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MEDICAL RECORD 



A Weekly Journal of Medicine and Surgery 



EDITED BY 

THOMAS L. STEDMAN, A.M., M.D. 



EDITORIAL STAFF 

Charles A. Clouting. M.D. Edward Preble, M.D. 

Kathleen Hamblen R. J. E. Scott, M.D. 

O. S. HiLLMAN, M.D. Mildred K. Smith 

John E. Lind. M.D. Wesley G. Vincent. M.D. 



"gTolume 94 

JULY 6, 1918— DECEMBER 28, 1918 






WILLIAM WOOD AND COMPANY 
1918 



V 
/v-^- 



Copyright, 1918, 
By WILLIAM WOOD & COMPANY 






\^> 



LIST OF CONTRIBUTORS TO VOL. XCIV. 



Aaron, Charles D., Detroit, 

Mich. 
Abrams, Albert, San Francisco, 

Cal. 
Anderson, H. B., Toronto, Can. 
Aronson, Captain J. D., Camp 

Doniphan, Ft. Sill, Okla. 
Aspinwall, F. E., La Grange, Ky. 

Babcock, W. Wayne, M. C, U. 
S. A. 

Balfour, D. C, Rochester, Minn. 

Barnes, H. E. W.. Santa Ana, Cal. 

Baruch, Simon, New York. 

Bassler, Anthony, New York. 

Beates, Henry, Philadelphia, Pa. 

Beebe, S. p.. New York. 

Bishop, Louis Faugeres, New 
York. 

Block, Siegfried, Brooklyn, N. Y. 

Boehme, Gustav F., Jr., New 
York. 

Bowers, Edwin F., New York. 

Brown, Robert Curtis, Mil- 
waukee, Wis. 

Browning, William, Brooklyn, 
N. Y. 

Buerger, Leo, New York. 

BuLKLEY, L. Duncan, New York. 

BuRGE, W. E., Urbana, 111. 

Climenko, H., New York. 

Coleman, Joseph, New York. 

Conner, Charles H., War In- 
dustries Board, Washington, 
D. C. 

Cornell, Wm. Burgess, New 
York. 

Corning, J. Leonard, New York. 

Cornwall, Edward E., Brooklyn, 
N. Y. 

Corson, Eugene R., Savannah, 
Ga. 

Crutcher, Howard, . Tularosa, 
N. Mex. 

Daniel, Annie S., New York. 

Davin, John P., New York. 

Dawes, Spencer L., New York. 

Delav.^n, D. Bryson, New York. 

Diner, Jacob, New York. 

Doubleday, J. Stewart, New 
York. 

Drake, Daniel E., Newfound- 
land, N. J. 

Draper, John William, New 
York. 

Dublin, Louis I., New York. 

Duncan, Rex. Los Angeles, Cal. 



Dunn, B. Sherwood, Paris, 

France. 
DUTTON, W. Forest, Tulsa, Okla. 

Edgar, Thomas W., New York. 
Einhorn, Max, New York. 
Epstein, J., New York. 

Farnell, Frederic J., Provi- 
dence, R. I. 

Fine, M. J., Newark, N. J. 

Fischer, Louis, New York. 

Flagg, Paluel J., New York. 

Friedberg. Major S. A., Camp 
Doniphan, Ft. Sill, Okla. 

Friedman, Lewis J., New York. 

Getson, Philip, Philadelphia, Pa. 
Glasgow, Maude, New York. 
Graham, Douglas. Boston, Mass. 
Grossman, Jacob, New York. 

Harrower, Henry R., Los An- 
geles, Cal. 

Hassin, G. B.. Chicago, 111. 

Head, Joseph, Philadelphia, Pa. 

Heffron, John L., Syracuse, 
N. Y. 

Heiser, Victor G., New York. 

Hemmeter, John C, Baltimore, 
Md. 

Herz, Lucius Felix, New York. 

Holden, W. B., New York. 

Holt, L. Emmett, New York. 

Humbert, Chas. R., Kansas City, 
Mo. 

Hunt, Edward Livingston, New 
York. 

Hyder, Herman P., Washington. 
D. C. 

Johnson, Clarence A., Los An- 
geles, Cal. 
Jones, Howard, Circleville, Ohio. 
Josephson, Emanuel, New York. 

Kahn, Alfred, New York. 
Kahn, Moses, Brooklyn, N. Y. 
Kaufmann, Jacob, New York. 
Kearney, J. A., New York. 
Keister, Bittle C, Roanoke, Va. 
Keller, Henry, New York. ' 
Kerrison, Philip D., New York. 
Kindred, John Joseph, Astoria, 

L. I., N. Y. 
King, James Joseph, New York. 
Knopf, S. Adolphus, New York. 
Koch, E. W., Buffalo, N. Y. 

Landsman. Arthur A., New 
York. 



Lee, Edwin Cordery, Philadel- 
phia, Pa. 

Levy, Julius, Newark, N. Y. 

Lewinski-Corwin, E. H., New 
York. 

Lynch, Jerome Morley, New 
York. 

McClelland, Everett S., Los 
Angeles, Cal. 

McCoMBS, Carl E., New York. 

McCready, E. Bosworth, Pitts- 
burgh, Pa. 

MacDonald, Arthur, Washing- 
ton, D. C. 

McMichael, a. R., New York. 

McMurtrie, Douglas C, New 
York. 

McNutt, Sarah J.. New York. 

Macht, David I., Baltimore, Md. 

Marcus, Joseph H., Atlantic 
City, N. J. 

Markoe, J. W., New York. 

Meltzer, S. J., New York. 

Montgomery, Douglass W., San 
Francisco, Cal. 

Moriarta, D. D., Saratoga 
Springs, N. Y. 

Morris, Robert T., New York. 

Nammack, C. E., New York. 
Newton, Richard Cole, Mont- 
clair, N. J. 

Oberndorf, C. p.. New York. 
Onuf, B. (Onufrowicz), Park 

Ridge, N. J. 
Otis, Edward O., Boston. 

Pacini, August J. P., New York. 

Paget, Owen, Fremantle, W. Aus- 
tralia. 

Phillips, W. F. R., Charleston, 
S. C. 

Porter, William Henry, New 
York. 

Rankin, Egbert Guernsey, New 
York. 

Rappleye, W. C, Foxboro, Mass. 

Reasoner, Lt.-Col. M. a., Wash- 
ington, D. C. 

Reynolds. Walter S., New York. 

Rice, James Francis, Buffalo, 
N. Y. 

ROBBINS, F., New York. 

Robinson, Beverley, New York. 

Round, John, London, Eng. 

RuGH, J. Torrance, Washington, 
D. C. 



CONTRIBUTORS TO VOL. XCIV. 



Satterlee, G. Reese, New York. 
Saunders, M. B., Waco, Tex. 
ScHEFP'EL, Carl, Boston, Ma.s.s. 

SCHEPPEGRELL, WILLIAM, New 

Orleans, La. 
Schiller, A. Noah, New York. 
Secor, William Lee, Kerrville- 

on-the-Guadalupe, Tex. 
Servoss, George L., Reno, Nev. 
Sexton, L., New Orleans, La. 
Shannon, James W., San Diego, 

Cal. 
Shufeldt, Major R. W., M.C, 

U.S.A., Wa.shington, D. C. 
Simpson, F. F., Washington, D. C. 
Stein, Gertrude R., New York. 
Stewart, Douglas H., New York. 
Stewart, Francis E., Philadel- 
phia, Pa. 
Stewart, George A., New York. 
Stone, Warren B., Schenectady, 

N. Y. 
Strobell, Charles William, New 

York. 

Taylor, J. Madison, Philadel- 
phia, Pa. 

Tompkins, Ernest, Pasadena, 
Cal. 

Tweddell, F., Great Neck, Long 
Island, N. Y. 

Twinch, Sidney A., Newark, 
N. J. 

Verbrycke, J. Russell, Washing- 
ton, D. C. 

VooRHEES, Irving Wilson, New 
York. 



Wakefield, Homer, New York. 
Wald, Lillian D., New York. 
Walsh, Wm. S., West Pownal, Me. 
Whitman, Royal, New York. 
Wilcox, Reynold Webb, New 
York. 

Zingher, Abraham, New York. 
Zueblin, Ernest, Cincinnati, 
Ohio. 

Societies of Which Reports Have 
Been Published 

American Association for the 
Study and Prevention of 
Infant Mortality. 

American Association for Tho- 
racic Surgery. 

American Association of Im- 
munologists. 

American Association of Ob- 
stetricians AND Gynecolo- 
gists. 

American Association of Path- 
ologists AND Bacteriolo- 
gists. . 

American Climatological and 
Clinical Association. 

American Gynecological So- 
ciety. 

American Medical Assoclation. 
Section on Obstetrics, Gynecol- 
ogy and Abdominal Surgery. 
Section on Pediatrics. 
Section on Practice of Medicine. 

American Medical Editors' As- 
sociation. 



American Orthopedic Associa- 
tion. 
American Pediatric Society. 
A.MERICAN Therapeutic Society. 
Association of American Physi- 
cians. 
College of Physicians of Phil- 
adelphia. 
Section of Industrial Medicine 
and Public Health. 
Medical Society of New Jersey. 
Medical Society of the Coun- 
ty OF New York. 
Committee on Public Health. 
Medical Society of the State of 
New York. 
Section on Eye, Ear, Nose and 

Tliroat. 
Section on Medicine. 
Section on Obstetrics and Gyne- 
cology. 
Section on Surgery. 
Medical Society of the State 
OF Pennsylvania. 
Section on Medicine. 
Section on Surgery. 
New York Academy of Medi- 
cine. 
Committee on Public Health. 
Section on Obstetrics and Gyne- 
cology. 
Section on Pediatrics. 
Section on Surgery. 
Phii^delphia County Medical 

Society. 
Philadelphia Neurological So- 
ciety. 



Medical Record 



A Weekly Journal of Medicine and Surgery 



Vol. 94, No. I. 
Whole No. 24&7. 



New York, July 6, 1918. 



$5.00 Per Annum. 
Single Copies, 1 5c. 



(iriginal Artirks. 

THORACIC SURGERY. 

S .1 MELTZKK. MP. 1.1.1) 



We are on the point of starting a new National 
Medical Society. It is a part of the duties of the 
presiding officer to state at such an occasion the 
aims and scope of the society and the reasons for 
its creation. But the present officer feels that first 
of all he owes a duty to the members and to him- 
self to tell something of the circumstances which 
gradually brought him into the Presidential Chair 
of an Association for Thoracic Surgery. The 
little story is perhaps worth telling. When about 
forty years ago, I began my very modest career a.^ 
an exi>erimental investigator -in the domain of 
medicine, I had no reason to anticipate that one 
day the honor would be conferred upon me to pre- 
side over a body of progressive physicians who 
wished to discuss particularly the surgery of the 
chest. I began my career by introducing stomach 
tubes into my esophagus. There seems to be no 
clear connection between this heroic act and 
thoracic surgery. But by good will a series of 
loose events can be detected and forged together 
into a chain capable of connecting both end point.*. 
My studies of the physiology of deglutition ripened 
in me the general conception that the phenomenon 
of inhibition is an important factor in all functions 
of the animal body. This conception of the 
mechanism of life never left me. It was a work- 
ing factor in my studies of the respiratory func- 
tion. When later, about twenty years ago, I came 
across the depressing action of magnesium salts. 
it then occurred to me that the magnesium is per- 
haps the representative of inhibition in the animal 
body. This view became a working hypothesis in 
our numerous investigations of the action of mag- 
nesium salts. Further on, in the attempts to util- 
ize our new knowledge for therapeutic purjwses, 
we soon realized that magnesium may inhibit the 
function of respiration. Now magnesium salts 
leave the circulation quite rapidly, and any danger 
from an inhibition of respiration could be met by 
temporary artificial respiration. But there were 
no satisfactory methods of artificial respiration 
which could be readily used in such emergency 
cases. The manual methods were entirely insuf- 
ficient for our purpose. In our search for ef- 
jficient methods we developed, Auer and I, the 
method of intratracheal insufflation. You probably 

*President's Address at the meeting of the American 
Association for Thoracic Surgery, Chicago, June 10. 
1918. 



remember the little battle between differential 
pressure and intratracheal insufflation. It occurred 
only eight years ago ; but it seems now like history. 
When I presented my paper on intratracheal insuf- 
flation at the New York Academy of Medicine, my 
views were opposed, in the interest of conservatism 
in surgery, by three able surgeons. Now, these 
same surgeons are among the principal founders 
of the American Association for Thoracic Surgery, 
and my being the first presiding officer of the Asso- 
ciation is due exclusively to their generous spirit 
and not to any merits of mine. This is my little 
story of how the introduction of a stomach tube 
carried a mere medical man into the presidential 
chair of a National Surgical Association. 

Now I am coming to the performance of my 
duties, namely, to tell of the aims and scope of 
the Association and to give the reasons for its 
creation. Of course this could have been done better 
i)\ the real founder of the association, by the mem- 
ber who is going to give us a review of the evolu- 
tion of thoracic surgery in the past fourteen years 
and who by right should have been the occupant of 
this chair. But he willed it otherwise. As the 
name indicates, the chief aims of the Association 
are the advancement of the knowledge of and skill 
in thoracic surgery. It is expected that a greater 
progress will be attained in this line of medical re- 
search by focusing the attention of a group of prac- 
tical surgeons to the thoracic cavity, by working 
together with physicians and surgeons, who are in- 
terested in special diseases of the thoracic cavity 
and its adjoining regions, and by working together 
with various experimental investigators in these 
fields. 

Is it necessary to single out the thoracic cavity 
for special activities and is the thoracic cavity not 
part and parcel of the domain of all general sur- 
geons? In looking for light on this question I did 
not have to go far to discover the fact that the 
thoracic cavity apparently has no special attraction 
for most of our leading surgeons. I shall cite only 
two illustrative instances. The program of the 
American Medical Association reflects the medical 
and surgical activities of the entire country. In 
looking over the program of the coming meeting, 
as it was published a few weeks ago in the 
■Journal of the Association, I found that there were 
numerous papers on abdominal surgery sufficient 
to crowd the programs of two surgical sections 
with an overflow into the Section of Gastro-enter- 
ology; but there was not a single paper on thoracic 
surgery. Then I glanced through the volumes 
from the Mayo Clinic. They show us the sort of 
work which is done in this brilliant surgical insti- 
tution. I found only two or three papiers belong- 



MEDICAL RECORD. 



