best adapted to the control 
of causative conditions. 

4. Our old ideas with relation to cardiac dimen- 
sions should be radically revised and brought into 
correspondence with the facts as at present defi- 
nitely established. 

5. Modem methods of percussion, accurate and 
definitive, should replace the older practice still in 
vogue. 



6. The cardinal value and importance, together 
with the nature and diversity, of subjective symp- 
toms of cardiac insufficiency should receive their 
full value as means of early diagnosis and indica- 
tors for therapeutic initiative. 

7. The extraordinary usefulness of test doses of 
digitalis, with or without physical rest, constitute 
the very foundation of timely diagnosis. 

8. .\ thorough understanding of the anatomical 
peculiarities of the drop heart is essential because 
of its association with a definite constitutional state, 
its remarkable prolixity with respect to symptoms 
of a most varied and obscure character, together 
with the misleading narrow diameters present even 
in dilatation. 

9. The common occurrence of the drop heart, its 
constant relationship to general visceroptosis of 
which it is a part, its frequent association with so 
called nervous dyspepsia, and the almost universal 
tendency to lose sight of the true cause of its symp- 
toms by referring them to the bastard symptom 
conglomerate long known as "neurasthenia" are 
facts of decided clinical importance. 

10. The existence of the drop heart in the male 
is a matter of great importance with respect to the 
fitness of its possessor for hard manual labor and 
actual service in warfare. 

11. An application of those newer discoveries in 
the cardiovascular field as are here enumerated can- 
not fail to exercise a striking effect on both the pre- 
vention of cardiovascular disease and the retarda- 
tion of established cases. 

LowRY Building. 



SECONDARY MASTOIDITIS. 

Complete Atresia of External Auditory Canal ■with 

Subperiosteal Abscess. Radical Mastoid 

Operation zvith Secondary Skin Graft. 

By Robert C. Myles, M. D., 

New York, 

AND J. MORRISSETTE SmITH, M. D., 

New \ork. 

When this patient, a boy seventeen years of age, 
first presented himself to us, he had a subperiosteal 
swelling of seven days' duration behind the right 
ear and a complete atresia of the external auditory 
canal. He gave a history of having had a mastoid 
operation seven years ago following middle ear in- 
fection, the mastoid drained for quite a while, and 
then closed. Two years later he had scarlet fever, 
and a swelling again appeared behind the right ear. 
The swelling ruptured spontaneously and healed 
after draining a while. Two months later another 
swelling appeared and a second mastoid operation 
was performed. The mastoid wound healed, and 
the external auditory canal closed completely. 
Twice following this, the swelling appeared behind 
the ear, and subsided following a simple incision. 

We advised immediate operation, and upon mak- 
ing the post auricular incision a subperiosteal col- 
lection of pus was evacuated, the mastoid was 
sclerosed, and a small but deep cavity was found 
filled with pus and granulation tissue. 

At the previous operation a radical mastoid oper- 



January 27, igi?.] 



TRACY: BRONCHIAL ASTHMA. 



149 



ation had evidently been attempted, but not com- 
pleted, since we found a deep antrum with the lower 
part of the bridge between the facial ridge and the 
dural plate still intact. This was removed, and a 
radical mastoid operation was performed. The mid- 
dle ear was completely tilled with pus and granula- 
tions. After cleaning it out thoroughly, a flap was 
cut, a new canal made, the post auricular incision 
closed, and the usual dressing applied. 

In spite of our eflrorts, the middle ear rapidly 
filled with granulations, and the canal contracted so 
much that the patient was given another anesthetic, 
the granulations were scraped out, and the canal 
was enlarged. Ten days later a secondary skin graft 
was done without reopening the post auricular in- 
cision, the graft being placed in the cavity through 
the external auditor^' meatus. The canal remained 
open, although it contracted. A paste composed of 
scarlet red, one part, and Beck's paste, three parts, 
as suggested by Doctor Myles, was used in the after- 
treatments. 

The middle ear dried up, and the patient can now 
hear a spoken voice in that ear, and a C2 fork in 
the air. 

1 1 E.^sT Forty-eighth Street. 

171 West Seventy-first Street. 



BRONCHIAL ASTHMA AND ITS CUR.V 

BILITY. 

By J.\mes L. Tracy, M. D., 

Toledo, Ohio. 

Every feature of bronchial asthma, as shown by 
its clinical history, from the time of the appearance 
of its first symptom to the last effort at treatment of 
the patient, fully proves it to be a deeply seated dis- 
ease. There is in fact no other disease which offers 
less hope of some day finding a single sure treat- 
ment for it than does this. These facts should not. 
however, discourage its study. Indeed they are, on 
the contrary, prime reasons for studying the dis- 
ease from every possible viewpoint. 

Pathology.- — A man has had bronchial asthma 
since he was sixteen years old. His elder brother, 
in the same surroundings, has never had asthma nor 
any of the diseases which are looked upon as having 
possible relationship to asthma. Some questions 
suggest themselves : Is the asthmatic brother's 
trouble representative of familial diathesis? Is it 
an acquirement? Is the nonasthmatic brother's 
health representative of transmitted family vigor? 
Has he a natural or acquired immunity to asthmatic 
infection? 

Whatever the answers to these questions, it will 
be conceded that all manifestations of health, and 
of disease as well, must of necessity have their 
foundations in special histological conditions of ana- 
tomical structure. Whether the conditions are in- 
herited or acquired, does not matter. In the case of 
the younger brother, it is evident that there is a 
standard of systemic purpose which so reacts to en- 
vironment as to produce asthma. And it is this 
constitutional standard, itself the production of 
some formative force, which is the pathology of 
asthma Bronchial asthma has a neuropsychic 



basis peculiarly its own. Some force so dominates 
as to set up a pathological nerve cell histology. This 
histology IS responsible for the presence and fact 
of the abnormal nerve impulses, and also for the 
erratic mental conditions which are found in asthma. 
Hence, without a specialized nerve cell structure 
there can be no asthma. The asthmatic nerve cell 
structure and its functioning, when taken as a whole, 
constitute asthma. The phenomena from the func- 
tionings of such nerve cell structure, when taken 
alone, are the disease symptoms. 

The neuropsychic base of itself, however, only^ 
represents asthma as a possibility or as a probabil- 
ity'. And, besides, the presence of such nerve 
cells, together with the consequent; asthmaticward 
impulse, there must be the addition of a specific 
asthmatic excitant — or an excitant which is specific 
to existing histological conditions before there can 
be an asthmatic attack. The ner^-e force and im- 
pulse and the concomitant mental are of themselves 
— systemically speaking — a stored up force, poten- 
tial for evil, to be sure, but in fact an undisturbahle 
equilibrium of energy, until some asthmatic stimulus 
or depressant of controlling centres tips the balance, 
and then there is asthma. Obviously, there must 
have been in asthmatics a preexisting nerve cell his- 
tology with its nervous productions for the excitant 
to act upon, as the exciting cause of asthma is com- 
mon to many people, and yet it causes asthma in 
only one victim. The cause is specific only 
to a specialized nerve cell structure. The cause 
may be either a plus or a minus quality, that is, it 
may unbalance nerve force by raising or lowering 
systemic tone. 

If asthma were in the infectious thing itself — so 
to speak — then everyone coming in contact with 
that particular infection would have asthma. In 
most other infectious diseases this rule is reversed, 
and the disease is the infecting agent. These state- 
ments regarding infectious diseases refer, of course, 
to the rule and not to the exceptions. Common ex- 
periences of life seem to prove that at certain times 
most people are immune to pathogenic infection. 
The argimient here is that there are very many 
agencies which may precipitate an asthmatic attack, 
but only one agent which can bring on an attack of 
typhoid fever — a very distinct difYerence. Giver 
asthmatic preparedness, and almost anything will 
cause an asthmatic attack. Given almost any kind 
of systemic condition, and the t\T>hoid germ will 
produce typhoid fever. 

Inheritance, as the word inheritance is referred to 
in the question at the beginning of this paper, is not 
thought of as carrying over to the one who is to be- 
come asthmatic, the identical nerve cell of the ances- 
tor; but there is carried forward from the one to 
the other that composite of cell life which dominated 
the cell's functions in tlie ancestor. To call cell 
life inheritance does not explain very much, but it 
does help a little in explaining how asthma is passed 
over through the cell, to point to the fact that physi- 
ognomy is passed over in the cell in exactly the same 
way. 

In the case of the elder brother the cell had ap- 
parently dropped the asthmatic tendencv, and had 
brought forward the ancestral form ; while it is pos- 
sible that the cell of the asthmatic brother had left 



150 



TRACY: BRONCHIAL ASTHMA. 



[New Yokk 
Medical JouR^ 



behind the parental physical, and had brought over 
a familial systemic trend, or that which is called the 
atavistic strain instead. It amounts to this in the 
case of the younger brother, that the systemic varia- 
tion from the physiology of the elder brother has 
become the pathology of asthma. On the other 
hand, until asthma had set up in the younger 
brother, he was just as well off as was the nonasth- 
matic. Inasmuch as it must be admitted that 
asthma, as a disease, had at some time a starting 
point, pathogenesis must grant the possibility of the 
disease setting itself up as an innovation in a family 
whose history had hitherto been free from diseases 
which are looked upon as consanguine to asthma. 
However, the study of asthmatics so generally dis- 
closes inheritance weakness, as to put the burden 
of proof strongly upon the assumption of an asth- 
matically clean family history. The nerve cell in 
asthmatics is, in essential life purpose, a normal sys- 
temic nerve cell and functions health impulses after 
its kind. But the impulse from such so called 
healthy nerve cell is ready upon occasion to precipi- 
tate spasm, and in this it is not physiological. This 
nerve cell quality of instability under specific pres- 
sure is, of course, either a gift of inheritance or 
else it is an acquirement. Here it is regarded as an 
inheritance. Whatever its origin, experience in try- 
ing to handle it abundantly proves that it is not a 
quality that can be readily controlled by treatment. 
That is to say, asthma is in no sense a trivial dis- 
ease. 