[July 6, 1918 



ing to the domain of thoracic surgery and these 
papers were written by a member of our Council 
while he was on the staff of the Mayo Clinic. 
Wonderful work is being done in this Clinic on or- 
gans below the diaphragm and above the thorax; 
but there is practically complete silence on intra- 
thoracic organs, at least so far as surgery is con- 
cerned. 

Does the development of thoracic surgery re- 
ceive attention and support from our brilliant 
practical surgeons equal in extent and intensity to 
that bestowed upon abdominal surgey? A fairly 
instructive answer to our query may be obtained 
from the following analysis of the history of two 
similar incidents in abdominal and thoracic sur- 
gery. It was about the same time, about the mid- 
dle of the last century, that a peritj'phlitic abscess 
(Hancock, 1848) and an abscess of the pleural cav- 
ity (empyema) (Sayre, 1842) were incised for the 
first time. Now let us compare the progress which 
followed both incidents. The opening of the 
perityphlitic abscess did not only lead to the re- 
moval of the appendix in acute stages of inflamma- 
tion and to frequent interval operations for apn 
pendicitis — the latter meaning the exposure of the 
riormal peritoneum, without trembling and with im- 
punity ; but it paved the way to the handling by the 
surgeon of every organ located within the abdom- 
inal cavity and to very frequent exploratory lapa- 
rotomies for mere diagnostic purposes. In other 
words, surgeons, great and of medium size, have 
nowadays no hesitation whatsoever in opening 
the abdomen, exposing the normal peritoneum, and 
manipulating the abdominal organs without urgent 
indications for its performance and without fear 
of untoward results. Would the celebrated sur- 
geons of half a century ago, who surely considered 
the opening of a typhlitic abscess as an heroic act, 
have admitted the possibility that a day will come 
when the normal parietal and visceral peritoneum 
could be exposed and manipulated with absolute 
impunity? 

Now let us look at the progress in thoracic sur- 
gery made during the same period. It is true 
that one or the other surgeon pleads courageously 
nowadays for an exploratory thoracotomy in 
cases of empyema; but we must bear in mind that 
that which they wish to explore and manipulate 
is a simple or multilocular abscess cavity and not 
the normal parietal and visceral pleura. Is there 
a greater danger in exploration of the normal 
pleural cavity than the exploration of the normal 
peritoneal cavity? Our leading con.servative sur- 
geons seem to think so. But after the introduction 
of intratracheal insufflation Carrel and others have 
in numerous instances opened freely and simulta- 
neously both pleural cavities for the purpose of 
patching the thoracic blood vessels and other oper- 
ative procedures with complete impunity. Carrel 
and other experimental thoracic surgeons could do 
it, because they employed methods which, above all, 
insured the safety of the respiratory function. But 
our conservative surgeons say that for the surgical 
work on the thorax the new, hazardous methods of 
artificial respiration can be dispensed with, because 
the operations performed upon the thoracic cavity 
of human beings can be carried out under simple 
anesthesia without complicated methods. Here is 



the rub. The masters of technique, and fearless 
operators in the field of abdominal surgerj-, when 
they come to thoracic surgery confine their work 
chiefly to the abscess cavity of the pleura, which, 
by means of the abscess wall and the newly formed 
adhesions, protects the respiratory capacity of the 
lung in the other pleural cavity and also the remain- 
ing respiratory power of the non-collapsible part of 
the lung on the operated side. 

Does the thoracic cavity possess features which 
distinguish it from other serous cavities so as to 
merit particular attention? Indeed, it does, and in 
a striking fashion. Every elementarj' textbook on 
physiology will tell you so; only the successful oper- 
ations upon the abscess cavities of the thorax dim 
the vision of the surgeons. The opening of a nor- 
mal pleural cavity causes a complete collapse and 
immobility of the corresponding lung. In dogs, the 
opening of one pleural cavity is, as a rule, sufficient 
to cause the death of the animal. As to human 
beings, I believe that no experience is available to 
answer this question; the opening of a pleural 
cavity was made, as a rule, either in diseased condi- 
tions which may have caused adhesion of some 
part of the lung or at least a complete isolation of 
the two cavities by means of a thickened mediasti- 
num; or the opening was made under some form of 
artificial distention of the lung. Besides the res- 
piratory mechanism, the thoracic cavity harbors the 
chief organ of circulation. An interference with 
the activity of this incessantly-beating organ may 
unexpectedly lead to danger, and even to immediate 
death. These serious problems confront the sur- 
geon who has to work in the thoracic cavity, in 
addition to the serious features which the surgeon 
has to consider in dealing with all serous cavities. 

I wish to emphasize here the significant fact that 
the additional serious problems which confront the 
thoracic surgeons are essentially of a physiological 
nature. Surgeons are generally well trained in 
anatomy, in technique, and in mechanical manipula- 
tions. Here there is hardly any limit to their cour- 
age and progressiveness. But when it comes to 
problems which have a predominant physiological 
aspect an undesirable form of conservatism comes 
to the fore. 

I believe that I brought forward a sufficient num- 
ber of reasons showing the desirability of knitting 
together a group of medical men who possess the 
necessary scientific preparations and the aptitude 
to work along lines which will help us to advance 
the knowledge and the skill of thoracic surgen.-; 
in other words, I gave you reasons for the creation 
of the Association for Thoracic Surgery. In per- 
forming my duties as the president of the associa- 
tion I may rest here my pleading the cause of the 
association, but I ask permission to add some re- 
marks on subjects which interest me as an active 
worker in the problems belonging to the domain of 
our association. 

I shall deal first with the method of intratracheal 
insufflation. I entertained the conviction that the 
right of this method to permanent citizenship in 
the domain of surgery has been established beyond 
a doubt. But in looking over the literature I came 
across a paper which contains a rather se%ere judg- 
ment against the method, rendered in a sharp, cate- 
gorical manner. The paper was written by a man 



July 6, 1918] 



MEDICAL RECORD. 



who at all times is entitled to a respectful hearing. 
But just at present he is the man of the hour; he 
will be the next president of the great American 
Association; it was written by Dr. Bevan. It is, 
perhaps, fortunate for a president of such a young 
and small society as ours to be in the position to 
rub against the president of the largest national 
society; my discussion with him may thus get a 
hearing. In a paper, entiled "The Choice and 
Technique of the Anesthetic," published in 1915 
in the Journal of the American Medical Association 
(the issue for October 16), Dr. Bevan deals among 
others with the intratracheal anesthesia. From his 
conclusions it is sufficient to quote two which leave 
no mistake as to his views. "The method is dan- 
gerous," he begins, and finishes up by saying that, 
"On the whole, therefore, intratracheal anesthesia 
has little place in practical surgery." On what ex- 
perience are these dicta of Dr. Bevan based? I 
received from a most reliable source the informa- 
tion that no patient was operated in Dr. Bevan's 
clinic by the method of intratracheal insufflation. 
If Dr. Bevan has seen the method used elsewhere 
and with bad results, he should have expressly stated 
that fact. On what information, then, did Dr. 
Bevan base his categorical statement? He quotes 
the paper of Dr. Robinson of several years ago in 
which fourteen hundred cases were collected with 
seven deaths. It is quite strange to find that in 
striking contrast to Bevan's conclusions, Robinson, 
on the basis of his statistics and observations, 
proves himself in this paper to be an ardent sup- 
porter of the method. He says there, "Those of us 
who have managed intratracheal -anesthesia during 
general surgical operations are universally im- 
pressed with the ideal condition which exists." Did 
Bevan try to analyze the seven cases of death men- 
tioned in Robinson's paper? Well do I remember 
three cases. In one case the ether bottle was 
reversed by mistake and pure ether was driven into 
the lungs ; in another, the nurse pushed the intra- 
tracheal tube, while being connected with the pres- 
sure apparatus, deep into the bronchus, which led. 
of course, to rupture of the lung. In a third case 
the patient was in a prone posture with the anterior 
part of the neck hanging over the edge of the 
table; the patient was not looked after, and it was 
discovered late that the insufflated air and ether 
mixture had no chance of escaping. Does Dr. Bevan 
believe that these gross "errors" have anything to 
do with the method as such? On the other hand, 
how does he explain the facts that men like Dr. 
Elsberg. who used the method in more than twelve 
hundred cases, and Dr. Peck, who used it in more 
than five hundred cases, never encountered any acci- 
dents? 

Without entering into a further discussion of the 
validity of Dr. Bevan's dicta in this instance, I may 
be permitted to refer here to two instructive state- 
ments. Tuffier, who is probably as good an author- 
ity on thoracic surgery as Dr. Bevan (on invita- 
tion, he presented an e.xtensive report on thoracic 
surgerj- before the Surgical Section of the Inter- 
national Congress in London in 1913) published 
an article"-^ in which he says, among others, that 

'Tuffier (Presse Medicate. June 1. 1914, p. 497). 

"Ces indications nous paraissent devoir etre les sui- 
vantes; 1° Eile constitue, sans aucun doute, la meilleure 
methode d'anesthesie et de pression positive dans la 



according to his opinion, based upon personal experi- 
ence with the method, intratracheal insufflation 
anesthesia will be in the future the only method of 
anesthesia for thoracic surgery. 

In an article (.submitted by the Section of Plastic 
and Oral Surgery and approved by the Surgeon 
General, U. S. A.) published in the Military Surgeon 
for May, 1918, the following simple statement is 
made: "The utility of intratracheal anesthesia for 
certain types of operations is well established." 
Perhaps I may add that in the many thousands of 
cases in which intratracheal ether anesthesia was 
used not a single case of ether death occurred. 

There is another point which I wish to bring out 
here. Intratracheal insufflation is generally dis- 
cussed from the point of view as a method of admin- 
istering anesthesia. It is overlooked that it pro- 
vides the patient during the anesthesia with a lux- 
urious artificial respiration. It is not generally 
appreciated how important this point is. Auer and 
I found that ether has a curare-like action upon 
the endings of the motor nerves, and Githens and 
I found that during ether anesthesia both the 
diaphragm and the phrenic nerves lose some of 
their irritability. It is no doubt that during ether 
anesthesia an element of asphyxia is present. Now, 
this fact is very important, especially when one 
works in the neighborhood of the heart. When the 
individual receives efficient artificial respiration 
simultaneously with the ether anesthesia the heart 
may be handled with practical impunity. It is dif- 
ferent when the respiration is insufficient; the heart 
often responds to each touch with a series of irreg- 
ular beats which in some hearts may lead to ven- 
tricular fibrillation and a heart death. 

The so-called pharyngeal method of anesthesia, 
of which Be%'an and other surgeons are now speak- 
ing favorably, is, of course, incapable of providing 
efficient artificial respiration. It is different with 
the pharjngeal insufflation which I described about 
a year ago and the efficiency of which I have re- 
cently demonstrated to hundreds of military medical 
officers and other interesting parties. But I do net 
intend to dwell here on this subject. 

Finally, as the president of the Association for 
Thoracic Surgery, I shall avail myself of the oppor- 
tunity and the privilege to make one or two remarks 
on topics of human thoracic surgery. It seems to 
me that the most desirable object in thoracic surgery 
is the proper development of exploratory thoracot- 
omy with the object of using it in the same manner 
and for the same purpose as exploratory lapar- 
otomies are used, that is, in the first place for 
making a proper diagnosis. I risk making the 
statement that in some conditions the exploratory 
incision in itself may even exert a therapeutic effect. 
In some instances exploratory laparotomies un- 
doubtedly influence favorably pathological processes 
in the abdominal cavity. I have a theorj- for it; 
but I shall not dwell upon it now. At any rate, an 
exploratorj' thoracotomy may lead to a proper un- 
derstanding as to the therapeutic measures which 
could be employed now or later. On the other hand, 
I would rather counsel conservatism in the attempts 

chirurgie intratheracique, nous pouvons dire restrictions 
la methode d'avcnir. nous I'avons utilisee dans la resec- 
tion de I'oesophage thoracique et, malgre une installation 
rudimentaire, la fonetionnement de I'appai^il et les 
resultats de I'anesthesie ont etc parfaits." 



4 



mj:dical record. 



[Jub- 6. 1»18 



to peilorm untried and unstudied methods of opera- 
tion. An occasional success rapidly leads to repe- 
titions and numerous failures, and this discredits 
thoracic surgery. Patient, practical, and experi- 
mental studies should be the means of paving the 
way to the final success in thoracic surgery. 

My,. second suggestion is rather hold, and I am 
well aware that it will not be acceptable to most 
of you if to any. Nevertheless, I am throwing out 
this suggestion, looking upon it as a seed which 
may perhaps take root somewhere some day. I pro- 
pose that large intercostal incisions should be made 
for the treatment of pulmonary tuberculosis. If 
the procedure does not interfere with the respira- 
tion, that is, if it proves that the mediastinum suffi- 
ciently protects the respiratory activities of the 
lung in the opposite cavity, steps should be taken 
to keep the incision open for a longer period. If 
the lung of the opposite side is also affected, the 
same procedure should be followed out later when 
the first incision is healed. The idea underlying this 
suggestion has nothing in common with the method 
of treatment by means of insufflation of nitrogen 
in the pleural cavity. Forlanini's method is based 
upon the supposition that rest will act as a cura- 
tive agent. The ideal rest of the kidneys does not 
prevent development and progress of tuberculous 
processes in their parenchyma. My suggestion is 
stimulated by the experience of the curative effect 
of laparotomy upon tuberculous peritonitis; the 
introduction of nitrogen or oxygen into the peri- 
toneal cavity exerts no such curative action. We 
should bear in mind that the treatment of tubercu- 
lous peritonitis by laparotomy owes its origin to 
mistaken diagnoses which were made by Spencer 
Wells in England and by Van De Walker in this 
country. In years gone by nobody would have 
thought of suggesting the treatment of tubercu- 
lous peritonitis by an abdominal incision, and if it 
had not been for the accidental errors in diagnosis, 
it might never have been performed. So far we do 
not possess a clear explanation of the nature of 
the therapeutic effect of the laparotomy; but there 
is no doubt as to the fact of the therapeutic result. 
Thoracotomy may exert a similar therapeutic effect. 
If we could only test and establish the fact of thera- 
peutic action, the explanation of the effect may wait 
in thoracotomy as it has had to wait in laparotomy. 
I venture to throw out the further hypothesis that 
the moderate distentions of the partly adherent ex- 
posed lung may rather prove to be a favorable factor 
in the possible therapeutic action of a thoracotomy. 
I have my reasons for this hypothesis, but I shall 
not discuss them; I think I have done more than 
enough by venturing to make the bare statement. 

I do not expect to live to see my suggestion taken 
seriously and tested. But, you see, a physiologist 
rushes in where surgeons fear to tread. 

Tub Hockct'ELLkh Institute for Medical Reskahcm 



Magnesia and Cancer. — Dubarde gives from 8 to 12 
grains of white magnesia daily to all of his operative 
cases of cancer, his theory being that poverty of the 
organism in magnesia favors the development of malig- 
nancy. Remineralization would seem to be an important 
aspect of the problems of prophylaxis and immunity. — 
Ln Prrn.te ;V<'rfiVn/c. 



RELATION OF IxXTERNAL SECRETIONS AND 

FAULTY METABOLISM TO MENTAL 

PERVERSIONS.* 

By BITTLE C. KEISTER. A.M.. M.D.. 

KOANOKE. VA. 

We are to-day facing many and divers theories on 
the subject of internal secretions, their effect on 
metabolism, and their relation to mental perversion. 
We are all more or less familiar with the caprice 
and peculiar freaks played by the ductless glands. 
Take, if you please, the thyroid, the thymus, the 
pituitary, the pineal, etc., whose physiological func- 
tions are exciting the liveliest interest thoughout 
the scientific world. Our foremost scientists are to- 
day puzzling their brains over these apparently in- 
significant organs. 

The most definite clue to the action of internal 
secretions has been obtained with the thyroid. Re- 
cent experimental work on this gland makes it 
necessary to distinguish between the thyroid and 
the parathyroid tissue. The thyroid proper con- 
sists of two oval bodies located on the sides of the 
trachea at its junction with the larnyx. These have 
no ducts, and are composed of vesicles of various 
sizes, which are lined by a single layer of cuboidal 
epithelium, and contain in their interior a material 
known as colloid. This material is formed within 
the lining of epithelial cells, and when the vesicles 
rupture it is discharged into the surrounding 
lymphatics. The nature of this colloid material has 
given rise to much speculative thought, and will be 
referred to later on in this paper. 

We have what is known as a set of accessory thy- 
roids, and having a similar structure to that of the 
thyroid, no doubt their functions are somewhat 
similar. 

The parathyroids are quite different in structure, 
being composed of solid masses of epithelial cells 
which are not arranged in vesicles, and contain no 
colloid material. It has been demonstrated that 
when the parathyroids alone are removed the ani- . 
mal dies quickly with acute symptoms, muscular 
convulsions, tetany, etc.; while if the thyroids alone 
are removed the animal may survive for a long 
period, but develops a condition of malnutrition, a 
slowly increasing cachexia, which may later assume 
a condition resembling myxedema in man. 

We find after a cursory study of these glands, 
that after any form of traumatism or disease which 
may cause hypofunction or stagmation of their se- 
cretion, quite an array of peculiar synnptoms ari^o. 
The mental forces become weakened and inactive, 
the skin becomes thick and immobile, owing to a col- 
lection of mucine-like material in the corium, the 
connective tissue fibrils thicken, and the hair falls 
out. Weakness of the muscles and disturbance of 
sensation are associated with a general loss of in- 
telligence. 

While these and many other pathological symp- 
toms and conditions are the result of any serious 
impairment of the thyroids causing a loss of func- 
tion, we have on the other hand from hyperfunc- 
tion of the thyroid such a condition as exophthalmic 
goiter (Graves' disease"), with all of the horrible 

*Read before the State Medical Society of Virginia, 
Nov. 2, 1917. 



July 6, 1918] 



MEDICAL RECORD. 



symptoms and suffering that usually accompany 
that disease, such as tachycardia, sjTicope, asphyx- 
ia, and asthmatic breathing from excessive pres- 
sure, etc. 

In discussing the subject of internal secretions we 
do not confine our argument simply to the ductless 
glands, but include the pancreas, ovaries, and other 
internal secreting glands. 

The thymus gland, about which there has been 
much speculation of late years, belongs to the duct- 
less class, and its physiological function is yet quite 
obscure. Formerly this gland was supposed to reach 
its full development at birth, and subsequently to 
atrophy, being replaced by a growth of lymphoid 
tissue, but of late this belief has been abandoned 
and many observers have learned that it continues 
to grow, and that true thymus tissue may persist 
through life. Its proximity to the thyroids and 
parathyroids, and its similarity in origin would in- 
dicate that, like them, it may have some important 
specific influence upon metabolism. 

There seems to be some reciprocal relation be- 
tween this gland and the reproductive glands. We 
find that when this gland is removed it hastens the 
developrnent of the testes, and when the testes are 
removed the thymus becomes slightly enlarged for 
a time prior to a retarded atrophy (Henderson). 
There is no doubt in my mind that a similar rela- 
tion holds good in females under like conditions. 
And if we will read between the lines and take the 
time to consider, we may be able to account for 
much of the peculiar phenomena that follow the 
spaying of our women by "unbaked" gynecologists. 

It is a well known fact among writers on the sub- 
ject of internal secretions that the ovaries play an 
important part in the nutrition of both body and 
mind. In gjmecological practice it is often observed 
that following complete removal of the ovaries 
with the premature menopause that ensues, we 
find many distressing symptoms, both mental and 
physical. There are cases whose mental condition 
becomes so serious that they are fit subjects for an 
insane asylum. 

It was the writer's unfortunate privilege some 
years ago to attend a number of this class of mu- 
tilated patients who had undergone complete ovari- 
itomy. All honor to our modei'n gynecologists for 
their conservatism in the matter of not removing 
in toto these important glands from our young and 
middle-aged females. 

One of the class of these patients above referred 
to, attended by the writer was a refined, highly cul- 
tured lady of twenty-six, who had been for some 
time previous quite nervous, bordering on hysteria. 
Acting on the advice of her relatives, she went to 
her young uncle's sanatorium in a distant city for 
treatment, and was operated upon for supposed 
cystic ovaries and hysteroepilepsy. Within a few 
months following the operation she began to run 
down both physically and mentally. At regular 
monthly intervals she had attacks of hallucina- 
tion or cyclic insanity preceded by a state of mo- 
roseness. At other times her mind would appear al- 
most normal, but this lasted only a short while. 
when she would gradually revert to the abnormal. 
This patient was under my obser\-ation at intervals 
for .several months. She seemed to find temporay 
relief in coming to my office at irregular intervals to 



take electricity and vibratory massage administered 
by a trained nurse under my careful supervision. If 
I had been accessible to some reliable manufacturer 
of ovarian extract I should have administered a 
thorough course of it, aided by other constructive 
treatment. 

To keep this young lady out of the lunatic asylum 
and save her family from the remorse, I sent her 
to a specialist's sanatorium for the treatment of 
nervous diseases where she remained only a few 
weeks prior to being sent back home to die. Being 
absent from the city when she returned, I failed 
to see her, but was informed that her physician 
diagnosed her last illness as cerebrospinal menin- 
gitis. This, in my judgment, was the closing scene 
of a typical case of abnormal internal secretions, 
complicated by autointoxication, superinduced by 
the complete extirpation of both o%'aries of this 
young woman. 

In older literature it was affirmed that not only 
the entire nature of woman, but her character as 
well, depended on the reproductive organs. Hei- 
mont said : "Propter solum uterum mulier est, quod 
est." Chereau said : "Propter ovarium solum mulier 
est, quod est." 

Virchow's statement that a woman is a woman 
simply because of her generative glands, is fa- 
miliar to us all. Prof. Hochwart, in the American 
Journal of the Medical Sciences, deliberately states 
that, "The peculiarities of woman, both in body 
and mind, in fact, all the femininity which we ad- 
mire in the true woman, are dependent on the 
ovary." 

Every up-to-date physician and neurologist who 
has had ten years experience is quite familiar with 
these cases of psychoneurosis among our women of 
the past decade, who had been operated upon. 

The function and sacred mission of these import- 
ant organs are being studied with more care and 
zeal during the past half decade, and instead of 
the radical a more humane operation is being ad- 
vised by our leading gynecologists, giving more 
consideration for after results. 

These psychoses are well known to the careful 
observer, from early puberty to the menopause, in 
a verj' large percentage of women who may be ap- 
parently healthy in all other respects. Recent in- 
vestigations have shown that the menstrual life of 
women is not a suddenly appearing or disappearing 
event. On the contrary, the phenomena seems to be 
a continuous wave-like condition which is not 
found before the beginning nor after the close of 
menstruation, either in early youth or old age. Much 
of the variability of mood and disposition may be 
explained in this, the often inexplicable vacillating 
temperament, in the sexually mature woman. 

The question of the not infrequent insanity dur- 
ing menstruation has been likewise discussed. Sui- 
cides have been frequent at these times. A. Pilez 
found intramenstrual changes of the sexual organs 
in more than one-third of female suicides. 

Among fift>--six shoplifters, Legrand Soulle found 
that thirty-five were "unwell" at the time of the 
crime. Icord who has written quite extensively on 
the subject of internal secretions observes that in 
perusing the diary of a young girl it does not re- 
quire much perspicacity to discover the pages which 
were written during menstruation. 



6 



MEDICAL RECORD. 



[July 6, 1»1« 



We observe these psychic disturbances at the 
climacterium, which is considered the most danger- 
ous and critical age of woman. At the time when 
menstruation begins to be irregular, sometimes 
even months or a year before, women fall into a 
strange state of unrest, sometimes accompanied by 
sexual over-excitability. Deep depression, a tend- 
ency to outbreaks of weeping, periods of irritability, 
psychic vacillations, a decrease of intelligence, evil 
forebodings, etc. These are some of the well known 
conditions in a large percentage of women during 
this critical time. In some cases it reaches a very 
high degree of p.sychosis, as is shown in the follow- 
ing case that came under the writer's observation. 

A lady of 46 years, whose family history was nega- 
tive so far as I could ascertain. Her peculiarities in 
temperament and disposition were such that her family 
life was anything but pleasant; her husband, who was 
a railroad man, was living apart from her, her two 
married sons could not tolerate living under the same 
roof with her, hence we can only surmise the kind of 
life she was living. .A.fter the first day or so of her 
entrance into my private sanatorium I made several 
very thorough examinations and found quite an array 
of abnormal conditions, both physical and mental. 
.\mong the physical my attention was first drawn to 
her enlarged thyroids and slightly protruded eyeballs 
(exophthalmos), fast and nervous heart sounds, marked 
tenderness over both ovaries with slight protuberance 
and tympanites; speculum examination showed a 
double laceration of the cervix, an endometritis with 
catarrhal discharge, clitoris double the normal size; 
urinary analysis revealed albumin and casts with s.g. 
1.010 (24-hour specimen). The mental sjTiiptoms at 
this and subsequent examinations were: Hysteria, mel- 
ancholia, insomnia, psychic blindness, syncope, nympho- 
mania, etc. My diagnosis and treatment at the time 
(several years ago) were both purely symptomatic, but 
to-day I would diagnose this case as one of simple "ab- 
normal internal secretions complicated with nephritis 
and lacerated cervix." The first week's treatment con- 
sisted of absolute quiet in bed under special trained 
nurse and nervines with special diet ; second week 
operation for lacerated cervix and curett<ige of the 
uterus under local and H. M. C. anesthesia; during the 
third, fourth and fifth weeks I administered the dry- 
hot-air treatment (Sprague method) with massage, 
and a strict select cereal and milk diet. At the end of 
the seventh week the patient was dismissed as partially 
cured. My last account of this patient was that she 
was doing light housekeeping and other ordinary house- 
hold duties, and had had a i-econciliation with her hus- 
band and former friends. 

This is only one of many similar cases that the 
general practitioner meets and puzzles his brain 
over, and then wonders wh\- w-e know so little w^hen 
there is so much yet to learn. 

Would that our physiologists and anatomists, our 
chemists and laboratory w-orkers would delve a 
little deeper into their respective sciences and bring 
to surface the respective functions and anatomical 
relation of these ductless and other internal-secret- 
ing glands, with their special bearing on meta- 
bolism and mental forces. 

We have the pancreas and its allied coworker, the 
liver, with their peculiar generating and secreting 
forces producing pathological conditions such as 
diabetes mellitus, a disease about which, until with- 
in the past decade or so, we knew but little. And 
even at this late day we are guessing between ab- 
normal internal secretions and faulty metabolism 
with their respective relation to the islands of 
Langerhans as the real factor in the etiology of this 
well known disease. The fell symptom of acidosis 
in the production of diabetic coma in this disease 



points very conclusively to the fact that faulty 
metabolism plays an important role in diabetes. 

We have conditions very similar to these in cer- 
tain diseases of the kidney when the functions of 
that organ become impaired to such an extent as to 
cause uremia with its long train of mental and phy- 
sical symptoms. When we consider the vast array 
of psychic symptoms and phenomena produced by 
faulty metabolism and deranged internal secretions 
we become somewhat bewildered in differentiating 
these conditions from some of the ordinary forms o! 
insanity. No doubt many a poor devil has been 
sent to a lunatic asylum on account of some suddei. 
outbreak of anger or other erratic act due to dys- 
function of some one or more of the ductless gland? 
or possibly to deranged body metabolism. 

Since we ha%'e discovered that there is direct com- 
munication between the sympathetic nervous system 
and the ductless glands, we can the more readily 
understand why these organs with their secretions 
become influenced by mental emotion either of anger 
or distress. Many cases of melancholy, hypochon- 
driasis, etc., may be caused by derangement of the 
internal secretions. We may also have mental per- 
versions, a lack of control of the sexual passions and 
anger. Our paranoiacs with their cunning schemes, 
our alcoholic and drug fiends, our eccentric, so-called 
religious fanatics who are suddenly and without 
preparedness called by a Higher Power to preach 
some strange emotional doctrine, dogma, or cult. 
These are only a few of the pathological effects of 
abnormal internal secretions on mental depravity. 
We have the various kinds of faulty metabolism that 
give rise to the purine bodies such as uric acid, 
xanthine, guanine, etc. We also have the toxins 
that are set free, and invade the entire system when 
these ductless and other internal secreting glands 
become impaired, causing every imaginable form of 
mental perversion such as illusions, hallucinations, 
etc. The cardinal feature of the pathogenesis o; 
various forms of insanity is involved in this connec- 
tion, since the foregoing data and illustrations 
clearly indicate that hypothymia and hypothyroid- 
ism may, by inhibiting the efficiency of the defens- 
ive functions of the ductless glands in general, en- 
tail a pathological toxemia capable of evoking men- 
tal disorders. Hypofunction of any of the ductless 
glands may give rise to toxemia by simply depriv- 
ing the .system of this regulating or harmonizing 
fluid whose function is to destroy the toxins. This 
is especially true of the parathyroids, since we 
know that tetany is nothing other than a form of 
toxemia caused by hypofunction of these glands. 