The argument locates the asthma in the nerve cell, 
and thus pathologizes the cell. But there is more 
than this in the pathology of asthma. Why does 
the neuron function unphysiologically ? At the 
present time, idiosyncrasy, as explanation for such 
aberrant direction of physiological function, no 
longer explains the anomaly. Diathesis, which 
would account for the upbuilding of the spasmodic 
tendency as being due to an inherent neuronic qual- 
ity, is passing. Error in inhibition or error of in- 
hibition as a nerve cell handicap or as an impover- 
ishment, is becoming an answer to the question re- 
garding the nerve cell's instability. If the otherwise 
unexplainable deep seated nature of the disease is 
derived from the pathogenesis of inheritance, then 
the channels through which the inheritance reaches 
the neuron and exerts its force upon it, naturallv 
become subjects of prime importance. But here, 
again, a change in terminology' is virtually all that is 
offered in the above outlined shifting of hypotheses 
respecting the neuronic acquirement of the inherit- 
ance force, and the manner of operation of that 
force which finally brings on the asthmatic attack. 

As a matter of physiological fact, it is about as 
easy to conceive of the force of inheritance connect- 
ing itself up with one anatomical structure as with 
another. There ever remains a bridgeless space 
between the neuron and the ancestral force which 
dominates its functionings. To locate the point in 
a more or less inhibitory nerve centre does not help 
much. At the present time, speculation as to just 
how this immaterial becomes material, is useless. 
But in the study of asthma it is helpful to keep in 
mind the fact that its pathology is cell life influ- 
enced bv the power of inheritance. The immaterial 
— whatever that immaterial was or is — which was 



dominant at birth, is still dominant in the asthmatic 
patient. This statement represents the hard and 
fast facts regarding the pathology of asthma. 

Etiology. — In order that there might be something 
definite in the mind fur the exciting cause — the 
etiology of asthma — to be thought of as active agent, 
the study of the pathology of the disease has pre- 
ceded the discussion of its etiology. It would be 
very difficult, though, to write all of the pathology 
of asthma, and only its pathology, above a straight 
line, and only the etiology and yet all of the etiology 
of asthma below the line. Pathology and etiology 
of asthma overlap or at least intermingle. 

The elusive point referred to &s the place of con- 
tact of the inheritance force with the nerve cell, has 
really to do with the processes of life itself, and no 
one has ever got very deeply into the secrets of 
those processes. Nevertheless, the initial functional 
derangement which begins to differentiate the patho- 
logical from the physiological, must ever be the 
fascinating objective and aim of all pathological 
study. As a matter of fact, however, eft'orts at 
tracing any particular derangement of function are 
as yet soon confused and frustrated, by meet- 
ing the workings of the law of the interdependence 
of all systemic functions. The single derangement 
at once takes on systemic proportions. In looking 
in this way into the etiologj' of asthma, it is seen to 
be tlie province of functional pathology that just 
as soon as the inheritance governed nerve cell has 
produced the asthmatic mental ; as soon as the nerve 
cell has produced the asthmaticward impulse; as 
soon as these meet the specific stimulus; just so 
soon does the mental, the nerve impulse, and the 
nerve cell become mutually helpful to the stimulus 
and to each other, in the workings out of their ata- 
vistic depravity instincts. 

That which actually tips the balance and ushers 
in asthma, is not easily expressed in words. But 
after it has seemingly clothed itself in the theory of 
anaphylaxis, or in the resulting bronchitis, rhinitis, 
coryza, or in phenomena of thymic incompetency ; 
after pyorrhoea alveolaris is present ; when there is 
sinusitis, submerged tonsils and adenoids, astigma- 
tism, flat foot, disease of the ductless glandular 
system, eczema, urticaria, erythema nodosum, or an- 
gioneurotic edema ; or when some other pathological 
condition is prominently present, then these demon- 
strable irritations naturally take the place of the 
sought for, but intangible real cause for the asth- 
matic attack. Also, food fails to digest, or there 
is malassimilation. Constipation develops, and the 
resulting choline in some way may, and no one 
know how often it does initiate the attack. It is 
easv to recognize the etiology of asthma after it has 
become flesh and blood, so to speak, but not before 

These conditions and diseases are not asthmatic 
pathologies, although some of them may be present 
in each case of asthma. Neither of them is either 
more than secondarily an etiological factor, al- 
though the asthma may stop and never return after 
the condition is arrested. But given the before 
described nerve cell groundwork, there may 
be asthmatic attacks from sight and smell — and 
even from association. There is asthma that is of 
purelv mental origin. Anger and grief and fear 
mav bring on the asthmatic attack. Further, there 



TRACY: BRONCHIAL ASTHMA. 



151 



is asthma which is doubtless due to changes in at- 
niospneric pressure, changes in carbon dioxide 
pressure, changes in oxygen pressure. And still 
lurther, there is asthma which, to all possible human 
investigation to prove the contrary, is out of a clear 
blue sky. So far as is known to medicine, there is 
no other recognized disease which is ushered in 
by so many like and unlike agencies, as is the 
spasmodic syndrome called bronchial asthma. The 
same conditions which apparently precipitate spas- 
modic asthma exist in other people, and yet the 
mind does not become introspective, apprehensive, 
nor is it swayed by suggestiveness, the sympathetic 
nervous system maintains its equilibrium, the dia- 
phragm does not give way to spasm, pulmonary sta- 
sis does not ensue, the blood does not back up in 
the right side of the heart, and the patient is not 
seized with violent oxygen hunger. 

The etiology of bronchial asthma — not that 
power which apparently precipitates the attack, but 
the real origin of the disease — is practically insep- 
arable from its pathology. If the pathaWgy of 
asthma is regarded as the material neuron, then the 
etiology of asthma is the transmitted immaterial 
force which dominates the neuron. No good can 
come from looking upon the etiology of asthma as 
being of less depth than is really the case. Much 
hami can come from attaching too great importance 
to visible abnormalities. 

Treatment. — Herein, treatment is based upon the 
biological fact that so far as can be known, the 
younger brother, when a baby, took precisely the 
same kind of food as the other brother had had, and 
that out of that nourishment he built up, not a 
physiological constitution, but one that was domi- 
nated by an asthmatically inclined ner\-e cell. Treat- 
ment must be in outline only. 

The asthmatic nerve cell was clearly not due to a 
particular food. That is to say, if the babies had 
been alike to begin w-ith, they would have been 
fathers to like constitutions. Metabolism as it 
worked out in the bodies of those two babies, is a 
big word. Asthma is dependent upon the metabo- 
lism in the younger brother. The curability of 
asthma is entirely dependent upon the ability to 
change that metabolism. Here, the aim is to re- 
duce metabolism to specific lower terms. There is 
no one factor of metabolism which is more specific 
than is the action of the alimentary canal upon the 
food in the canal. Specificity so used is, of course, 
a "bull," but differentiation between the babies was 
worked out in those alimentary canal actions upon 
food, and the place to begin to change the asthmatic 
tendency is where the tendency was first nourished. 
Moreover, ever}'thing in the treatment of bronchial 
asthma that has been of betterment to the asthmatic, 
logically connects itself with some change in me- 
tabolism. And in cases which have ended in com- 
plete recovery, there has been a metabolic regenera- 
tion of the neuronic type. Asthmatic preparedness 
is no longer present. The proof of which is that 
asthmatic attacks are not brought on by their for- 
mer causes. 

Then, to point out in a few lines the different 
measures which will most quickly and surelv change 
metabolism : In the first place, home life is. in a hun- 



dred ways, a handicap to the successful treatment 
of bronchial asthma. Home life perpetuates sur- 
roundings, and almost of necessity routes the same 
mental processes in the same well worn channels, 
and those channels lead to asthma. Whether me- 
tabolism is before mentality, or mentality before 
metabolism, may never be definitely determined. 
But radical change in the patient's intellectual 
ground work is as essential to metabolic change as 
is the change of foods and their manner of prepara- 
tion. The patient need not change his business, but 
the everyday associations which feed his mind and 
prepare it for business, should be changed. Asso-- 
ciations need be neither less nor more cheerful and 
enjoyable, but the sympathy of home life seldom 
tones the nervous system in a beneficial way. More 
humane than the bestowing of sympathy are en- 
forced associations which stimulate the will of the 
patient. The taking up by the patient of a side 
line occupation which burdens him with new re- 
sponsibilities, is helpful. In fact, anything which 
obliterates mental ruts and reroutes the mind on 
cardinal principles of right living, is humane treat- 
ment. 

As has been pointed out, it is impossible to ex- 
plain the effects of the mind upon systemic function 
and of systemic function upon the mind. But in 
very early life the mental and the physical were 
working in harmony in this younger brother. 
Symptomatic treatment largely aims at removal of 
exciting causes of the spasmodic attacks. Specific 
treatment seeks to remove constitutional defects 
which become disorderly under stress, and is 
better. 

Next in importance to change of the patient's 
surroundings is the change of his intestinal flora. 
This means a radical change in food, both in kind 
and quantity. It means the continuous sweeping out 
of the intestinal canal. It means chemical changes 
in intestinal secretions. It means possibly the in- 
troduction of combative germ life. Complete con- 
trol of the patient is necessary. Physical exercise 
taken out of doors — when the exercise is not thought 
of as a curative measure — makes for constitutional 
change. In some amusements and entertainments 
there is an inherent quality which prompts healthy 
thinking. They feed the mind wholesome food. 
They create a desire and dare for better things. 
There are other amusements and entertain- 
ments which just as surely do the opposite. The 
effects of one are physiological, and the effects of 
the other are pathological. To prescribe recreation 
for the asthmatic patient so as to benefit the patient, 
requires scientific study of amusements on the part 
of the physician. Mere sentiment in either phvsi- 
cian or patient ought not weigh in the least in mak- 
ing choice of sports for the patient. Each case is 
a separate study, and yet the general plan of treat- 
ment, to try to bring about rational changes in 
everything affecting the patient, applies in all cases. 

At first thought such measures of constitutional 
treatment of bronchial asthma are visionarv and im- 
practical. On the other hand, the opprobrium to 
medicine from the results of symptomatic treatment 
of the disease, points to the need of its deeper 
study. A surgical operation may and often docs 



152 



JACOBSON: THE NATURE OF GENIUS. 



[New York 
Medical Journa 



relieve the patient, and sometimes it actually cures 
the disease; but if constitutional measures could re- 
move the asthmatic tendency, then the surgery would 
be not for the treatment of asthma, but for the 
removal of diseased conditions. As a matter of 
fact, too, the effect of the surgery upon asthma is 
almost entirely psychical. The formidableness of 
the operation, the glamour and the hoped for bene- 
fit from the surgery, coupled with the thought of 
being a martyr, in actuality sometimes transport the 
patient to a new mental world. 

The taking of a new medicine or a change in 
physicians also induces hopefulness, but the psychic 
impression is less profound and not so lasting as 
surgery brings about. Mere hopefulness seems to 
be mildly preventive of asthmatic attacks, but the 
despair that is sure to follow is always antithet- 
ically in every way equal to the good which had 
come from the hopefulness. That is to say, for per- 
manent good to follow, there must be a constitutional 
background for hope. But to carry the analysis a 
httle further, with a physiological constitution once 
established, there is not the least need for hope. 
Possibly hopefulness may be of use in inspiring the 
patient to faithfulness in carrying out measures for 
bringing about constitutional change, but the deter- 
mination of a dogged will is worth much more. 
This brings up the thought of suggestive therapy, 
but such is only mentioned to be condemned. As 
well slide to the idiotic level of Mrs. Eddy and be 
done with it. 

It must be admitted that there is less of bril- 
liancy in a cure of asthma which has been brought 
about through the tedious process of a change of 
life's habits, than is offered in the proposed cure by 
surgery ; but at the same time there are better 
grounds for expecting a cure in the painstaking un- 
dermining of old systemic order, and in upbuilding 
a new. The cure of the disease is, in fact, half 
accomplished when the patient is rightly started in 
measures of constitutional treatment. It would, 
though, be as far from truth to say that neither 
surgery nor medicine is necessary after such treat- 
ment lias been begun, as to say that in the treatment 
of asthma nothing but surgery and the giving of 
medicines are ever required. As has been said, ev- 
erj-thing medically and surgically possible should be 
done to correct other abnormalities, but always with 
the emphatic assertion to the patient that the treat- 
ment of coexisting conditions and diseases is but 
a means toward the aimed for deeper physiological 
end. Bronchial asthma is curable — is cured by 
drawing out of the patient's mind thoughts that are 
in accord with strict physiological facts, and by the 
addition to tliis body of physiological thought, the 
supporting entity of nerve cell force generated by 
a physiological neuron. 

West Woodruff Avenue and School Place. 



Sodium Cacodylate in Syphilis. — H. N. Cole 
(Journal A. M. A.. December 30, 1916) states that 
ten cases of syphilis, representing the various mani- 
festations of the disease, were treated with sodium 
cacodylate, given intravenously up to the maximum 
of tolerance. The results were negative. 



POSSIBLE CLUES TO THE NATURE OF 

GENIUS. 

Jiv Arthur C. Jacobson, M. D., 

New ^'oI■k-. 

We are gradually coming to understand better the 
phenomena of divided consciousness, thanks to the 
labors of Flournoy, Janet, Prince, Sidis, White, and 
others. So called secondary selves coexist in the 
subliminal mental life, and in certain circumstances 
may usurp the reign of the primary self for varying 
periods of time. 

A medium is one who is supposed to be controlled 
in speech and action by the will of another person 
or of a disembodied being. There is, of course, 
nothing supernatural about mediumship. The me- 
dium is merely controlled for the time being, not by 
a disembodied spirit or the will of another, but by 
a secondary personality that has come up out of his 
(usually her) own subconscious mind. It is hard to 
understand wh)- men like Conan Doyle attempt to 
put a supernatural interpretation upon such facts as 
these. There is no excuse whatever for a man of 
Hyslop's scientific training to leave in his writings 
and in his talk the implication that there may be a 
supernatural significance in the phenomena known 
as ''communications." 

Sccondar)' personalities may behave rationally, or, 
in persons of low intellect, irresponsibly, which ac- 
counts for the mediums. The secondary personality 
of a medium concerns itself with mystical things, 
and imagines itself in touch with the spirit world. 
The trivial data heaped up by the psychical research 
societies betray very clearly the third rate minds that 
gave them birth. The medium, usually an abnormal 
woman of inferior and uncultivated mentality, trans- 
mits phenomena which are always a measure of this 
inferiority. 

What we are really concerned with is elucidation 
of the thought that genius may reside in the sec- 
ondary personality of a person of superior mental 
endowment. Genius may not be an element in the 
primary self at all. The genius is a supemian — a man 
plus a secondary' personality, his genius residing, not 
in the primary self, but in this secondary personality. 

In the one case we have the medium — low men- 
tality, irresponsible secondary personality ; in the 
other case we have the genius — high mentality, su- 
perrational secondary personality. 

Is there not a striking analogy between a Paga- 
nini, or a Shelley, or an Edison in the throes of 
creation, oblivious to all about him, the primary self 
completely eclipsed for the moment, fairly possessed 
by his dcrmon, or secondary self, and the medium in 
a trance? 

There would appear to be nothing in the primary 
self of the so called genius accounting for his cre- 
ative powers save his superior mind — a sine qua non 
for the successful operation of a genius endowed 
secondary personality. This type of mind affords 
a delicately attuned instrument for the facile 
operation of the latent power residing in the 
secondary personality. When successfully set 
free — sublimated, as the Freudians say — this 
becomes creative power, or genius manifest in 
works. In this light we can see both the trance of 



Jaiiuiry 27. IQ'?-] 



JACOBS ON: THE NATURE OF GENIUS. 



IS3 



tlie medium and the inspired performances of the 
genius as demonstrations of successful conflicts 
against repressions, seeking spirituahzed avenues of 
expression far removed from the old and conven- 
tional sexual channel. Flournoy has already attrib- 
uted the origin of differing personalities to the sex- 
ual cenesthesia of the subject. 

Thus do we get that wonderful complex — the 
often unattractive physical tenement — Socrates, 
Francis Thompson, Carlyle, Steinmetz — the primary 
self inclusive of a first rate mind, and the genius 
endowed secondarj- personality — the dcus ex nia- 
cliina. 

Bateson conceives of evolution and life as "an un- 
packing of an original complex." All men, he thinks, 
have divine potentialities packed in them somewhere, 
somehow. A longshoreman has the same essential 
equipment as a Shakespeare. So the genius, instead 
of being one to whom something has been added 
from without, is one who for some reason or other 
has experienced a release of his powers. In him the 
forces that mask the hidden faculties of common- 
place beings are abated or lost. 

What does this mean, if not usurpation by a sec- 
ondary personality? Paralyze the inhibitions of a 
peasant and you get a Bobbie Bums. Viewed in this 
light, the personality that took possession of the 
country btunpkin christened William Shakespeare is 
shorn of much of its mystery. 

The real miracle that invites our contemplation is 
the paralysis of inhibitor)- mechanisms. What hap- 
pens is becoming clear enough, but why does it hap- 
pen ? Now that we have a glimmering, if not a fair 
insight into what happens — which is a big and un- 
precedented step — we are in a position to prosecute 
an inquiry into determining causes. 

We may say that certain relevant data have al- 
ready been accumulated, though naturally their exact 
significance and correlation have not been fully 
grasped. We think it would be wholly possible, 
utilizing the good working hypothesis which we have 
submitted, to arrive at determining factors in in- 
stances which offer full facilities for expert study 
and analysis. The societies for psychical research 
seem to confine their attentions to mediums. A much 
saner field of inquirj- would be the study of genius 
and geniuses. Why delve so exhaustively into the 
lesser sphere, and fool with Calibans, when the Pros- 
peros, waving their magic wands, stand before us ? 