Then as a result of the deficiency of the nucleins, 
the catabolic phase of metabolism is also impaired, 
and toxic wastes accumulating in the blood, includ- 
ing that which circulates in the brain cells, cata- 
tonic phenomena are invited. Chemical changes in 
the cortical cells of a degenerative type may ensue, 
causing autointoxication. After a study of the fun- 
dus of the eye in 109 consecutive cases of this char- 
acter, H. L. Tyson and L. Pierce Clark deliberately 
state that the visual syndrome, as obser\'ed by them 
was, "a distinct contribution to the theory that de- 
mentia precox is an autotoxic disease, and that the 
poison is primarily vascular, which finally induces 
neuronic degeneration. 

Concerning the genesis of the poison, these au- 



July 6, 1918] 



MEDICAL RECORD. 



thors, with many others, conclude that the syn- 
drome points conclusively to the fact that this toxin 
is generated in the gastrointestinal tract. 

To antagonize the intoxication by any wrong 
method of treatment, the ductless glands which take 
part in the defensive functions of the body, the thy- 
roids, the parathyroids, and the adrenals become 
abnormally active in some instances, and incidental- 
ly excite the dystrophic brain cells, provoking the 
catatonic form of the disease (Sajous). 

Dercum and Ellis, in a postmortem study of 
eight patients suffering from dementia precox, all 
of whom had succumbed to tuberculosis, found that 
in seven the thyroid was under weight. The other 
seven glands showed colloid abnormalities, both 
quantitative and qualitative, and four showed retro- 
grade changes in the acinal epithelial cells. The 
adrenals, on the other hand, showed a marked ex- 
cess in weight. 

It is a well-known fact that 65 per cent, of all 
idiots, before the age of six years, are deprived 
of the thymus gland (Sajous). It is also a fact 
that this class is more susceptible to infectious dis- 
eases, and about the same percentage succumb to 
these infections. Many die of tuberculosis in the 
incipient stage. As previously intimated, when we 
have a suppression or stagnation of the secretions 
of any one or all of the ductless glands, we may 
have a state of degeneracy of both mind and body. 
We may have amentia, ranging from the slight 
backwardness of the moron or imbecile to profound 
idiocy, including the amaurotic, moral, and micro- 
cephalic forms. Hebephrenic phenomena of mel- 
ancholic type incident upon puberty are quite no- 
ticeable among school girls who rarely pass the in- 
termediate grade of the public high school. 

It is not within the scope of this paper to dis- 
cuss fully the hyperfunction of the glands of in- 
ternal secretion. When, however, in the presence 
of toxemia, we have clear evidence of overactivity 
of these organs, it is reasonable to conclude that 
we are dealing with a defensive reaction. If, after 
a trial of the desiccated thyroids and iodothyrin, we 
observe an increase of the motor symptoms of cata- 
tonia and those peculiar to Graves' disease, such as 
rapid pulse, muscular tremors, hyperhydrosis, over- 
active eye reflexes, increased muscular excitability, 
dermographia, loss of weight, and skin pigmenta- 
tion, we may reasonably conclude our diagnosis. 
The only clear indication, in our judgment, is a 
partial thyroidectomy, which has proven quite suc- 
cessful of late. Dr. Fallis treated by this method 
eight successive patients with "catatonia," who re- 
covered their mental integrity. This treatment 
applies more particularly to the young than to 
the old and long standing cases. In mild cases 
of dementia precox, we might administer a thor- 
ough course of thymus extract aided by lecithin, 
which is a phosphorus compound, and is indicated 
in the treatment of the active nervous symptoms 
of both catatonia and Graves' disease. Dr. Bayard 
Holmes adds emphasis to the importance of this 
subject when he writes : "There is no disease, not 
even general paresis, that finds the profession in 
60 helpless, hopeless, and pitiable a condition as de- 
mentia precox does." There is no disease that 
costs the state a larger amount in care and custody 
than this disease. According to various estimates 



it represents about 25 per cent, of the total admis- 
sions to the institutions of the insane (Ingham). 

In view of these established facts, sanctioned by 
such men as Sajous, Dercum, Hochwart, Howell, 
and L. F. Barker, from whose able pens I have 
learned much and quoted liberally in the prepara- 
tion of this paper, let us as progressive medical 
men and humanitarians, give the subject of inter- 
nal secretions more zealous study, and use our in- 
fluence toward the establishment of institutions for 
the study and treatment of psychiatry and its re- 
lation to internal secretions and metabolism. By 
this lofty endeavor we may relieve the profession 
of the stigma of permitting 30 per cent, of our fel- 
low mortals to be doomed to the asylum for the in- 
sane. 

"More might be said hereof to make a proof, 
Yet more to say were more than is enough." 



DEATH AND ITS SEMITIC TKADITIONS. 

By JOSEPH H. MARCUS, M.D., 

ATLANTIC CITY, N. J. 
ATTENDING PHYSICIAN TO THE JEWISH SBASIDB HOMB. 

In the Bible death is viewed under form of an 
angel sent from God, a being deprived of all volun- 
tary power. Throughout the Bible are mentioned 
the following : The "angel of the Lord" smites 185,- 
000 men in the Assyrian camp; "the destroyer" 
kills the firstborn of the Egyptians, and the de- 
stroying angel rages among the people of Jerusa- 
lem. In I Chronicles xxi:15 the "angel of 
the Lord" is seen by David standing "be- 
tween the earth and the heaven, having a 
drawn sword in his hand stretched out over Jerusa- 
lem." Job uses the general term "destroyer," 
which tradition has identified with "destroying 
angels," and Proverbs xvi:14 uses the term the 
"angels of death." The rabbis found the angel of 
death mentioned in Psalms lxxxix:45, where the 
translation reads : "There is no man who lives and, 
seeing the angel of death, can deliver his soul from 
his hand." Ecclesiastes viii :4 is thus explained in 
the passage: "One may not escape the angel of 
death, nor say to him, 'Wait until I put my affairs 
in order,' or 'There is my son, my slave; take him 
in my stead.' " 

The angel of death occurs very frequently in 
rabbinical literature. Where the angel of death 
appears there is no remedy. If one who has sinned 
has confessed his fault, the angel of death may not 
touch him. By acts of benevolence, the anger of 
the angel of death is overcome ; when one fails to 
perform such acts, an angel of death will make his 
appearance. God commands the angel of death. 
As soon as he has received commission to destroy, 
he does not discriminate between the good and the 
bad. In the city of Luz, the angel of death has no 
power, and when the old people are prepared for 
death they leave the immediate precincts of the 
city, and die in the outskirts. A legend to the same 
effect existed in Ireland in the Middle Ages. 

The angel of death was created by God on the 
first day. His dwelling place is in heaven, whence 
he reaches the earth in eight flights, whereas pesti- 
lence reaches it in one day. He has twelve wings. 
"Over all people have I surrendered to thee the 



MEDICAL RECORD. 



[July 6, 1918 



power," said God to the angel of death, "only not 
over this one which has received freedom from 
death through the law." It is said of the angel of 
death that he is full of eyes. In the hour of death 
he stands at the head of the departing one with 
a drawn sword, to which clings a drop of gall. As 
soon as the dying individual sees the angel he is 
seized with a convulsion, opens his mouth, where- 
upon the angel of death hurls the drop into it. 
This drop is the cause of his death, and he turns 
putrid and his face becomes yellow. The expres- 
sion "the taste of death" originated in the concep- 
tion that death was caused by a drop of gall. The 
soul is said to escape through the mouth or, as is 
mentioned elsewhere, through the throat; there- 
fore the angel of death stands at the head of the 
I)atient. When the soul forsakes the body its voice 
travels from one end of the world to the other, but 
it is not heard. The drawn sword of the angel of 
death indicates that the angel of death was re- 
garded as a warrior who kills off the children of 
men. "Man, on the day of his demise, falls down 
before the angel of death, like the beast before the 
slayer." 

In later representations the knife sometimes is 
substituted for the sword, and reference is also 
made to the cord of the angel, which indicates 
death by throttling. Moses said to God, "I fear the 
cord of the angel of death." Of the four methods 
of execution in this period, three are named in con- 
nection with the angel of death: burning (by pour- 
ing hot lead — the drop of gall), slaughtering (by 
beheading), and throttling. The angel administers 
the particular punishment which God has specified 
for the commission of sin. A peculiar mantle be- 
longs to the equipment of the destroyer. The angel 
of death assumes the particular form which will 
best serve his purpose; e.g. he appears to a scholar 
in the form of a beggar imploring pity. "When 
pestilence rages in the town, walk not in the middle 
of the street, because the angel of death (pesti- 
lence) strides there; if peace reigns in the towm, 
walk not on the edges of the road. When pestilence 
rages in the town go not alone to the synagogue, 
because there the angel of death stores his imple- 
ments. If the dogs howl, the angel of death has 
entered the city; if they make sport, the prophet 
Elijah has come." The "destroyer" (Satan Ha- 
mashhit) in a daily prayer is represented as the 
angel of death. 

There are six angels of death: Gabriel over 
kings; Kapziel over youths; Mashbir over animals; 
Mashhit over children; Af and Hemah over man 
and beast. 

When the Messiah comes all the dead will arise, 
and there will be an end to death, for the angel of 
death will be himself destroyed by the Messiah. 
■ The last enemy that shall be annihilated is death : 
the same idea seems to be expressed in the book of 
Jubilee, 29 and xxiii: "And they shall fulfill all 
their days in peace and joy and shall live on, since 
there will be no Satan and no evil to destroy them." 
The angel of death, who is identified with Satan, 
immediately after his creation had a dispute with 
God as to the light of the Messiah. When Eve 
touched the tree of knowledge she perceived the 
angel of death and thought: "Now I shall die. and 
God will create another wife for Adim." .■\dam 



al.so had a conversation with the angel of death. 

It was Moses who most often had dealings with 
the angel. At the rebellion of Korah, Moses saw 
him. It was the angel of death in the form of 
pestilence which snatched away 15,000 every year 
during the wandering in the wilderness. When the 
angel came to Moses and said, "Give me thy soul," 
Moses called to him, "Where I sit thou hast no 
right to stand," and the angel retired in shame and 
reported the incident to God. Again God ordered 
him to bring the soul of Moses. The angel went 
and, not finding him, inquired of the sea, the moun- 
tains, and of the valleys; but they knew nothing 
of him. Really Moses did not die through the 
angel of death, but through God's kiss ^bi- 
neshkah) ; i.e. God threw his soul out of his body. 
Legend seizes upon the story of Moses' struggle 
with the angel of death, and expands it at length. 

Solomon once noticed that the angel of death was 
grieved. When questioned as to the cause of his 
sorrow he answered : "I am requested to depart 
with your two beautiful scribes." Solomon at once 
charged the demons to convey his scribes to Luz. 
where the angel of death could not gain access. 
When they were near to the city, however, both 
perished. The angel laughed on the next day. 
whereupon Solomon inquired as to the cause of his 
mirth. "Because," answered the angel, "thou dist 
send the youths thither, whence I was commanded 
to bring them." In the next world God will permit 
the angel of death to fight with Pharaoh, Sisera, 
and Sennacherib. 

The teaching of God shields one from the power 
of the angel of death. The children of Israel have 
accepted the Torah (the five books of Moses — 
Genesis, Exodus, Leviticus, Numbers, and Deuter- 
onomy) only that the angel may exert no power 
over them. Since death can only result from sin, it 
cannot, of course, come to those who live in accord 
with the Torah. Although the sentence of death 
once pronounced could never be recalled, yet the 
angel may not visit teachers of the law; he is, on 
the contrary, their friend, and even imparts knowl- 
edge to them. 

Teachers of the law of the fourth century asso- 
ciate rather familiarly with him. When he ap- 
peared to one on the street, the instructor re- 
proached him with rushing upon him as upon a 
beast; whereupon the angel called upon him at his 
house. To another he granted a respite of thirty 
days, that he might put his affairs in order before 
entering the next world. To a third he had no , 
entry, because he was powerless to interrupt the J 
study of the Talmud. To a fourth he displayed a 
rod of fire, whereby he is recognized as the angel 
of death. Oftentimes does he resort to cunning 
means to approach and seize his victims. 

The death of Jo.shua ben Levi, in particular, is 
enhanced with a web of fable. When the time came 
for him to die and the proverbial angel of death 
appeared to him, he demanded to be shown his 
place in paradise. When the angel had consented 
to this, he demanded his knife that the angel may 
not frighten him on the way. This request was 
also granted him; and Joshua sprang with the 
knife over the wall of paradise; the angel, whti is 
not allowed to enter jiaradise, caught hold of the 
end of hi'^ raiment. Joshua swore that he would 



July 6, 1918] 



MEDICAL RECORD. 



not come out, and God declared that he should not 
leave paradise unless he was absolved from his 
oath ; if not absolved, he was to remain. The angel 
of death then demanded back his knife, but Joshua 
refused. At this point a heavenly voice rang out : 
"Give him back the knife because the children of 
men have need of it." 

In Arabic Literature, the angel of death is 
sfwken of in the Koran, and is called by the Mo- 
hammedans, Azrael. "When death was created by 
God, he, on account of his terrible power, had to be 
put in seventy thousand chains of a thousand 
years' journey's length each, and behind millions 
of barriers. When Azrael was placed in charge of 
him, and saw him he called the angels to look at 
him; and when he, at God's command, spread his 
wings over him and opened all his eyes, the angels 
fainted away, and remained unconscious for a 
thousand years. Azrael was given all the powers 
of the heavens to enable him to master death." 

Azrael reaches from one end of the world to the 
other and has seventy thousand feet and four 
thousand wings. His entire body is covered with 
eyes and with tongues as numerous as the living 
creatures on earth. When any of these latter die 
a corresponding eye bulges forth. At the end of 
the world all these eyes, excepting eight, are 
plucked out by God; those of Israfil, Michael, 
Gabriel, Azrael, and the four "Hayyot" of the 
heavenly chariot alone remaining. The times of 
the death of persons is made known to the angel 
of death through the roll-book in his possession, 
showing the white stripe around the name of the 
person doomed. Forty days before death, how- 
ever, a leaf falls from the tree of life, under the 
throne of God, into the lap of Azrael, who is 
seated in the seventh heaven, thus announcing the 
death. 

"When people lament and weep too much over tlie 
departed person the angel of death shall stand at 
the door, and say: 'What cause have you for sue!' 
violent complaint? I am only the messenger of 
God and have done His bidding, and if you relie! 
against Him I shall return often and take one ol' 
your house.' When a righteous person dies, th" 
angel comes with a host of good angels carrying- 
sweet odors of paradise and makes the soul leave 
the body like a drop taken out of a bucket of watp' 
When a wicked person dies the angel of death 
comes in the company of demons, who pull the soul 
out as with iron spits." 

The ancient Hebrews e.xpected to be gathered to. 
or sleep with, their fathers when death befell them. 
and feared only the idea of going down to Sheol 
(pit or destruction) mourning. To sleep and be at 
rest was the desire of the distressed. To die in "a 
good old age" was regarded as a blessing; to be 
cut off from the land of the living in the noon- 
tide of life was dreaded and looked upon as a 
calamity. Only at times the stings of mortality 
and the stroke of Sheol became objects of horror, 
from which the Lord was petitioned to redeem 
men. Nowhere, however, in the Bible is death re- 
garded as a genuine evil, except from the point of 
view that man, being of divine origin, .should have 
had, like any other heavenly being, access to the 
tree of life, and have existed forever. Accordingly, 
the eschatological view found expression in such 



phrases as that "death shall be swallowed up for- 
ever" and "the dead shall rise again." Satan is 
called in the New Testament "a murderer from the 
beginning" and the "destroyer." Death is con- 
ceived of as a person who has charge of the shades 
in the nether world. He is their general. The fol- 
lowing is a description of death as one of God's 
messengers: 

"When Abraham had refused to let the archangel 
Michael take his soul, God .said to the latter: 'Call 
Me hither, death of the shameless countenance and 
pitiless look.' Death shivered and trembled at be- 
ing called to come before the Lord, when God said 
to him: 'Come hither, thou bitter and fierce name 
of the world, hide thy fierceness, cover "thy cor- 
ruption, and cast away thy bitterness from thee, 
and put on thy beauty and all thy glory and go 
down to Abraham, My friend, and bring him to 
Me.' Death put on a robe of great brightness, and 
made his appearance like the sun, and became fair 
and beautiful above the sons of men, assuming the 
form of an archangel, his cheeks flaming with fire, 
and went to Abraham, a sweet odor and a flash of 
light, announcing his coming to the patriarch, who 
took him to be an archangel, the chief captain of 
God, and welcomed him as the purveyor of light 
and the most glorious helper. But death rejoined: 
'Most righteous Abraham, I am the bitter drop of 
death,' and when asked for his errand he said : 'P^or 
thy holy soul have I come.' Abraham again re- 
fused to relinquish his soul. Death followed him 
into his chamber, and when Abraham laid down 
upon his couch he sat by his feet, and would not 
depart, notwithstanding all the entreaties of the 
))atriarch to let him live. 

"On inquiry of the patriarch, he told him that 
only because of his great righteousness, his hos- 
pitality to man, and his love toward God, which be- 
came a crown of glory upon his head, did he ap- 
proach him in such beauty and glory; to sinners he 
came in fierceness, and corruption, and bitterness. 
"Show me these,' asked Abraham, but death re- 
plied, 'Thou canst not stand these looks.' Thereto 
Abraham answered: 'By means of the name of the 
living God, I shall be able to look.' So death put 
off his sunlike glory and put on his tyrant-like robe 
and made his appearance fiercer than all wild 
beasts, and filthier than all filth, and he showed 
Abraham seven fiery serpents' heads and fourteen 
faces: (1) of flaming fire, (2) of darkness, (3) of 
a viper, (4) of a precipice, (5) of a fierce asp, (6) 
of a terrible lion, (7) of . a cerastes, (8) of a 
basilisk, (9) of a fiery scimitar, (10) of terrible 
lightning and thunder, (11) of a stormy sea, (12) 
of a rushing river, (13) of a three-headed serpent, 
and (14) of a cup filled with jwison; and then he 
showed him every mortal disease emanating from 
the odor of death. Seven thousand man-servants 
and maid-servants of Abraham died from the effect 
of this odor and sight, so that Abraham implored 
death to hide his fierceness and to put on his for- 
mer garb of beauty. Death complied with his re- 
quest, and joined Abraham in a prayer to God to 
i-estore to life those who had died so suddenly by 
his fierceness, and the prayer was granted. 

"Abraham, however, would not consent to sur- 
render his soul until death had explained to him 
the different forms and faces he had displayed to 



10 



MEDICAL RECORD. 



[July 6, 1918 



him in all their fierceness; whereupon death an- 
swered that the seven heads of the serpents indi- 
cated the seven ages during which he is to destroy 
all men, rich and poor, and to bring them to the 
bottom of Hades. Because people die by fire, by 
falling from precipices, by the sword, by rushing 
rivers, on the raging sea, and in storms of light- 
ning, by wild beasts, or cups of poison, he assumed 
all those aspects. Finally, he spoke of the seventy- 
two kinds of death, and of the death of the holy. 
Then death took the right hand of Abraham, and 
his soul clung to him." 

Death appears here as the personification of 
psychic evil, with numerous traits, but not of moral 
evil. 

There are different views among Jews concern- 
ing death, and its cause. Some assign it to 
Adam's first sin in partaking of the forbidden 
fruit. This point of view is somewhat modified by 
the rabbis, who regard death as the fruit of per- 
sonal sin, maintaining that, like Adam, each per- 
son dies on account of his own sin, as "there is 
not a righteous man that doeth good sinneth not" 
(Ecclesiastes vii:20). Still the rabbis speak of a 
number of "saintly men who died without sin and 
only in consequence of the poison of the serpent": 
e.g. Benjamin, Amram, Jesse, the father of David, 
and Chileab, the son of David. Another view is 
that death was ordained at creation, and that Adam 
by his sin merely hastened death. According to 
others, Adam was destined to live forever and not 
to taste death, but, owing to the fact that men like 
Hiram of Tyre and Nebuchadnezzar wanted to be 
worshiped as Gods, God decreed death for man. 
The opinion is also expressed that God would have 
annihilated the power of the angel of death over 
Israel after its acceptance of the law, but for the 
fact that the decree could not be altered. From 
the point of view that sin precedes and causes 
death in each person, the Talmud designates special 
reasons for the death of innocent children. 

Modes of Death. — There are 903 distinct deaths. 
The hardest is by asthma, .and the easiest is 
called "death by the kiss" which is "like drawing 
hair out of milk," that is the interpretation of "by 
the mouth of the Lord." Six persons are known 
to have died in this manner; namely, the three 
patriarchs, and Moses, Aaron, and Miriam. 

Death coming after an illness of five days' dura- 
tion is considered an ordinary occurrence; after 
four days a reprimand from heaven ; after three 
days a severe rebuke; after one day, a sudden one, 
or, according to some, an apoplectic one. To die be- 
fore reaching the age of fifty is designated as "be- 
ing cut off." Sixty years is a ripe age; seventy is 
old age, and eighty is advanced age. 

Many allegorical tales are related in rabbinical 
literature regarding the communication of the dead 
with the living. A pious man, being censured by 
his wife for giving away a dinar (a Roman silver 
coin worth about fourteen cents) to a mendicant 
in time of famine, went to sleep in the cemetery. 
It was New Year's eve, and he overheard the 
spirits of two women gossiping. One of them pro- 
posed to fly and listen behind the curtain in the 
judgment chamlier to the promulgation of the 
future visitations in the world. The other spirit 
excused herself, saying: "I cannot accompany thee 



because I am buried in reed matting; go thyself 
and come back and tell me what thou hearest." 
Presently her companion returned and reported: 
"I heard that the hail will kill whatever is planted 
in the first rainy season." The pious man planted 
in the second rainy season. The following year he 
again went to sleep in the cemetery on New Year's 
eve, and overheard a similar conversation, gaining 
the information that whatever was planted in the 
second season would be consumed by blight. The 
pious man planted during the first season. His 
wife was curious to know how he managed to evade 
the calamitous visitations, and he, being pressed, 
related his story. A few days later the woman had 
a quarrel with the mother of the second spirit, and 
abused her for giving her daughter an indecent 
burial. The third year the pious husband again 
sought to obtain information regarding future 
crops. The second spirit said: "Hush, companion! 
Our former conversation was overheard by mortal 
man." 

The dead are supposed to take an active interest 
in worldly affairs. The assertion of one authority 
that "the dead know not anything" is interpreted, 
"the wicked who are considered dead while yet 
alive." R. Isaac said, "The sting of a worm to the 
dead is like the pricking of a pin to the flesh of the 
living." The dead are verj- sensitive. One must 
not tell tales around the deathbed of a scholar. 
Inasmuch, however, as the dead are exempt from 
performing the precepts, they feel slighted if such 
performance should take place in their presence 
by the living, as it would be like "mocking the 
poor." In burying a scholar it was customary to 
deposit in his coffin a scroll that was unfit for read- 
ing. 

The practice of praying for the intercession of 
the dead is of early origin. Caleb on entering 
Hebron visited the cave of Machpelah and prayed 
to the patriarch to be saved from cooperating in 
the conspiracy of the scouts sent by Moses to make 
a report of the conditions existing in the Hol\ 
Land. The Talmud mentions the custom of visiting 
the cemetery to request the dead to pray for the 
living. The noise of the soul's departure from the 
body reverberates through the world from one end 
to the other, yet the sound is unheard. Prior to 
the exit of the soul it sees the Shekinah (the ma- 
jestic presence or manifestation of God which has 
descended to "dwell" among man). The soul after 
death is in the same condition as it is in life when 
one dreams. Until the body is entirely consumed 
the soul hovers over the grave. Samuel said: "If 
one wants to have a taste of death, let him sleep 
with his shoes on." "And God saw everything that 
He made, and behold it was very good." This in- 
cludes death. "The day of death (is better) than 
the day of one's birth" is explained to mean that 
death tells of the meritorious life of the departed; 
it is like the vessel entering port laden with goods. 
The great ones of each generation must die to 
make room for the greatness of successors; "the 
righteous themselves ask for death as a favor." 
The Zohar (a commentary on the Pentateuch) calls 
death a festal day, and the day upon which Adam 
died was made a holiday. 

The windows of the death chamber .should be 
opened to allow the .spirits to enter and to depart. 



July 6, 1918J 



MEDICAL RECORD. 



11 



The angel of death is supposed to wipe his bloody 
knife in water near the dead; hence all water of 
the adjacent houses must be emptied on the ground. 
As the "shedim" (demons) are supposed to follow 
the dead or to wander around their graves, tho.- 
who follow a funeral cortege must wash their h^nd.-^ 
on their return, before entering a house; but should 
not dip them in a river. A special lavatory for this 
purpose is usually provided at the cemetery. On 
returning from the funeral one should sit down 
and rest on the way several times, so as to drive 
away the spirits that follow them. The board upon 
which the dead is cleansed must not be turned 
over. One should not visit the same grave twice 
during one day, nor sleep in a cemetery, nor look 
closely upon the face of a deceased person, nor kiss 
the dead, not even when a near relative. 

A common superstition is current that if the 
shadow of one's head is invisible against the wall 
in a house where a light is burning on Hosha'na 
Rabbah (the popular name for the seventh day 
for the feast of Booths) eve, it is a sign that the 
person will perish within the year. If visible, he 
will live. R. Ammi says, "If one wishes to ascer- 
tain whether he will live during the following yeai\, 
let him, during the ten penitential daj-s, burn a 
candle in his house where no wind can extinguish 
it. If it is not blown out he will live; otherwise 
not." To discover whether the husband or the wife 
will die first, calculate the numerical value of the 
letters in the names of both. If the amount is even 
the man will expire first; if odd, the woman. 

Fanaticisms relative to death in connection with 
dreams are quite numerous. One of them, the 
vision of a scroll in the ark, presages death, as the 
demise of Aaron follows the description of the 
tablets placed in the ark. A dying child may be 
released from the grip of dissolution, if nominally 
sold by the parents to a friend for a shekel. A 
change of name may save one from mortality. The 
removal of a feather pillow from beneath the bed 
of a dying individual aids the soul in an ea,sier de- 
parture. Some rabbis objected to this custom, on 
the supposition that it disturbed the patient and 
so hastened his demise. The iron keys of the syna- 
gogue, if placed under the pillows, are believed to 
accomplish the same effects. Announcement of a 
death should be made in an indirect manner, and it 
was for this reason that the shofar (the ancient 
ritual horn of Israel) was blown in talmudical 
times when death occurred in a town. The beadle 
who summons the congregation to early morning 
prayer and devotion, by knocking three times on 
their doors or windows, announces a death by re- 
ducing the number of raps to two. It is a happy 
omen to die with a smile on the face, or to die on 
one's birthday. Rain on the day of one's funeral is 
a sign of pity and condonation toward the departed. 
It is habitual to bend the thumb of the corpse so 
that the entire hand resembles the word "Shaddai" 
(Almighty), and to bind it in this position with 
certain fringes. A shard is placed over the eyes, a 
little stick in the hands, a piece of metal on the 
body, a small bag of earth from the Holy Land un- 
der the head, and a three-toothed wooden fork in 
the hand, to enable the dead to excavate a sub- 
terranean passage to the Holy Land on the day of 
resurrection, when all the Jewish dead will arise 



in Palestine. A towel is hung up and a glass of 
water placed next to it, so that the soul might 
bathe when it returns to the body. 

To demons were ascribed the various diseases, 
particularly such as affect the brain and the inner 
parts. In the main they were perpetrators of great 
harm to the body. There were a great many sup- 
posed to exist, some of which are mentioned below. 
"Shabriri" (lit. dazzling glare), the demon of blind- 
ness, who rests on uncovered water at night and 
strikes those with blindness who drink of it; "Ruah 
Zeradah," the spirit of catalepsy; "Ruah Zelatah," 
the spirit of headache, hovering on palm trees; 
"Ben Nefilim," the demon epilepsy; "Ruah Kezarit," 
the spirit of nightmare; "Ruah Tezazit," the spirit 
of delirious fever and madness ; "Ruah Zara'at," the 
spirit of leprosy ; "Ruah Kardeyakos," the spirit of 
melancholy; "Shibetta," a female demon, bringing 
croup to persons, especially to children, who do not 
wash their hands in the morn; "Bat Horin," a 
demon bringing a disease of the eye to one who 
fails to wash his hands after meals; "Kuda," a 
demon who attacks women in childbirth; "Esh- 
shata," the demon of fever; "Ruah Zenunim," the 
spirit of sexual desire; "She'iyyah," an ox-like 
fiend dwelling in desolate homes; "Puta" or "Pura," 
the spirit of forgetf ulness ; "Ben Temalyon," the 
demon of St. Vitus' dance. 