If we are challenged to cite from the clinic of life 
any outstanding proof of the existence of an agency 
paralyzing inhibitions at propitious times and re- 
leasing the spirits that give wings to the soul, or, in 
other words, setting free creative powers resident 
in a secondary personality, we are obliged to call the 
following galaxy as witnesses in favor of alcohol : 
Charles Lamb, Walt Whitman, Tasso, Swinburne. 
Byron, Verlaine. Goethe, Baudelaire, Hoffmann, 
Samuel Butler, Burns, Poe, Wilde, Horace, Cole- 
ridge, De Quincey, Ben Jon son, Tennyson, ^schy- 
lus, Anacreon, Omar, Marlowe, Cervantes, Gold- 
smith, Addison, Swift, Steele, Pope, Gay, Bacon, 
Herrick, Balzac, Schiller, Dickens, Sheridan, Tom 
Moore, Catullus, Ovid, Alcibiades, Cicero, Hobbes, 
Cowley, Rossetti, Thomson, Alfred de Musset, 



Gerard de Nerval, Guy de Maupassant, Lionel 
Johnson, Miirger, Richard Savage, Thomas Carew, 
Kleist, Melius, Charles Churchill, Thomas Parnell, 
Jack London, Richard Le Gallienne, Schubert, Dus- 
sek, Handel, Gliick, Turner, Cruikshank, Morland, 
Phil May, \'ictor Daley, Frans Hals, Jan Steen, 
Caracci, Adrian Brouwer, and Barbatelli. 

In an intensive study of genius along the lines in- 
dicated alcohol would be found an infrequent fac- 
tor, since it is only a small group of geniuses of 
peculiar constitution that furnish evidence of such 
idiosyncratic response. In our Chattertons and 
Platos and Edisons we should have to consider 
many other things. 

The toxins of tuberculosis have facilitated the re- 
lease of creative personalities in many notable in- 
stances. Again from the great clinic of life we call 
as witnesses Charlotte Bronte, Rousseau, Milton, 
Ruskin, Kingsley, Locke, Hawthorne, Robert Pol- 
lok, Michael Bruce, Channing, Kant, "Thomas In- 
goldsby," Beranger, Hannah More, Madame de 
Stael, James Ryder Randall, Scott, Shelley, Keats, 
Tom Hood, Sterne, Elizabeth Barrett Browning, 
Moliere, Thoreau, Stevenson, Lanier, Rachel, Bi- 
chat, Calvin, Watteau, Laennec, Bastien-Lepage, 
Emerson, Jane Austen, Francis Beaumont, Spinoza, 
David Gray, Georges do Guerin, Voltaire, Amiel, 
Nevin, von Weber, Chopin, Paganini, Washington 
Irving, John R. Green, Richard Baxter, Marie Bash- 
kirtseff, Hurrell Froude, Richard Lovelace, George 
Herbert, John Addington Symonds, Westcott, 
Blackmore, Adelaide Ann Procter, Joseph Rodman 
Drake, Kirke White, E. P. Roe, N. P. Willis, 
George Ripley, Grace Aguilar, Stephen Crane, H. C. 
Bunner, John Sterling, J. T. Headley, Henry Tim- 
rod, and Paul Laurence Dunbar. 

The release of creative secondary personalities 
would seem to depend largely upon some sort of 
intoxication, with resulting paralysis of inhibitions. 
This is obviously true of alcohol, also of the toxins 
of tuberculosis. 

Dr. William A. White, in his Mechanisms of 
Charaeter Formation, suggests that the body is 
really a transformer of energy taken in by many 
overlooked receptors, that our food may not be the 
chief source of supply, the energy derived from it 
being mainly for the upkeep of the body itself, and 
that the sun may be a principal source. The tre- 
mendous energy dispensed by some persons would 
seem, could it be concentrated, controlled, and trans- 
mitted, sufficient to light a city. Certainly the power 
of an idea, acting strongly and for generations upon 
society, cannot be related to caloric intake. 

White's conception gives us another glimmering 
into our problem, but at once the further thought 
occurs — not only do we have to consider inhibitions 
preventing the release of highly charged secondary 
personalities, but also inhibitions having to do with 
the receptors of energy and preventing the ade- 
quate charging of such personalities. 

No doubt the progress of the next few years will 
permit us to discuss without risk of confusion or 
ridicule the problem which we have posited, if not 
wholly to resolve it. 

115 Johnson Street, Brooklyn. 



154 



SANDERS: ANESTHESIA AND ACIDOSIS. 



[New York 
Medical Journal. 



ANESTHESIA AND ACIDOSIS. 

Bv Harold A. Sanders, B. S., M. D., 

New York. 

.\11 that was expected in the early use of the 
agents of modern anesthesia was that they keep the 
patient free from pain during operation and in such 
a state as to be capable of resuscitation at its com- 
pletion. Today we go further and demand that its 
nature and administration be such as to reduce the 
danger to life to a minimum. It must produce com- 
plete analgesia, quiet, and relaxation. Its nature and 
administration must be such as to interfere least 
with respiration, circulation, and other vital 
processes. It must aid in reducing general shock 
to the lowest degree. It must produce the minimum 
amount of toxemia, and not cause serious or lasting 
aftereffects. It must be pleasant for the patient to 
take and not cause him discomfort on awakening. 

A few years ago, many of the methods and means 
to cure disease were almost as distressing as the 
disease itself. Today patients require sugar coated 
pills and general therapeutic measures of a pleas- 
ant, as well as effective, nature. Many patients are 
kept from operation because of the dread of the 
anesthetic and its aftereffects. If then we are to 
make surgical relief more attractive, we must lessen 
its attending discomforts. 

Excepting the personal ability of the anesthetist 
there is nothing wdiich goes further toward produc- 
ing satisfactory narcosis than the right preparation 
of the patient. Many of the elements of the older 
methods of preparation tend to make the postopera- 
tive discomfort more severe. 

The great bugbear of all anesthetics is vomit- 
ing. Preparatory treatment has recently been shown 
to play a large part in banishing this dreaded com- 
plication. We are indebted to a long list of physio- 
logical chemists for elaborate experiments regarding 
this matter. Many theories have been advanced as 
to its cause. It has been thought to be influenced 
by the kind, amount, and method of administration 
of the anesthetic. The swallowing of ether soaked 
saliva was presumed to set up a gastritis which 
caused vomiting until the ether was eliminated. It 
was supposed to occur most in neurotic patients, 
those nauseated from slight causes, those frightened 
and fearing operation, and those whose physical 
condition predisposed to this complication. The 
nature of the operation and the manipulations of 
the surgeon also came in for their share of the 
blame. 

Physiological experiments and clinical oserva- 
tions have led many students to conclude that while 
the factors mentioned above are undoubtedly ele- 
ments in the causation of this complication, "post- 
anesthetic vomiting is, to a large extent, the result 
of some constitutional disturbance involving the 
body metabolism and resulting in the formation of 
toxic substances of an acid nature, and the best 
means of preventing such vomiting lies in the adop- 
tion of certain precautionary measures previous to 
the period of induction" (Buckler). 

Verworn has shown that anesthetics act by rea- 
son of their loose physiochemical combination with 
the lipoids, causing them to lose their normal rela- 
tionship to the other cell elements. This results in 



cellular inhibition so that the cell absorbs or utilizes 
less oxygen. This lessening of the oxygen supply 
to the cell and in turn to the organ produces an in- 
crease of acidity therein. 

.Vcid intoxication in the body occurs because of 
abnormal fat metabolism. The combustion of fats 
requires the simultaneous catabolism of carbohy- 
drates, in the absence of which fatty acids and ace- 
tone are formed. The carbohydrate deficiency re- 
sults from the disturbance of the glycolytic function 
of the liver. This follows the action of the anes- 
thetic or other disturbing factors on the liver cells 
or upon the splanchnic nerves controlling the glyco- 
gen output. It has been demonstrated that in every 
patient more or less acidosis develops after anes- 
thesia. The severe types such as the so called "de- 
layed chloroform poisoning" have long been recog- 
nized, but that all surgical patients show preanes- 
thetic acidosis, or a tendency to it of such a degree 
as to require treatment, is just beginning to be ap- 
preciated by the profession. The acidosis may not 
be of such degree as to give reactions in the urine 
for betaoxybutyric acid, acetone, or diacetic acid, 
but that the hytlrogen ion concentration of the blood 
is increased and tiie carbon dioxide tension de- 
creased by all the conditions necessitating and con- 
nected with operative measures, and that develops 
acid intoxication in these patients very readily, has 
been amply demonstrated (Roth and others). 

Martin Fischer has shown by his colloid theory 
that raising the acid content of a cell increases its 
capacity to take on water, with consequent edema 
of the cell. More water being held by the cell and 
tissue diminishes the amount free in the body for 
secretion. This explains why the patient acidosed 
by the anesthetic is thirstv and his secretions are 
reduced. 

From the foregoing it is evident that preanes- 
thetic treatment should provide carbohydrate, alkali, 
and water. Where emergency does not prevent such 
care, the surgical patient should be placed upon a 
special diet for three or four days previous to opera- 
tion. This diet should not be the light or starvation 
diet of the older methods of preparation, which con- 
tributed to acidosis. It should consist in the mini- 
mum of protein with correspondingly large amounts 
of carbohydrates. The dietary should include well 
cooked cereals served with plenty of sugar or 
honey ; malted milk and any of the prepared foods 
containing dextrose and maltose ; potatoes, best 
baked, and all the vegetables ; the fruits, especially 
apples, oranges, raisins, dates, and cantaloupe, with 
white bread or crackers. 