These demons were supposed to enter the body 
and cause the disease, while overpowering or "seiz- 
ing" the victim; hence the ordinary cognomen for 
"epileptic" is "nikpeh." The synonymous Greek 
word means the state of being in the authority of 
exorcism. To cure such diseases it was necessary 
to draw out the evil demons by certain incanta- 
tions and talismanic performances. Josephus, who 
speaks of friends as "spectres of the wicked which 
enter into men that are alive and kill them," but 
which can be driven out by a certain root, witnessed 
such a performance in the presence of the Emperor 
Vespasian, and attributed its inception to King 
Solomon. 

In the Book of Wisdom, Solomon claims to have 
received from God power over the demons. The 
same potency of curing by demonism such dis- 
eases as dumbness, blindness, epilepsy, mania, and 
fever were exercised by Jesus and His disciples, as 
also by their Jewish contemporaries. Occasionally 
a demon is called "Satan": "Stand not in the way 
of an ox when coming from the pasture, for Satan 
dances between his horns." The name "mashhit" 
(destroyer) seems to refer to the head of the 
demons in the sentence: "When permission is given 
to the destroyer to do harm, he no longer discrimi- 
nates between the righteous and the wicked." The 
queen of demons is Lilith, pictured with wings, and 
long flowing hair, and called the "mother of Ahri- 
man." "When Adam, doing penance for his sin. 
separated from Eve for 130 years, he, by impure 
desire, caused the earth to be filled with demons 
and evil spirits." And it was Lilith, as Adam's 
concubine, who bore them. 

Birds as Souls. — In Psalm xi:l the soul is com- 
pared to a bird: "Flee as a bird to the mountain." 
As living beings that move and fly through the air 
birds have suggested themselves at all times and 
in all lands to primitive man as images of the soul, 
the name for which in most languages is taken 



12 



MFDICAI. RECORD. 



I July 6, 1918 



from breathing (."nefesh," "neshamah" ^= "anima" 
or "psyche") ; the soul was represented in the form 
of a butterfly, as illustrated by the tombs of the 
early Christians. The soul of the king of Egypt 
was pictured on the monuments as a bird, and the 
Kenius of the kings of Persia and Assyria retained 
the wings of the bird. The Arabs also regarded 
the soul as a bird, and believed that after death 
it hovered at times around the body, screeching 
like an owl. This view was shared by the Jews. 
They placed credence in the supposition that all 
souls are gathered in a great cage or treasure house 
in heaven, a columbarian, called "Guf"; and so 
Kabbi Asi taught that the Messiah, the son of 
David, cannot come until all the souls have been 
taken out of the Guf, and have gone through human 
bodies. In the Greek Baruch Apocalypse, Baruch 
sees in the fourth heaven a lake full of birds, and 
is told that these are the souls of the righteous, 
who continually sing the praise of God. These 
stories are repeated by Christian saints who affirm 
having seen the souls of the devout in paradise. 
In the zohar the sparrow and the swallow, spoken 
of in Psalm ixxxiv:3, are compared to the souls of 
the religious which dwell in paradise. Three times 
a year, they rise upon the walls of paradise and 
sing the praise of the Master of the universe, 
whereupon they are ushered into the palace where 
the Messiah is secreted, called the great '"Souls' 
-Vest." They are adorned with crowns in his honor 
when he appears to them, and from beneath the 
altar of heaven, where dwell the souls of the pious, 
they prepare the erection of the temple of the 
future. It is customary among certain Jews, when 
a death occurs, to open a window in order that the 
soul may fly away like a bird. 

As previously recounted, the dead are assigned 
to a place called "Sheol," which connotes a locality 
where those that had passed away were believed 
to be congregated. Jacob, refusing to be comforted 
at the supposed death of Joseph, exclaims: "I shall 
go down to my son a mourner unto Sheol." (Genesis 
xxxvii:36) Sheol is underneath the earth and is 
very deep and it marks the point at the greatest 
possible di.stance from heaven. The dead descend 
or are made to go down into it; the revived ascend 
or are brought and lifted up from it. Sometimes 
the living are hurled into Sheol before they would 
naturally have been claimed by it, in which cases 
the earth is described as "opening her mouth." 
Sheol is spoken of as a land, but ordinarily it is a 
place with gates, and seems to have been viewed as 
divided into compartments with "farthest corners" 
one beneath the other. Here the dead meet without 
distinction of rank or condition — the affluent and 
the indigent, the pious and the iniquitous, the mas- 
ter and the bond servant — if the portrayal in Job 
iii refers, as most probably it does, to Sheol. The 
dead continue after a fjushion, their mundane exist- 
ence. Jacob would mourn there (Genesis xxxvii :35, 
xlii:38); David abides there in peace (I Kings 
ii :6) ; the warriors have their weapons there with 
them (Ezekiel xxxii:27), yet they are mere 
shadows. 

The following extracts, also, are quoted in the 
Bible: The dead merely exist without knowledge 
or feeling. Silence reigneth supreme, and oblivion 
is the lot of them that enter therein. Hence it is 



known also as "Dumah," the abode of silence, and 
there God is not praised. Still on certain ex- 
traordinary occasions the dwellers in Sheol are 
credited with the gift of making known their feel- 
ings of rejoicing at the downfall of the enemy. 
Sleep is their usual lot. Sheol is a horrible, dreary, 
dark, disorderly land, yet is the appointed house 
for all the living. Return from Sheol is not ex- 
pected; it is described as man's eternal house. It 
is "dust"; hence in the Shemonah Esreh, in bene- 
diction No. II, the dead are spoken of a.s "sleepers 
in the dust." God's rulership over it is recognized. 
Hence He has the power to save the pious there- 
from. Yet Sheol is never satiated ; she "makes 
wide her soul," i.e. increases her desire and ca- 
pacity. In these passages Sheol is personified ; it is 
described also as a pasture for sheep with death as 
the shepherd. From Sheol, Samuel is cited by the 
witch of En-dor. 

As a rule Sheol will not give up its own; they 
are held captives with ropes. The realm of the 
dead is in the earth, the gateway being in the 
west. It is the "land without return." It is a dark 
place filled with dust, but it contains a palace for 
the divine ruler of this shadow realm. Seven gates 
guard successively the approach to this land, at the 
first of which is a watchman. A stream of water 
flows through Sheol. 

This concept of Sheol reverts to primitive animis- 
tic conceits. With the body in the grave remains 
connected the soul, as in dreams ; the dead buried 
in family graves continue to have communion. 
Sheol is practically a family grrave on a large scale. 
Graves were protected by gates and bolts; there- 
fore Sheol was likewise similarly guarded. The 
separate compartments are devised for the separate 
clans, sects, and families, national and blood dis- 
tinctions continuing in effect after death. That 
Sheol is described as subterranean is but an appli- 
cation of the custom of hewing out of the rocks, 
passages leading downward for burial purposes. 

There is no .scriptural basis for the belief in 
retribution for the soul after death; this was sup- 
plied by the Babylonians and the Persians, and re- 
ceived the Jewi.sh coloring from the word "gehin- 
nom" (the valley of Hinnom) made detestable by 
the fires of the Moloch. The smoke of the sub- 
terranean fires came up through the earth in this 
place; there are cast the spirits of sinners and 
blasphemers and of those who work wickedness 
and pervert the words of the prophets. Gehinnom 
has a double purpose — annihilation and eternal 
pains. Gehinnom has seven names: "Sheol," "Ab- 
badon," "Pit of Corruption," "Horrible Pit," "Mire 
of Clay." "Shadow of Death," "Nether parts of the 
Earth." It is also called "Tophet." It has seven 
divisions, one under the other. According ti> 
rabbinical traditions, thieves are condemned to 
fill an unfillable tank ; the impure sink into a quag- 
mire; those that sinned with the tongue are sus- 
pended thereby; some are suspended by the feet, 
hair, or eyelids ; others eat hot coals and sand ; 
others are devoured by worms, or are placed alter- 
nately in snow and fire. These conceptions are 
ascribed chiefly to Joshua ben Levi, and have their 
parallel in the apocalyptic literature appropriated 
by the Christian church. The punishment of the 
evil endures twelve months, according to R. Akiba; 



July 6. 1918: 



MEDICAL RECORD. 



13 



the generation of the flood will in time be released, 
but the punishment of those who have led others 
into heresy, or dealt treacherously against the law. 
will never cease. 

The Garden of Eden is called the "Garden of 
Righteousness," being no longer an earthly para- 
dise. It is above the earth, and its inhabitants are 
clothed with garments of light and eternal life, and 
eat of the tree of life in the company of the Lord 
and His anointed. In Slavonic Enoch its place is 
in the third heaven ; its four streams pour out 
honey and milk, oil and wine. It is prepared for 
the "righteous who suffer innocently who do works 
of benevolence and walk without blame before 
God." It has been created since the beginning of 
the world, and will appear suddenly at the Judg- 
ment Day in all its glory. The pious dwell in those 
heights where they enjoy the sights of the heavenly 
■"Hayyot" (previously mentioned) that carry God'.< 
throne. There are seven divisions for the good 
which shine like the sun, the moon, the firmament, 
lightnings, torches, and lilies. Each of these divi- 
sions is placed differently before the face of God. 
Each of the holy will have a mansion, and God 
will walk with them and lead them in a dance. As 
the wicked have a sevenfold pain, the righteous 
have a sevenfold joy. 

"In the world to come there is neither eating, 
drinking, nor procreation, neither barter nor envy, 
neither hatred nor strife; but the holy sit with 
their crowns on their heads and enjoy the splendor 
of the Shekinah, for it is said: 'And they saw God, 
and they did eat and drink'; that is, their seeing 
God was meat and drink to them." 

Regarding death, the philosophical attitude of 
the Jew is beautifully expressed in the following 
narrative : 

During a brief absence of Rabbi Meir from home 
two of his sons died. Their mother, concealing her 
profound anguish, awaited the return of the father. 
He soon arrived, and after the customary exchange 
of greetings and a fond embrace she said to 
him: "My husband, some time ago, two jewels of in- 
estimable value were placed in my charge for safe- 
keeping. He who left them with me called for them 
this day, and I delivered them into his hands." 
"That is right," said the Rabbi, in an approving 
manner, "and I am very happy that you acted ac- 
cordingly. Furthermore, we must always return 
cheerfully and loyally those things that are left 
in our care for protection." Shortly following this 
exchange in words the rabbi asked for his boys, and 
the heartbroken mother, taking him by the hand, 
gently guided him to the chamber of death. Meir 
gazed upon his sons and, realizing the truth, wept 
bitterly. "Weep not, beloved husband," said his 
noble wife; "didst thou not say to me we must re- 
turn gladly when 'tis called for, and all that has 
been placed in our care for safekeeping and protec- 
tion? God gave us these jewels. He left them with 
us for a time, and we gloried in their possession, 
but now that He calls for His own we should not 
repine." 

The few following paragraphs are taken from the 
Talmud, which is replete with wit and wisdom : 

The question is asked, "Why is a man bom with 
his hands clinched, but has his hands wide open in 
death?" And the answer is: "On entering the 



world man desires to grasp everything, but when 
leaving it he takes nothing away." 

Even as a fox who saw a fine vineyard and lusted 
after the grapes within the confines of the fence 
surrounding the enclosure; but being too fat to 
crawl through the only opening there was he was 
compelled to fast for three days. Having attained 
the necessary slimness it was an easy matter to 
gain access to the grapes. After having fed to his 
heart's content he could not get out until he had 
fasted for three days more. "Naked man enters 
the world, and naked does he leave." 

Death is the haven of life, and old age the ship 
which enters port. 

Do not speak ill of the departed, but remember 
that his soul still lives, though the body is dead. 

It is our duty to comply with the last wishes of 
a dying person. 

The death of the holy is a calamity equal in mag- 
nitude to the burning of the temple. 

521 Pacific A^-exxte. 



FURTHER CONTRIBUTIONS TO THE TREAT- 
MENT WITH DIGITALIS PREPARATIONS. 

AN EXPERIMENTAL STUDY OF BLOOD PRESSURE .AND 
TOXICITTi'.-- 

By ERNEST ZUEBLIN. M.D . F.A.C.P.. 

CISCINXATI, OHIO. 



Digitalis preparations for a long time were con- 
sidered valuable remedies in the treatment of car- 
diovascular disease. While older colleagues are en- 
thusiastic about its therapeutic effects, frequently 
we hear complaints from younger observers that 
this drug should be selected for special cases, and 
should not be used so frequently as was the cus- 
tom in former years before we learned more about 
the occurrence of partial heart block and irregulari- 
ties of the pulse rate due to an overdose of the rem- 
edy. If unexpected symptoms arise, is it the fault 
of the anatomical lesion, or is it the fault of the 
patient, or must the explanation be looked for in 
the particular nature of the remedy? 

Without entering into the discussion of the first 
two questions, personal investigation has shown 
that the cardiovascular remedies are not constant 
in their physical properties; that they undergo 
changes as they become older, particularly as re- 
gards the ionisation studied by means of the fon- 
tactoscope.' It was found that notwithstanding a 
careful storage, excluding light and humidity, these 
changes take place. Furthermore, my investiga- 
tions have revealed the possibility that, by exposing 
digitalis preparations to the action of high fre- 
quency waves, these drugs present a higher degree 
of ionization after such treatment. The question 
came up whether such drugs would gain in thera- 
peutic efficiency by such a treatment. 

To solve this problem the following experiments 
may be recorded.! It cannot be the aim of this pa- 

*Paper read before the Cincinnati Research Society, 
December, 1917. 

tAt this opportunity I wish to express my thanks to 
Dr. Coulsson, biological chemist at the Laboratory of 
Messrs. Sharp & Dohme, as through their courtesy 
the present investigations were earned out under my 
supervision. 



MEDICAL KliC(JKD. 



[July 6, 1918 



per to report all the experiments made, but a few 
of them reviewed may be sufficient for the demon- 
stration of their therapeutic differences. 

The animals upon which the digitalis powder — 
crude and activated — was tried were cats, which, 
while kept under ether anesthesia when tracheo- 
tomized, had one carotid artery ligated and con- 
nected with the manometer filled with Ringer's so- 
lution, and the fluctuation of the blood pressure 
were recorded on the kymographion. The normal 
blood pressure was ascertained first for a period of 
at least 5 minutes. Into the femoral vein the test 
solution of either digitalin or activated digitalin 
solution of a given strength was injected, and the 
resulting changes in the blood pressure curve were 
studied until the death of the animal or until blood 
clot formation stopped the experiment. The lethal 
dose of the drug was calculated per one kilogram of 
animal weight. 