When possible, the patient should be fed to within 
six hours of operation. Castor oil makes the best 
laxative, as it produces no gas. Where enemas are 
used, those of sodium bicarbonate, one ounce to the 
quart, are most effective in supplementing this treat- 
ment. 

For the alkali element of the treatment, natural 
or artificially prepared alkaline waters, especially 
those containing the carbonates and bicarbonates of 
calcium, sodium, and magnesium, are both pleasant 
and efficient. Sodium bicarbonate and sodium ci- 
trate, in one dram doses, calcium acetate, in half 
dram doses, every three to four hours, may be used 
with plain water. These may be combined with mal- 



January 27, iqij.] 



SANDERS: ANESTHESIA AND ACIDOSIS. 



'55 



tose or lactose, if desired. The purpose is to have 
the patient come to operation with urine alkahne to 
litmus or rosalic acid and passing at least fifty 
ounces in twenty-four hours. 

Fear is a large contributing factor in the produc- 
tion of acidosis. It is also true that it contributes 
to shock. Therefore the reduction of fear and the 
production of rest add much to the patient's wel- 
fare. This object is accomplished by tactful reas- 
surance and by giving the patient ten or fifteen 
grains of veronal two hours before bed time the 
night preceding operation. 

The use of morphine and atropine preliminary to 
general anesthesia is now very widely practised and 
it does much to prevent anesthetic complications, 
(iwathmey, in a series of experiments made at New 
York University, showed that dogs which had been 
given preliminary doses of morphine required from 
one fourth to one half as much more anesthetic to 
kill them than those not so protected ; also that it 
took one fourth more time to kill those having a 
preliminar}' dose of narcotic than those to which it 
had not been given. 

Crile and Menton, after elaborate experiments, 
have shown that morphine given before anesthesia, 
not only makes it quieter and reduces the amount 
needed, but greatly lessens the degree of acidosis ; 
also that the preliminary dose of morphine not onl\- 
lessens the degree of acidity produced by the anes- 
thetic, but that it in no way interferes with the re- 
turn of the blood to its normal alkalinity ; "on the 
contrary, and the following observation is of great 
significance, if morphine was given after acidity had 
been produced by the anesthetic, it postponed the 
time of neutralization, and if given in large doses 
prevented the animal from overcoming the acidosis." 
In emergency, patients who have a severe preexist- 
ing acidosis, chloretone, veronal, and the bromides 
should be used beforehand, and the same drugs may 
be used for postoperative pain. 

Most of the details we have been discussing up 
to this point are in the hands of and are carried 
out by the surgeon, but the anesthetist should be 
conversant with them and with the case which he 
is to handle. It sometimes happens that the anes- 
thetist is brought face to face with the patient at 
the time of induction of the narcosis without either 
knowing anything about the other. This cannot al- 
ways be avoided, but the sense of comfort enjoyed 
by both patient and anesthetist when the latter 
knows his case and is able to select the best anes- 
thetic and method, and prepare for possible contin- 
gencies, go far toward a happy outcome. 

Prepared in the way outlined, the patient gen- 
erally comes to the operating room in a state of 
mental calmness. She should be placed upon the 
operating table before the narcosis begins, and as 
much of the final preparation completed as possi- 
ble. In such a mental state an anesthetizing room 
is unnecessary^ provided that conditions in the op- 
erating room are right, i.e., the instruments are cov- 
ered and the room is quiet. Removal of a patient 
from the stretcher to the table in the early period 
of anesthesia is a dangerous procedure which often 
causes respirator\' arrest, vomiting, and disturbance 
of the plane of anesthesia. It also contributes to 



acidosis and shock, often transforming a quiet nar- 
cosis into a troublesome one requiring resuscitaiivc 
measures or large doses of the anesthetic to restore 
the patient to a satisfactory condition. 

The induction of the anesthesia should be brought 
about by the most pleasant possible means. The 
writer generally finds this to be nitrous oxide in 
adults and ethyl chloride in children. The aim is 
to avoid suft'ocation and eliminate the stage of ex- 
citement. Restraint should not be used, unless ab- 
solutely necessary, as it only causes more vigorous 
resistance. Once established, the narcosis should 
be as even as possible and just deep enough to i)ro- 
duce muscular relaxation. Alvin Powell found in 
a long series of cases that with imperfect relaxa- 
tion patients showed more irritation of the kidneys 
than when they were anesthetized longer and more 
deeply. On the other hand, excessively deep anes- 
thesia was followed by more albumin and casts. 
Imperfect muscular relaxation leads to the produc- 
tion of a large amount of acid products because of 
the unconscious struggle of the patient in his efforts 
to resist the surgical trauma. It is important that 
the patient be kept warm during the operation, as 
Boothby has shown that there is a great loss of 
vital heat at this time which tends to shock and 
acidosis. 

It may be said that with properly given anes- 
thesia, cases frequently end in recovery without 
vomiting. This is true, but patients often vomit 
severely and persistently after skillful anesthesia of 
brief duration. The most striking evidence of the 
role than an acidmtoxication plays in postanesthetic 
vomiting, and the efficiency of prophylactic treat- 
ment, is seen in patients who have had several anes- 
thesias followed by severe vomiting, but none at all 
when thus protected. Some patients are more sus- 
ceptible than others. The nervous and badly fright- 
ened children, the exhausted, the starved, the 
shocked, the severely injured, the infected (Crile) 
are especially prone to it. Persons with dilated and 
displaced stomachs, gallbladder disease, intestinal 
obstruction and all others with preexisting vomit- 
ing are apt to have this complication. In all such 
cases lavage with bicarbonate solution should be 
practised before the patient is removed from the 
operating table. 

When the patient is returned to the warm bed, 
he should have a pillow unless shock treatment is 
required. The room should be quiet, darkened, and 
well ventilated. A retentive enema of one pint of 
a five per cent, solution of lactose and sodium bi- 
carbonate two per cent, is given at once. Eight 
ounce retentives of the same solution are given at 
three to four hour intervals. Quinine muriate in 
ten grain doses added to the first four of the 
enemas, prevents backache and gas pains. If pre- 
ferred, the solution may be given by the drip 
method. 

In cases of severe infection, Hogan recommends 
a five per cent, solution of anhydrous dextrose by 
the drip method, adding, 'T have found the rectal 
or intravenous injection of sterile hypertonic anhy- 
drous dextrose solutions — up to eighteen per cent. — 
to produce most spectacular results in anuria, ileus, 
coma, persistent vomiting, and glaucoma." 



1^6 



ULIHNSIS AND ME.\'DELSO.\' : ADD/SON'S DJSE.ISIi. 



[New York 
Medical Journal. 



As soon as the patient can take liquids by mouth, 
sips of the sodium or calcium bicarbonate water 
should be given. Fruit juices with sugar added, 
forming a "fruitade," make them more grateful to 
tht patient. The sugar furnishes the additional car- 
boiiydrate needed, wliile the fruit acids are oxidized 
to bases constituting a further feeding of alkali. 
Later, carbohydrate feeding may be increased by 
use of malted milk, cereal gruels, then fruit albumin 
and i>eptonoids. 

Pain and restlessness are relieved by the use of 
the bromides, chloretone, and veronal. When vomit- 
ing does occur, vigorous sugar alkali treatment 
should be pushed, and lavage with the alkaline solu- 
tion practised, if necessary. Sodium bromide or 
chloretone given per rectiun is helpful. 

A powder, of cocaine one fortieth grain, menthol 
one tenth grain, tincture of nux vomica one minim, 
bismuth subnitrate one grain, and cerium oxalate 
two grains gives relief in some severe cases. 

Some who have tried this treatment have reported 
that it did not give the results which its advocates 
have stated. I believe this is because they have not 
fully followed out the really simple details of the 
technic as given above. I am sure this was so 
in a number of the cases which I have observed. 

One of the first reports which the writer heard 
on the use of the alkali sugar treatment covering 
a large number of cases, was from Buckler, of 
Baltimore, in his paper read before the American 
Association of Anesthetists at Atlantic City, in June, 
1914. Working with Stickney of the Woman's Hos- 
pital he reported their results as "astonishing." 
"There were no cases of severe vomiting and many 
with absolutely none." 

Doctor Buchanan in a private communication to 
me, reports over five hundred cases treated with 
the sugar alkali method. His conclusion is "that 
there has been a decided improvement in the re- 
coverjr of my cases since I have instituted these 
methods." 

Dr. James J. Hogan says of this treatment: "So 
prepared, patients recover rapidly from the effects 
of their anesthesia. They are without headache, 
absence of brain edema ; vomit little or none at all ; 
absence of edema of the medulla ; they urinate an 
hour or two after operation ; absence of kidney 
edema and early presence of free water; the urine 
is practically free from albumin, casts and excess 
ammonia. Moreover, the traumatized tissues at the 
seat of the operation swell less and are less painful, 
owing also to decreased edema." 

The writer has followed this treatment, where- 
over possible, for the past two years and has been 
much pleased with the results. In a long series of 
operations on the head and mouth, in which he 
had charge of both preparatory and aftertreatment, 
the effect has been most gratifying. There were no 
cases of severe vomiting such as are often seen in 
these patients ; in most of them none after they 
were conscious, and in many none at any time. 

In the larger group of general surgical cases, 
where the method was used more or less perfectly 
by the operator, there have not been any reports 
of severe vomiting, while the majority have had 
little or none. 



I believe that the technic here outlined, consci- 
entiously carried out, will do much to increase the 
safety and comfort of the surgical patient and add 
to the reputation of the surgeon. 

REFEREN'CES. 
I. J. T. GWATHMEY: Anesthesia. 2. PAUL ROTH: The Esti- 
mation of Carbondioxide Tension in Alveolar Air, Journal A. M. A., 
Ixv, July 3>, 1915, PP- 413 to 418. 3- BLATHERWICK: Specific 
Role of Foods in Relation to the Composition of the Urine, Archives 
of Internal Medicine, xiv, pp. 409-449. 4. JAMES J. HOGAN: 
Kidney Function and Anesthesia, American Journal of Surgery, 
Anesthesia Supplement, i, 3, p. 75. 5. H. W. BUCKLER: Prophy- 
laxis of Postanesthetic Vomiting, ibidem, October, 1914, xxviii, 10. 

6. GEORGE W. CRILE: Journal A. M. A., Ixiij, 1914, p. 1335- 

7. GEORGE W. CRILE: Ibidem, xxviii, 10. 8. E. L. OPIE and 
L. B. ALFORD: Influence of Diet on Hepatic Necrosis and Toxicity 
of Chloroform, Journal A. M. A., Ixii, 12. 9- S. A. CHALFANT: 
Acetonuria, Its Relation to Post-operative Vomiting in 700 Cases of 
Ether Anesthesia. 10. M. R. BRADNER and S. P. REIMANN: 
Observations upon the Elimination of Acetone and Diacetic Acid in 
214 Surgical Cases, American Journal Medical Sciences, 191 5. 

8^6 Park Place. Brooklyn. 



A CASE OF ADDISON'S DISEASE. 

By a. E. Oliensis, M. D., 

Philadelpliia. 

AND Jos. a. Mendelson, M. D., 

Philadelphia. 

Through the courtesy of Dr. William Egbert 
Robertson, chief of the medical department of the 
Samaritan Hospital, we are enabled to present a 
true and well marked case of Addison's disease, 
first seen by Dr. A. C. Menger, the patient's family 
physician, who referred the case to the hospital for 
further study and treatment. 

The patient, a white man, first seen at home, in 
bed, appeared fairly comfortable, of average intelli- 
gence and good physique. We were struck by the 
man's color contrasted with the white covering of 
the pillow on which his head rested. The asthenia 
was marked, the patient being exhausted in answer- 
ing the few questions asked as a routine before con- 
veying persons to the institution in the ambulance. 
The following history was obtained : 

Case. Mr. R. R., married, fifty-one years of age, native 
of Austria, white, a polisher of roller bearings by occupa- 
tion, admitted complaining of weakness, pain in left loin, 
feeling of epigastric discomfort, nausea, and atiorexia. The 
family history indicated nothing definite. The father al- 
ways coughed, died at sixty-seven years of age, having been 
thrown from a horse. The mother died at sixty-eight 
years, presumably of cardiac disease. One sister died at 
twenty-three years of pneumonia ; one brother living and 
well. No collateral history of importance. In the past personal 
history there was little to be noted. Was born in Italy of 
Austrian parentage and taken to Austria in early infancy; 
had measles and chicken pox, otherwise always well ; mar- 
ried at twenty-six years. No venereal disease at any time. 

From the patient's statement it appeared that he dated 
the onset of his present illness July. 191S. about which 
time he had a good deal of worry and anxiety occasioned 
throiigli being annoyed by his employer, a woman in ill 
health and of uncertain temper, who required of the pa- 
tient impossible tasks. 

About nine months ago, after leaving the situation where 
he was employed as a houseman, the patient took a position 
as a polisher of roller bearings. About this time he noted 
that lie could not eat the same quantity of food or with 
the same relish as heretofore, and did not work with the 
same vigor as in the past. It took more effort to accom- 
plish the same amount of work. On April 27th he worked 
in a draft which caused him the next morning to have pain 
across the lumbar region ; went to bed and called physician. 
The patient never had any bronchial trouble or cough, and 
until the onset of this condition the digestive system had 
always been good. 



January 27, 1917.! 



OLIENSIS AND MENDELSON: ADDISON'S DISEASE. 



157 



The patient observed about eight months ago that his 
skin was growing dark, but attributed this to the 
presence of grease and metallic dust in the atmosphere 
of the workroom. Complained of shortness of breath at 
night: was very weak, emaciated, and markedly asthenic; 
easily tired by conversation ; vomited at intervals, regard- 
less of taking food, though the ingestion of edibles was 
followed by prompt and sudden regurgitation of the in- 
gesta. The nausea was not marked. 

Physical examination showed a poorly nourished, ema- 
ciated, and asthenic white male about fifty-one years old, 
whose head was symmetrical, scalp in good condition, hair 
gray black and plentiful. Ears normal, hearing average. 
Face was dark brown (bronzed), lips cyanotic, expression 
listless and weak. Eyes sunken, pupils reacting normally 
to light and accommodation, conjunctiva; pale; brownish 
pigmentation on lower lid. Mouth had only two molars, 
the canines and two incisor teeth; no teeth in lower jaw. 
Slight inflammation of the gum ; mucous membranes of the 
buccal cavity, the tongue, which was dry and slightly 
coated, and gums showed areas of brown pigmentation. 
Throat injected. 

Glands in both axillary regions enlarged ; small posterior 
cervical on the right side. Skin pigmented but showed 
scattered areas in which the bronzing was more marked, 
these especially noticeable around the forehead, neck, over 
the shoulders, around the waist, and below both knees. 
Muscles fairly well developed, poor tone. Bones and joint 
normal. Chest was long, emphysematous, and had an 
acute angle, scattered rales all over the chest, particularly 
at the right apex. There was an area of dullness, decreased 
tactile and vocal fremitus with distant breath sounds at 
the right base and some fullness on the lower right side of 
the chest. 

Apex beat one inch outside the nipple line ; heart dull- 
ness one inch to the right of the right margin of the ster- 
num and one inch to the left of the left midclavicular line. 
There was also an area of dullness in the first and second 
interspaces, extending from one half inch to the right of 
the right margin of the sternum to two inches to the left 
of the left margin of the sternum. First sound was weak, 
second sound relatively accentuated. Vessels fibrosed, pulse 
small volume, rapid, weak ; very low tension and equal on 
both sides. Blood pressure 80 and 70. 

Abdomen scaphoid, rigidity present over right hypochon- 
driac and right iliac regions ; no pain or tenderness. Liver 
came down to one finger's breadth below the costal margin 
and began at the sixth interspace. Stomach, lower border 
one inch above umbilical line. Kidneys and spleen not pal- 
pable. Finger nails cyanotic. Lower extremities presented 
no edema. The crests of the tibia, especially the left, were 
saw edged; tenderness along the nerves of legs; patellar 
reflexes gone; no Babinski or ankle clonus. Meatus was 
inflamed. 

Temperature 96.2° F. ; was never above 97° and once 
so low as to preclude reading with the ordinary clinical 
thermometer. Pulse 92. Respirations 24 a minute. 

Urine light amber, specific gravity 10.22, acid, sediment 
flocculent, albumin a trace, negative for sugar, urea 21.7 
grams a litre, occasional squamous and pus cells ; showers 
of hyaline and granular casts. Indican, large trace. Bile, 
diazo and urochromogen were negative. 

The blood showed a red count of 4,640,000, whites 11,800, 
hemoglobin seventy-five per cent, cyanotic and difficult to 
obtain. A differential count could not be made. Sputum 
contained many pus cells and micrococci, but no tubercle 
bacilli. The Wassermann and Xoguchi reactions on the 
blood were negative. The Moro reaction was tried, but the 
patient died about twenty-four hours after admission and 
it indicated nothing ; in fact, had he survived we doubt if 
a positive reaction would have been obtained because of 
his low resistance and marked general asthenia. 

The usual routine admission treatment was given 
and stimulation begun. It was our purpose to have 
given by mouth the desiccated adrenal gland coinci- 
dent with intravenous injections of epinephrin in 
saline solution, as we have found that drugs given 
intravenously act more promptly and give as good, 
if not better, clinical results than when administered 
by mouth. The patient, however, was seen so late 



that we were unable to carry out the plans we had 
formulated, as he passed away very suddenly on the 
evening following admission. We may be permit- 
ted to doubt if treatment would have availed at this 
stage. 

The post mortem findings are given here, and it 
was found that the tubercle bacillus was the of- 
fender. 

The post mortem examination of R. R. — clinical 
diagnosis Addison's disease — shows a middle aged, 
white male, emaciation marked. Bronzing of face 
and neck marked, pigmented areas scattered over 
face, neck, thorax, abdomen, and extremities. Not 
much subcuticular fat. Nipples markedly pigmented. 
Muscles of chest wall quite red. Left lung appar- 
ently free from adhesions, except at apex, running 
posteriorly — no free fluid. Lung crepitates through- 
out, congested, and red ; moderate amount of pig- 
mentation ; at apex several indurated areas extend 
into lung about 0.5 c. c. ; much congestion in lower 
lobe. Section shows lung markedly congested. 

Right lung presents adhesions to anterior and lat- 
eral chest walls which do not run posteriorly. Very 
dense adhesions at apex ; seems to be bound down 
to pericardiiun ; fibrinous exudate over surface. 
Lower lobe ; moderate congestion, crepitates ; at 
apex, torn in removing, is a hard, indurated mass, 
size of a walnut, microscopic section through this 
shows several calcified tubercles. 