Before entering into the discussion of our results 
let us consider the pressure curve* obtained by us- 




^ — Normal Pressure Line 



ing digitalin dissolved in normal saline solution, one 
mil corresponding to .001 gram of digitalin. 

Control animal, cat, male, weight 3.5 kg. Experi- 
ment begun on March 24, 1917, at 9.58 a. m., with 
normal pressure 166 mm., primary waves. 3 cm. in 
length, .3 cm. high, compo.sed of two ascending and 
two descending wavelets measuring .1 15 cm. in 
height. Blood pressure 4 minutes later 163 mm., 
3 mm. less when 2 mils were injected into the 
femoral vein. As a result we find a primary fall 
of 1.7 cm. after the injection, the maximum being 
reached at 1.9 cm., the difference in height being 
.2 cm., which decline then is succeeded by a steep 
and prolonged ascent, the primary waves measur- 
ing .4 cm. in length and .4 cm. in height, the 
amplitude of the secondary wavelets being .3 cm. 

Blood pressure at the beginning of the 6th minute 
registered 197 mm. or 34 mm. above the normal fig- 
ure, at which moment 2 more mils were introduced 
into the femoral vein. A rapid drop of 1.2 cm. fol- 

*The pressure tracings cannot be reproduced, but 
instead a description of the changes observed on the 
records will be given. 



lowed, which occurred at an earlier moment than 
before, and the average height of the secondarj- 
wavelets becoming less — .25 cm. — an unsuccessful at- 
tempt is made for a rise in the blood pressure, the 
drop in the pressure becoming more manifest, while 
the secondary wavelets reach an amplitude of 
.3 — .35 cm. When 2 more mils of the test solution 
were introduced, the pressure reading at 7 minutes 
gave a lower figure, 181 mm., or only 18 mm. above 
the average normal value. A moderate rise of .3 
cm. is the result with secondary wavelets not higher 
that .2 cm., irregular with groups of 4 wavelets and 
a more pronounced drop in the pressure curve com- 
posed of very shallow wavelets not higher than .1 
cm. Following this, a steep rise of the pressure is 
observed to a higher level — 20 mm. — while the pri- 
mary waves become less pronounced and irregular 
in succession with small superposed wavelets not 
exceeding .1 cm. This rise is of short duration, 
since at the beginning of the 8th minute the pres- 
sure registered was 195 mm., ar 32 mm. higher than 
the average. 

Two more mils of the test fluid injected were fol- 
lowed by no further rise, but by a drop of 12 mm., 
which occurred at an earlier period than in former 
observations. A blood clot in the carotid vessel ob- 
served at that time, though removed, complicated 
the experiment, so a further discussion of the curve 
is not attempted. It will be of interest to note that 
15 mils of the test solution were required to kill 
the animal weighing 3.5 kg., or per kg. weight of 
animal 4.28 mils or .00428 grams of untreated digi- 
talin in the course of 22 minutes were needed to 
produce the same result. 

Since in the preceding experiment the formation 
of a blood clot did not permit any further discus- 
sion of the experiment beyond 6 minutes after the 
injection was given, I report another control ex- 
periment. 

Control cat, male, weight 3.13 kg., examined on 
March 24, 1917. Ether anesthesia employed, tra- 
cheotomy done. Solution used consisted of digitalin 
—Merck — in normal saline solution. 1 mil corre- 
sponding to .001 gram of the original substance. 
Experiment started at 11.42 a. m.. medium pressure 
for the following 4 minutes, 139 mm. No pri- 
mary waves noticeable, the height of the secondary 
wavelets averaging .3 cm. With the introduction 
of the first 2 mils of test solution into the femoral 
vein a rapid but temporary drop in the pressure 
results, rapidlv followed by a rise and a greater 
amplitude of the secondary wavelets, the heieht of 
which is .4 cm. The pressure has risen to 162 mm. 
5 minutes after the start of the experiment, equiva- 
lent to a gain of 23 mm. The same amount of 
fluid injected is succeeded by a drop first in the 
pressure curve, which is compensated rapidly by a 
rise, the primary waves being just sugsrested, the 
secondary wavelets maintaining an amplitude of .4 
cm., and 2 minutes after the first injection the 
pressure registers at 166 or 27 mm. above the nor- 
mal. 

Shortly after the repeated injection of .2 mils, a 
small depression in the pressure curve is noticed 
with a following attempt to reparation, but not 
reaching the former le%'el. The primary waves are 
more manifest, with an amplitude of .3 cm. of the 
secondary wavelets. At the beginning of the next 



I 



July 6, 1918] 



MEDICAL RECORD. 



15 



minute the pressure shows the same level and a 
further injection is succeeded by a drop in pres- 
sure and more accentuated primary waves and with 
secondary wavelets the height of which is not in-' 
excess of .1 — .2 cm. Four minutes after the injec- 
tions were given we notice a fall in the blood pi-es- 
sure, namely, 158 mm., only 19 mm. above the aver- 
age reading. Two mils injected results in a further 
drop of the pressure curve, presenting short pri- 
mary waves and hardly perceptible secondary wave- 
lets not exceeding .1 cm. in amplitude. Five minutes 
after beginning of the injection experiment the 
pressure curve has reached its normal level, the 
curve demonstrating an irregular rhythm and a 
hardly perceptible amplitude of the secondary wave- 
lets. 

Without any immediate injection 6 minutes after 
the start the pressure is just .2 cm. above normal 
and 1 mil injected produces a further drop and an 
irregular pulse curve, and the primary waves are 
not higher than .3 cm. in height and of irregular 
duration. Eight minutes after the onset of the 
experiment the pressure shows no improvement, just 
as if no further action of the drug could be ex- 
pected. One mil of the fluid injected gradually is 
succeeded by an irregular, verj' accentuated curve, 
in which arrhythmia and extrasystole are suggested. 
Within 10 minutes after the beginning of the ex- 
periment the pressure curve registered a very low 
level, 56 mm. or 83 mm. below normal. One mil of 
test solution introduced results in a very rapid de- 
cline and no more secondary wavelets being en- 
countered the animal succumbs a few seconds later. 
Thirteen mils being the lethal dose for the animal 
weighing 3.13 kg., or per kg. of animal weight, or 
corresponding to .004153 gram of untreated digi- 
talin, with a treatment hardly exceeding 10 minutes. 

In the animals which were injected with a solu- 
tion of digitalin — Merck — which was subjected to 
the passage of high frequency waves the following 
pulse curves were obtained: 

Test animal, cat, weight 2.65 kg., male, test solu- 
tion 1 mil, corresponding to 0.001 gram digitalin, 
subjected to the high frequency waves, in normal 
saline solution — animal kept under ether anesthesia 
and tracheotomized. Experiment started on March 
28, 1917, at 11.03 a. m. Mercury pressure for 3 
minutes 155 mm., primary waves measure .25 — .3 
cm. in height, and consist of small crescendo and 
decrescendo wavelets, with an elevation of about 1 
cm. After injection of the first 2 mils of digitalin 
solution into the femoral vein an immediate rise of 
.7 cm. is noticed, followed by a deeper depression 
and a steady ascent of the curve, with more pro- 
nounced primary waves and a longer amplitude of 
the secondary wavelets, measuring .2 cm. Three 
minutes after the beginning of the experiment the 
pressure is found at 182 mm. or 27 mm. higher. 
With an injection of 2 more mils the short rise is 
succeeded by a greater descent of the curve, which 
rises to a higher level, registering 186 mm., or 31 
mm. more than at beginning of experiment. After 
another introduction of 2 mils a slightly more pro- 
nounced drop in the curve is noticeable, which then 
ascends to a higher level, while the primary and 
secondary wavelets show a higher amplitude. Three 
minutes after the injection the pressure has reached 
191 mm., or 36 mm. above the normal reading?. 



The next dose of 2 mils injected coincides with 
a rise and a more accentuated drop of the pressure 
curve, succeeded by a lessened ascent, less marked 
primary waves and secondary wavelets of higher 
amplitude, measuring from .35 — .4 cm., alternating 
with lower ones, which gradually lead to a lower 
pressure of 183 mm., or 28 mm. above normal at the 
beginning of the fourth minute. The fifth dose of 
2 mils solution injected presents, after a small 
initial rise, a steady depression, an incomplete at- 
tempt to restoration and a smaller amplitude of the 
secondary wavelets measuring .2 cm. Five minutes 
after the first injection, the pressure curve regis- 
tering 176 mm., or 21 mm. above normal, without 
any further injection, the primary waves became 
irregular and the secondary wavelets were fur- 
ther reduced to .1 — .2 cm. 

With six minutes' observation the pressure was at 
175 mm., 20 mm. above the normal. One mil digi- 
talin solution being injected the depression in the 
curve becomes more noticeable, also the primary 
waves are less marked, longer in duration, and very 
small secondary wavelets are encountered and only 
a slight increase of the pressure — 22 mm. above 
normal — is noticed with 8 minutes' test. One mil 
injected results in a drop of the pressure curve, 
which slowly is compensated, the primary waves 
are less pronounced and the secondary wavelets 
again are very small. Ten minute pressure read- 
ing shows no difference in the former reading, and 
1 mil more injected into the femoral vein results in 
a depression of similar depth as noticed before, with 
flattened primary waves, quite irregular in their 
registration. 

Though with 12 minutes we notice a pressure of 
185 mm., or 30 mm. in excess of the normal, the 
further dose of 1 mil coincides with a more ac- 
centuated drop of the primary waves and a decided 
irregularity in the height and succession of the 
same, with secondary wavelets barely noticeable. 
With 14 minutes the pressure reads 181 mm., or 26 
mm. in excess of the normal figures. One mil of 
solution being injected the following drop of the 
curve is not restored to the former level, the irreg- 
ularity of the primary waves, as to their height and 
succession, is still more noticeable. Sixteen min- 
utes after the first injection the pressure has fallen 
to 120 mm., or found 35 mm. below the normal. The 
next dose of 1 mil, with a very irregular tracing, 
reveals only primary waves and 18 minutes' read- 
ing shows a pressure of only 80 mm., or 75 mm. be- 
low normal, when the last dose of 1 mil given re- 
sults in the death of the animal 15 seconds after- 
wards. The lethal dose of the test animal found as 
16 mils or 16 mg. of digitalin previously treated 
with high frequency current for 1 kg. of the weight 
of the cat would correspond to 0.00603 gram of the 
treated drug, acting over a period of 18 minutes. 

Before entering upon the results of this experi- 
ment another instance may be given of a female 
cat weighing 2.24 kg. treated on March 28 in an 
identical way. Experiment begun on the etherized 
and tracheotomized animal at 2.57 p. m. Normal 
pressure for the first 3 minutes 87 mm., the height 
of the primary waves being .6 cm., the height of 
the secondary wavelets measured .2 cm. The first 
dose of 2 mils of the activated digitalin solution 
corresponding to 0.001 gram of digitalin in normal 



16 



MEDICAL RECORD. 



[July 6, 1918 



saline solution, injected into the femoral vein caused 
a primary fall in the pressure curve, but was 
quickly followed by a rise to 113 mm. pressure or 
26 mm. above the normal average in the first min- 
ute. The repetition of the .same dose showed less 
marked primary waves, but a greater amplitude of 
the secondary wavelets, amounting to .4 cm. ampli- 
tude, the pressure curve at the end of the second 
minute having reached 125 mm. or 38 mm. above 
normal. The following pressure readings are ob- 
tained after 2 mils were injected up to the fourth 
minute. Third minute 131 mm., or 44 mm. above 
normal, and fourth minute 137 mm. or 50 mm. 
above normal. The primary waves are hardly no- 
ticed, the secondary wavelets become very marked 
by their amplitude of 5 mm. Five minutes after 
the first injection the pressure is found at 139 mm. 
or 52 mm. above normal. 

The first indication of irregular waves is no- 
ticed, and the next injection of 1 mil is given within 
6 minutes after the pressure had dropped to 44 mm. 
above the normal line. Irregularity of the primary 
waves and the small amplitude of the secondary 
wavelets was noticed, but still the ascent of the 
pressure curve to 138 mm. or 51 mm. above normal 
is conspicuous 8 minutes after the treatment was 
started. 

The pressure readings are taken every 2 min- 
utes and at the end of these notations 1 more 
mil of the test solution was injected. The varying 
length and the irregularity of the waves in their 
succession will be noticed, the secondai-y wavelets 
becoming smaller and hardly noticeable. The 
pressure readings at 10 minutes are recorded at 
149 mm. or 62 mm. above normal; at 12 minutes, 
173 mm. or 86 mm. in excess, the maximum being 
reached within 14 minutes, 191 mm. or 104 mm. 
above the normal level. The irregularity in rhythm 
and the tendency to drop occurring at that moment 
leads to a decided drop in the 16th minute, namely 
to 161 mm., being still 74 mm. in excess of the 
normal, and in the 17th minute with a pressure of 
only 55 mm., or 32 mm. less than normal the ani- 
mal expires. 

The lethal dose for this animal was found to be 

16 mils of the solution, corresponding to .016 gram 
of activated digitalin, or calculated per kilogram of 
animal weight 0.00714 gram of digitalin acting for 

17 minutes. 

A comparison of the results with untreated and 
activated digitalin powder as recorded above may 
show the following possibilities, although we must 
bear in mind the individual differences in the ani- 
mals used for comparison. 

In taking control animal 1 the maximum pressure 
was reached in 6 minutes offer the observation was 
begun or 2 minutes after the first injection, 
amounting to 197 mm. or 34 mm. above normal 
with only a slight difference in pressure after 
4 minutes and after 8 mils of test fiuid had been 
given. 

Control animal 2 has reached its maximum pres- 
sure of 16G mm. or 27 mm. above the normal level 
in 2 minutes when 4 mils of the teat solution had 
been administered and remained unchanged after 
the following dose. 

For animal 3 receiving the activated digitalin' 
product the maximum pressure was reached, namely 



191 mm. or 36 mm. in excess of the normal 3 min- 
utes after the first injection, and after the incor- 
poration of 6 mils of test fluid, which result com- 
pares favorably with animal 2. 

Test animal 4 has reached its maximum pressure 
14 minutes after the first injection was given, show- 
ing an excess pressure of 104 mm., exceeding all 
previous observations. It will be noticed that al- 
ready, in the second minute after the first injection 
with 4 mils te.=t fluid was given, the rise in pressure 
is more marked than compared with the control 
animals. 

From a perusal of the tracings we may learn that 
in the control animals the amplitude of the second- 
ary wavelets diminishes more rapidly in height and 
occurs at an earlier moment than in the tracings 
referring to the instances when activated digitalin 
was given. Coincident with this fact we have ob- 
served an irregularity in the primary and secondary 
waves. 