Small amount of fat over pericardium; small 
amount of fluid ; heart larger than normal in size, 
extremely flabby, and has a large amount of fat. 

Aorta normal ; no clots ; aortic valves normal. 
Abdomen distended. Liver slightly increased in 
size ; fair consistence, few adhesions over superior 
surface ; on section liver is dark and friable ; mark- 
edly pigmented, inoderate parenchymatous and some 
fatty degeneration. 

Gallbladder enlarged, adherent, and distended. 
Greater omentum extends down to left iliac region ; 
dense adhesions are present on the right. No free 
fluid in the abdomen. Spleen is normal in size, 
flabby, and on section the substance oozes ; no tu- 
bercles. Stomach dilated and extends to left dia- 
phragm ; is filled with a large quantity of brownish 
colored fluid. Pigmentation of mucous membrane 
of stomach, slate gray in color; part of mucous 
membrane dotted with grayish white plaques. 

Pancreas normal in size and consistence, head a 
little harder than normal, though normal on section. 
No palpable mesenteric glands. 

Left kidney normal in size and consistence. Cap- 
sule strips with moderate ease. Kidney pale, cortex 
increased in size ; on section pyramids stand otU 
prominently. Section of left adrenal shows a hard 
indurated area at lower pole of adrenal, also some 
creamy pus. Gland is enlarged and fibrotis in na- 
ture. Right kidney rather long and narrow, cap- 
sule strips easily ; cortex enlarged and pyramids 
stand out prominently. No masses in pelvis. Ap- 
parently no pus in right adrenal, on section no case- 
ated mass, but nodular areas present. Both kid- 
neys show moderate parenchymatous degeneration. 
Section of the adrenals shows tuberculous caseation 
necrosis. 

3302 North Broad Street. 



i=;8 



FRANKEL: INFLUENZA VS. TUBERCULOSIS. 



[New York 
Medical Journa 



INFLUENZA VS. TUBERCULOSIS. 

By Bernard Frankel, M. D., 
New York. 

During the summer influenza is frequently com- 
plicated by disorders of the digestive and nervous 
systems, as witness the infantile paralysis (i) and 
gastrointestinal complications of the grippe of last 
summer ; while during the winter, late fall, and early 
spring its most common complications are diseases 
of the respiratory organs. These latter often pre- 
sent great difficulties in etiology, diagnosis, and 
treatment, more especially when they become 
chronic, although even in their acute stage some of 
them may tax to the utmost the resources of the 
most astute diagnostician, as the following interest- 
ing case may illustrate: 

Cask I. Last winter I was called to treat a man forty- 
five years old, a painter of Manhattan, who gave the fol- 
lowing history : Two weeks previously he contracted a 
cold which was accompanied liy some elevation of tem- 
perature and an enlargement of some of his cervical and 
a.xillary glands on the right side. He applied for treat- 
ment to a local dispensary, and was rcferr^-d to a well 
known hospital in the same neighborhood, where his case 
was diagnosed as Hodgkin's disease, for which nothing 
could be done. 

I found him with a temperature of 101.5' F., pulse 100. 
and respirations twenty-si.x, irregular bowel movements, 
scanty, high colored, and very acid urine, which showed 
an excess of urates, but no albumin or casts. He was 
poorly nourished, very nervous, and comiilained of ex- 
treme distress from insomnia. He had a slight cough and 
his physical examination revealed some dullness and 
diminished breathing over his right lower lobe posteriorly, 
but no rales. Neither then nor at any subsequent time 
was there any further enlargement of his glands. Under 
treatment with la>:atives, nerve sedatives, and alkaline 
diuretics he improved markedly within a few days : his 
temperature came down to normal, the restlessness sub- 
sided, he slept better, and seemed to be on the high road 
to recovery, when all of a sudden his temperature rose to 
103° F. and assumed a hectic character, his cough and 
physical signs became more pronounced, and the general 
condition much aggravated. I told his relatives that, al- 
though some of the symptoms simulated tuberculous pneu- 
monia, I su.spected an empyema and suggested an explora- 
tory puncture, but they insisted on his being taken to a 
hospital. 

About a week later his wife came to my office to com- 
plain against the hospital physicians for transferring her 
husband to a tuberculous ward. I communicated with the 
physician in charge and was told that some tubercle bacilli 
were found in the .sputum of the patient, but he insisted 
that his sputum was not even collected, and therefore 
could not have been examined. I had him taken home at 
once and sent the sputum for examination to the board 
of health and also to the National Pathological Labora- 
tory. All reports were negative as to tubercle bacilli in 
these and subsequent examinations, but from the National 
Pathological Laboratory numerous streptococci were re- 
ported present. 

During the following three weeks his condition fluctu- 
ated markedly; his physical signs would clear up and the 
temperature come down to normal with considerable im- 
provement in his general condition, only to be followed by 
a sudden relapse with high hectic fever, severe cough, and 
physical signs of consolidation at the base of his right or 
left lung, which in turn would resolve and disappear 
within a few days. 

I finally came to the conclusion that I had to deal 
with a case of influenza, with repeatedly recurring 
pyemic teinperature accompanying the develop- 
ment of localized pneumonic patches, which 
presented some features of metastatic ab- 
scesses. Repeated attempts to place him in 
a hospital failed, the admitting physicians insist- 



ing on a diagnosis of pulmonary tuberculosis, and it 
was with great difficulty that I finally succeeded in 
having him admitted to the New York German Hos- 
pital. He was suffering at the time from one of 
his relapses, and his cachectic appearance, together 
with the hectic fever and the history of the case, 
strongly stiggested a tuberculotis origin of his fresh 
pnetimonic process, btit close observation and a thor- 
ough bacteriological study of the case enabled the 
attending physicians to rule out tuberculosis. On 
the other hand, the fact that numerous colonies of 
streptococci were found in cultures of his blood 
tended to confirm my diagnosis of influenza, the 
causative agent of which I believe to be streptococci 
and not Pfeiflfer bacilli (2). This theory of the 
streptococcic origin of grippe is supported by recent 
investigations of Doctor Moody, of Chicago. 

But the greatest difficulties in etiology, diagnosis, 
and treatment are encountered, as I observed before, 
in the chronic cases with a dry paroxysmal cough 
recurring for months or even years after even slight 
exposures, and accompanied at times by hemoptysis 
or attacks of asthma, leading possibly to bronchiec- 
tasis, putrid bronchitis, pulmonary abscess, and dur- 
ing some acute exacerbations also to pneumonia or 
empyema. 

.Although the gross lesions of some of these respi- 
ratory complications of influenza may be recognized 
by their physical signs, their etiology is frequently 
misunderstood, cases accompanied by hemoptysis or 
pleurisy being especially apt to be mistaken for pul- 
monary tuberculosis. In fact, many physicians to 
this day believe almost all pleurisies to be of tuber- 
culous origin. 

The following cases, which I selected from among 
many others similar to them, may serve as illustra- 
tions : 

Case H. L. H., a young girl of about twenty-two years 
and previously in perfect health had an attack of the 
grippe in the fall of 1912, accompanied by a dry paroxys- 
mal cough which, although yielding to treatment after a 
time, continued recurring after every exposure. Subs - 
quently these attacks became accompanied by hemoptysis, 
but at no time could any tubercle bacilli be found in h r 
sputum, nor were there physical signs of any pathological 
process in the lungs until the winter of IQ14, when wi'h 
an unusually severe attack she manifested a temperature 
of 102° P., quite profuse hemoptysis, and dullness with 
diminution of breathing over her right lower lobe poste- 
riorly. .Mthough greatly puzzled by this case, I did not 
consider it to be one of pulmonary tuberculosis; but a 
prominent internist, who was now consulted by the pa- 
tient, made a diagnosis of galloping phthisis and gave the 
gravest prognosis. A few days later, however, the patient 
began to cough up pus, and this effective drainage of her 
pulmonary abscess — for that is wdiat it proved to be — 
brought about her rapid recovery. A few months spent 
in the country during the following spring and summer 
caused her to regain her health and the lost weight, but 
she is still subject to recurrent attacks of a dry cough 
with some hemoptysis. 

Case IH. L. B., a married woman aged forty-five years 
has been suffering for the past fifteen years from repeated 
"colds" accompanied by severe cough, and hemoptysis. The 
latter, only slight at first, became more profuse during the 
last four or five years, her attacks also becoming more 
frequent and severe, and accompanied by symptoms of em- 
physema, asthma, and chronic bronchitis, and also by some 
loss of weight; but tubercle bacilli are absent in her 
sputum. 

Professor Zinsser, of the College of Physicians 
and Surgeons of Columbia University, was kind 
enough to take an interest at my request in Cases 



FRAXKEL: INFLUENZA VS. TUBERCULOSIS. 



159 



II and III. He had these patients come to his bac- 
teriological laboratory, where a complement fixation 
test was applied, I believe, by Doctor Miller, who, 
together with Professor Zinsser, has done a great 
deal of important work on that subject. The test was 
negative in both cases, showing the absence of any 
active tuberculous process. 

C.-\SE IV. — P., a Bronx butcher, forty years old, con- 
tracted an attack of grippe in the fall of 1914. accom- 
panied by a sharp pain in his left infrascapular region 
and some elevation of temperature. There were no phys- 
ical signs on which his physician could base a definite 
diagnosis, but the pain and temperature persisted for a 
couple of weeks, until finally, after a severe fit of cough- 
ing followed by vomiting, he brought up a large amount 
of fetid pus. He continued coughing up pus during the 
following few weeks, gradually regaining his health, 
which was interrupted by recurring attacks of cough with 
some hemoptysis. Last spring he had a severe attack, ac- 
companied by high fever and by symptoms of what his 
physician diagnosed as pneumonia. He was removed to 
Lebanon Hospital, where in a few days his temperature 
came down to normal and his condition improved to such 
an extent that he was permitted to leave the bed and was 
promised his immediate discharge, when — as so often hap- 
ens in influenza — there was a sudden relapse accompanied 
by a violent rise of temperature. Within a few days his 
temperature came down, although it remained above nor- 
mal, and he complained of a sharp pain in his left infra- 
scapular region. Repeated exploratory punctures failed to 
reveal any pleural exudate (for two weeks) until one day, 
two weeks later, pus was found by the exploring needle. 
A rib was then resected and effective drainage established, 
after which he rapidly recovered, although up to the pres- 
ent he is still suffering from repeated attacks of cough 
with slight hemoptysis after exposures. His sputum on 
repeated examinations showed absence of tubercle bacilli. 

Case \'. E., fifty years old, has been suffering for over 
eight years from frequent attacks of asthma, with severe 
dyspnea and cough, accompanied by hemoptysis. His spu- 
tum was always negative, but physical examinations dis- 
closed some dullness over his right apex with diminished 
respiration and crepitant rales. These signs made a very 
prominent pathologist diagnose the case as pulmonary tu- 
berculosis four years ago. and three years ago an internist 
predicted his speedy death. Despite all that, however, the 
patient held his own very well and under better hygienic 
surroundings improved markedly and regained some of 
his lost weight, while the attacks, although not ceasing 
altogether, became much less frequent and severe. 

C.'VSE VL A., a butcher of fifty-four years, contracted 
a "cold" last winter and manifested a severe paroxysmal 
cough with profuse fetid expectoration and a moderate 
remitting temperature. His sputum show-ed many strepto- 
cocci, but no tubercle bacilli, and there were no physical 
signs to support the tentative diagnosis of pulmonary ab- 
scess ; its central location was therefore suspected. In the 
course of a few months his attacks became more severe 
and were accompanied by more or less profuse hemop- 
tysis. This was relieved by complete rest in bed combined 
with opiates ; but when subsequently the patient, disre- 
garding my repeated warnings, overexerted himself, a se- 
vere and rapidly fatal hemorrhage followed. 

Case VII. Mrs. E.. the wife of a dentist, about twenty- 
three years old, had an attack of grippe in the winter of 
1913. accompanied by a dry cough with some pain in her 
left side and dyspnea. When I saw her a few days later 
I found absence of the respiratory murmur with complete 
flatness over the lower half of her left chest and made a 
diagnosis of pleurisy with effusion, which I believed to be 
serofibrinous, in view of the comparative mildness of her 
general symptoms, including the temperature. As the 
chest was filling up rapidly, and the dyspnea became more 
marked, I advised immediate aspiration, and her nervous 
parents called in a specialist to do it. The latter removed 
a large quantity of fluid, and made a positive diagnosis 
of tuberculous pleurisy, predicting a refilling of the chest 
within a few days, which would necessitate repeated as- 
pirations ; he therefore advised her removed to a hospital. 
I however insisted on my former diagnosis of sero- 
fibrinous pleurisy complicating influenza, w-hich was also 



corroborated by the subsequent course of events, as the 
patient made a perfect recovery and has remained in good 
health ever since. The fluid still left in the pleural cavity 
after the incomplete aspiration was gradually absorbed, 
and there was no subsequent refilling of the chest. 

During epidemics of grippe I have frequently ob- 
served certain of its forms, which I have not seen 
mentioned in medical literature. I refer to the 
latent, subacute, or chronic grippe. These forms 
may occur independently of any acute attacks, 
they :nay follow such attacks during the periods of 
apparent convalescence, or they may bridge over the 
periods intervening between the repeatedly recurring^ 
acute attacks. 

The most pronounced feature of these forms of 
grippe is the accompanying asthenia with no appar- 
ent cause to account for it. These patients complain 
of extreme weakness ; they can hardly drag them- 
selves about and prefer lying down most of the 
time, every exertion throwing them into a profuse 
perspiration, and causing a feeling of utter exhaus- 
tion, so that at times they are "ready to drop dead," 
as they graphically express it. 

This asthenia is usually accompanied by loss of 
appetite, sometimes amounting to complete aversion 
to food, and by extreme sensitiveness to changes of 
temperature. These patients feel best in a warm 
room, and the most effective means for the preven- 
tion of acute exacerbations and of severe complica- 
tions to which their weakened resistance predisposes 
them is plenty of rest in a moderately warm room, 
at a temperature of about 70° F., and with adequate 
ventilation arranged in such a way as to prevent the 
patient from coming in contact with currents of cold 
outside air before it is warmed to the temperature 
of the room ; he must therefore not be permitted to 
be near open windows. The popular slogan of 
"wide open windows in grippe," which is interpret- 
ed as meaning that it is beneficial for grippe patients 
to lounge around and sleep near open windows, has 
been the cause of many cases of pneumonia 
and other coinplications. "For, although the benefit 
of open air treatment is well established in pulmo- 
nary tuberculosis and some other conditions, grippe 
is the disease most adversely affected by exposure : 
this is a fact that cannot be emphasized too strongly 
for the benefit of the afflicted. These forms oi 
grippe have usually a rather protracted course, are 
frequently accompanied by some loss of weight, and, 
when complicated, as they sometimes are, by acute 
exacerbations with a more or less severe cough ac- 
companied by some hemoptysis, or with resulting 
pneumonia or pleurisy, are very apt to be mistaken 
for pulmonary tuberculosis. 

There also seems to be some analogy between the 
more or less sudden lighting up of acute processes 
in previously quiescent cases of pulmonary tubercu- 
losis, and tlie frequent recurrence of acute respira- 
tory diseases with these forms of latent or chronic 
grippe. 

In pulmonarv tuberculosis these relapses are ex- 
plained bv the liberation of tubercle bacilli from en- 
capsulated quiescent lesions through the breaking 
down of their fibrous capsule. Whether such acute 
relapses, occurring with these forms of grippe, can 
be similarly explained by the liberation of previous- 
ly encapsulated streptococci remains to be seen. 



i6o 



GRIMBERG: HUNTINGTON'S CHOREA. 



[New York 

Medical Journal. 



Be that as it may, the fact remains that, because 
of our failure to recognize tiieir influenzal origin, 
many of these chronic respiratory complications of 
grippe cannot be made to fit into any of our classifi- 
cations previously established, and therefore cannot 
be diagnosed. On the other hand, some of them, 
and more especially those accompanied by hemopty- 
sis, pleurisy, etc., often present symptoms simulating 
pulmonary tuberculosis and are frequently mistaken 
for that disease. 

That is how some of these patients sometimes find 
their way into tuberculous institutions, despite the 
very wise ruling that limits admission to tuberculous 
wards only to patients with tuberculous sputum, 
whereas in the sputum of these influenza cases tu- 
bercle bacilli are invariably absent. 

These mistakes are of course made in perfect good 
faith ; for the fact that tuberculous patients may for 
some time show no tubercle bacilli in their sputum 
is well established, and some physicians, after mak- 
ing what appears to them to be a positive diagnosis 
of pulmonary tuberculosis, admit such cases to tu- 
berculous wards either without any preliminary spu- 
tum examination — as happened to my case — or even 
after an examination of the sputum fails to show the 
presence of any tubercle bacilli. 

In view of this there seems to be urgent need of 
a thorough reexamination of all those patients in 
tuberculous institutions whose sputum fails to show 
the presence of tubercle bacilli, because, if even a 
few cases of what I would call pulmonary influenza 
are discovered and removed from such surround- 
ings, our labor would be rewarded, for contact with 
cases of active pulmonary tuberculosis at the time 
when their own resistance is at its lowest exposes 
these influenzal cases to the grave danger of really 
contracting that disease. 

CONCLUSIONS. 

Many respiratory diseases following grippe are 
not correctly diagnosed because of our failure so far 
to recognize the origin of such disorders. 

Some of these cases, especially when accompanied 
by hemoptysis, pleurisy, etc., are frequently mis- 
taken for pulmonary tuberculosis, often to the detri' 
ment of the patient. 

Failure to recognize and properly treat latent 
grippe exposes the patient to the danger of serious 
complications through unguarded exposures, etc. 
The triad of extreme asthenia with no apparent 
cause to explain it, anorexia, and vmusual sen- 
sitiveness to changes of temperature, occurring dur- 
ing an epidemic of grippe, in the absence of neu- 
rasthenia or any febrile disorder, is quite pathog- 
nomonic of latent grippe. 

Rest and avoidance of exposure are among the 
most effective means at our command for the pre- 
vention of severe relapses and dangerous complica- 
tions in grippe. They must be enforced not only 
during the height of an acute attack, but also during 
the period of convalescence, as well as in latent, sub- 
acute and chronic grippe. In this way many of the 
chronic respiratory diseases following grippe could 
also be prevented. 

For the treatment of such chronic respiratory dis- 
eases of gr