With reference to the toxicity of the genuine and 
activated digitalin products, it will be of interest 
to call attention to the difference revealed by the 
foregoing experiments. 

Control animal No. 1 was killed in 22 minutes 
by a dose of 0.00428 gram; No. 2, in 10 minutes 
by 0.0041.53 gram; No. 3, in 18 minutes by 0.00603 
gram, and No. 4 in 17 minutes by 0.00714 gram 
of activated digitalin powder, and such differences 
would suggest that the crude product is more toxic 
than the activated powder. 

In the accompanying chart, containing also ex- 
periments with a solution of digitalin in the usual 
strength and then exposed to the high frequency 
waves, these differences in the physiological action 
are recapitulated. The full line indicating the 
activated powder shows, in comparison to the crude 
digitalin powder, that a higher blood pressure is to 
be expected which remains a longer period above 
the normal level at a time when the crude digitalin 
already presents its detrimental effects. 

In presenting this .study of digitalis remedies to 
the public, I am aware that more work has to be 
done to determine the physical and chemical changes 
which take place in these complex compounds, but 
as a preliminary communication, the subject ap- 
pears to me of great interest. 

Clinically speaking a few observations would 
suggest that cases of myocardial degeneration can 
be favorably influenced by subjecting cardiovascular 
remedies to the influence of the Herziaii waves," or 
by giving such cases a combination treatment of 
pharmaceutical remedies in addition to electric 
wave applications. From the chemical standpoint 
the proposition of changing the qualities of an or- 
ganic substance by the exposure to electric waves 
is of interest, since my experiments have taught 
me that organic compounds are more susceptible to 
the action of wave energy, a conception which has 
been gained by experiments with ultraviolet light 
acting upon benzoic acid and iron compounds chang- 
ing the first into salicylic acid (Neuberg").' 

REFERKNCES. 

1. Zueblin, E.: Medical Record, March 2, 1918. 

2. Zueblin. E.: The Lancet Clinic. Nov. 11, 1916. 

3. Wagner, K. Allftcm. mcrfi-. Central-Zeituiuj. 
1913, No. 5, 6, quot. Neuberg. 

Prick Hill. 



July 6, 1918] 



MEDICAL RECORD. 



17 



VACCINE DOSAGE IN THE ELIMINATION OF 

THE SYSTEMIC EFFECTS OF MOUTH 

INFECTION.* 

1 Br JOSEPH HEAD, M,D., D.D.S., 

PHILADELPHIA, PA. 

\'accine dosage is a problem that is being solved 
by accredited clinicians in a manner that theoret- 
ically might seem to altogether discredit vaccine 
therapy as a science. Initial doses of 500 million 
are given on the one hand, while other practitioners 
find that doses of one one-thousandth or even one 
ten-thousandth of these quantities gives satisfac- 
tory therapeutic results. 

One cannot help feeling that the state of knowl- 
edge concerning the routine administration of vac- 
cines is about the same as that held formerly in the 
routine administration of calomel or quinine, when 
these were first discovered and administered as 
drugs. Ten to fifteen grain doses of calomel were 
given, frequently with good therapeutic results, and 
then again salivation sometimes occurred under 
such dosage with permanent injury. In the same 
way quinine was frequently administered in fifty 
or sixty grain doses. When the patient was not 
sensitive to quinine unqualified good results were 
obtained, but when there was an idiosyncrasy dis- 
astrous if not fatal effects were encountered. 

Some seven years ago when I began the treatment 
of my patients with vaccines I also used large doses. 
I gave myself experimentally forty-two weekly doses 
of vaccine, thirty-two of which each contained 1100 
million mixed germs. The results were excellent. 
But during the first four or five years of my experi- 
ence in this treatment I encountered very occasion- 
ally reactions in my patients so serious that at times 
I wondered whether the anxiety and worry occa- 
sioned made the treatment worth while. However, 
such satisfactory cures were obtained in 90 per 
cent, of the cases without any bad symptoms at all 
developing that there was more than sufficient en- 
couragement to continue the treatment. Never- 
theless, the result of my experience steadily 
impelled me to use smaller doses, so that instead of 
starting with a minimum dose of twelve to twenty- 
five million germs, or even fifty million, if the 
vaccine consists of four or five different species, I 
now start with doses of thirty thousand, and in 
some very exceptional cases this dose has to be 
reduced instead of increased. I believe that in a 
certain percentage of cases it will prove harmful 
to give a first dose of five to ten million germs until 
the tolerance of the patient is carefully ascertained. 
I do not desire to have an intense reaction as shown 
by depression, fever, acute or local inflammation, 
or marked variations in the blood pressure. I wish 
just to avoid these symptoms, and by so doing obtain 
better therapeutic results. 

I am well aware of the incredulity that will be 
aroused by this statement since it is largely, if not 
entirely, based on clinical experience, but a little 
consideration may well show that it is not so pre- 
posterous as it may first appear. Webb has found 
that one or two tubercle bacilli when injected hypo- 
dermically are capable of giving excellent clinical 
results, and Myer Solis-Cohen, Archives of Pedi- 

*Read before the American Association of Immunol- 
ogists, March 30, 1918. 



atrics, January, 1918, has shown that one ten-mil- 
lionth of a milligram of tuberculin residue may be 
an effective dose. If this is so, why then should 
the tubercle bacillus be absolutely in a class apart 
from all of the other organisms that infect the 
body? I have been growing cultures anserobically 
from material taken from the tips of extracted 
teeth. Formerly aerobic cultures alone were used 
but by the anserobic cultivation we appear to have 
discovered a new Gram-negative coccobacillus that 
is associated with the absorption of root tips, which 
germ seems to have extreme virulence and toxicity. 
And, as just stated, this new germ may partly but 
not entirely account for the reactions that occa- 
sioned the reduction in dosage. 

It is claimed by many observers that certain peo- 
ple cannot advantageously take vaccine. This state- 
ment, when applied to autogenous vaccines, seems 
illogical, for, as a matter of fact, the patient by 
the mere presence of the disease has already taken 
the germs in a living state. I believe that any 
patient suffering from a localized infection can 
safely and usually beneficially take an autogenous 
vaccine prepared from the localized infection, if a 
judicious dosage is employed. And so again we 
come back to the question of dosage. The determi- 
nation of the size of the dose depends primarily or 
the interpretation of what constitutes a preliminary 
reaction, and this interpretation is dependent upon 
a nice discrimination. 

Seven or eight years ago the general procedure 
was to start treating a so-called normal patient with 
12 to 25 million germs. If the patient showed de- 
pression or fever that did not last twelve hours the 
dose was doubled, and after a while it was again 
doubled, and doubled again, until incredibly large 
doses were given, the patient each time getting a 
terrific therapeutic bump. If the patient didn't get 
a bump the dose was increased, and if he did get 
a bump the dose was also increased, because it was 
noted by many authors and clinicians that those 
patients who had the worst reactions made the best 
recoveries. And so the rather loose philosophy of 
vaccine dosage seemed to be, "Give the patient small 
doses at first and increase them so as not to have 
too great a reaction, but if the patient does have 
too great reaction he will have a better recovery." 
Either way it's all right, and, strange to say, this 
vague unphilosophical theory of dosage seems ordi- 
narily to have worked out very well. 

The large doses administered gave good results 
and still do give good results in a great majority 
of cases but in a small though important percentage 
of cases they still do harm, and as the unfortunate 
results always make a greater impression than the 
good results it was not surprising that many physi- 
cians gave up the use of vaccines altogether. Many 
thousands of physicians were getting such good re- 
sults, however, that the despairing cries from some 
esteemed leaders were not sufficiently conclusive to 
make them discard vaccines. Many of us felt too 
sure of the value of the treatment to be stampeded 
by crudities that must of necessity be remedied in 
the near future. 

In my opinion there must be more investigation 
into the effect of small doses of vaccine. I still 
give my patients doses of one hundred and fifty 
million to three hundred million germs, but I in- 



18 



MEDICAL RECORD. 



[July 6, 1918 



variably start with a small dose. I believe the 
average patient with his various latent infections 
is very much in the position of a many chambered 
magazine containing powder that must be touched 
off without blowing out the sides of the building. 
If each room of the magazine has small quantities 
of powder in it and the powder is slightly damp or 
slow burning the task is comparatively simple and 
one room at a time can be safely fired by a judicious 
explosive charge, but if there are an infinite num- 
ber of compartments each full of explosive, and 
instead of slow-burning powder we have dynamite 
the difficulty is greatly increased and a much 
greater caution in the size of the explosive charge 
should be used. 

I propose to recite briefly a few cases that have 
reacted in an astonishing way to small vaccine 
doses. There are many other cases that I could 
quote that unmistakably responded clinically to 
small doses but a mere piling up of cases would be 
tedious and unconvincing. 

The first case was a man, aged 40, who had gouty 
deposits in the ears, crepitus and pains in the knee- 
joints, associated with sharp pains along the ten- 
dons of the thighs and legs whenever he walked — 
a typical case of systemic infection from diseased 
teeth and gums. The infected teeth were extracted 
and an autogenous vaccine was made. The first dose 
of 150 thousand germs made him uncomfortable, 
the second dose, a week later, of 210 thousand 
germs sent him to bed with inflammatory fever, 
painful joints, and swollen ears. After two weeks 
when the symptoms subsided a dose of 30 thousand 
germs was given that made his ears swell a little, 
but the dose was well borne. For four weekly in- 
tervals he was given 30 thousand germs, with 
marked improvement. Then he was given GO thou- 
sand germs and promptly went to bed again, this 
time for only two days. Then 30 thousand germs 
were given at weekly intervals for six times and he 
made a most satisfactory recovery. 

There are numerous cases where the patient 
showed marked improvement and also marked sys- 
temic reaction to weekly doses of 6 to 15 thousand 
germs, but I shall only mention one — that of a 
married woman, aged 36, of the systemic inflam- 
matory type. Teeth sensitive to heat and cold, re- 
sisting all treatment. When she came for treatment 
she had just weaned her baby. The first dose of 
thirty thousand germs caused her breasts to become 
painful and to swell. There was also a vaginal dis- 
charge and she was depressed and ached all over. A 
week later she was given fifteen thousand germs 
with similar reactions but less marked, and these 
symptoms recurred seven times at weekly intervals, 
although the dose was reduced to nine thousand 
germs. The breast and vaginal reactions are par- 
ticularly interesting as they could not have been the 
result of neurasthenia or hysteria. Meantime she 
showed marked improvement and the teeth were 
successfully treated and filled in a manner thereto- 
fore quite impossible. 

The last case I shall mention is that of a woman, 
age, 62, who could not bear thirty thousand germs 
without a severe reaction but could stand fifteen 
thousand germs. Finally I tried sixty thousand 
germs as a test, and she had great depression and 
lymphatic enlargement especially in the groins. For 



two days she was so weak that she required cardiac 
stimulants. 

In closing this paper it might be well to state 
my present method of ascertaining the proper vac- 
cine dose. Thirty thousand germs are given at the 
start and raised by weekly doses so long as the 
patient bears the dose well, even if the dose goes up 
to a billion. However, when the patient is showing 
satisfactory improvement under a dose, that dose 
is maintained. If thirty thousand germs are not 
accepted easily the dose should be reduced to a num- 
ber that are easily accepted. It is also especially 
important that the patient should be carefully 
watched for reactions. 

When grip and colds are prevalent the patient 
who is given a dose that cannot readily be borne is 
apt to get sore throat or grip. Such an attack must 
be regarded not as an unimportant, accidental sjTnp- 
tom, it should always be regarded as a possible re- 
action calling for dose reduction, and if the cold or 
grip should recur regularly with the vaccine admin- 
istration, its recurrence should be considered con- 
clusive evidence that the sore throat, cold or grip 
is a real reaction, calling for a corresponding modi- 
fication in dosage. 

It has been my experience that reactions occur in 
widely different forms and require most careful 
analysis on the part of the physician if the best 
results for the patient are to be obtained. It has 
also been my experience that large doses given at 
the start seem to mask a fine gradation of symptoms 
by which a just analysis of the patient's needs may 
be ascertained. Large doses may be accepted by 
the body because it is roused to combat a patho- 
logical assault, and being aroused, it protects itself 
and at the same time finds its energies exhausted, 
while the exactly ascertained dose that will just stop 
short of a reaction, philosophically may give the 
best therapeutic effect. 

My vaccines are standardized by Wright's method 
controlled by turbidity tests. 

Fifteenth and Locust Streets. 



Goats in War Time. — Goats have decided advantage 
over other animals because they can shift for them- 
selves. Even rabbits have to be provisioned. The goat 
costs practically nothing to keep and the return in 
meat, milk, etc., is highly advantageous. — La Presse 
Medicate. 

Action of Su^ar on the Bronchial Secretions. — San- 
martino having published the fact that injection of 1 
gram of saccharose increases the amount of milk in 
the nursing woman, Lo Monaco adds that in a sufferer 
from bronchial catarrh the same injection causes a 
rapid diminution in the secretions and eventually ar- 
rests them completely. In tuberculous and bronchiec- 
tasis cavities the result is less pronounced. Lo Monaio 
sees here a great advantage over the use of exp. r 
torants, which are bound to cause anorexia and digi vo- 
tive disorders. The patient also gains the caloric value 
of the injected sugar. Injections into the muscles are 
recommended, although these are somewhat painful. 
The action of the sugar is simple — that of a vaso-con- 
strictor. The author believes that in the earlier stages 
of tuberculosis sugar may exert a marked prophylactic 
action not only for the patient but for his entourage 
as well. — Rivifta Critica di CUnica Mcdica. 



July 6, 1918] 



MEDICAL RECORD. 



19 



iHilttarg iHfiitrinf, 

Epidemic Cerebrospinal Meningitis. — Surgeon 
A. G. L. Reade, R.X.V.R., writing in the Joui~nal of 
the Royal Sanitary Institute, February, 1918, says 
that previous to 1914 experience of cerebrospinal 
fever in Great Britain was mostly limited to 
sporadic cases and a few epidemics, the largest 
epidemic being in Glasgow in 1908. The unhy- 
gienic conditions, however, brought about by the 
mobilization and concentration of men in large 
naval military depots and camps favored an out- 
break of the disease in epidemic form. Reade 
deals with an outbreak at the naval barracks at 
Chatham, England, and suggests the following 
methods of prevention: (1) Increased sleeping ac- 
commodation is a matter of the first importance. 
It was found that under the stress of mobilization 
the cubic air per man had been greatly reduced, 
sometimes to 320 cubic feet. The men were there- 
fore thinned out by sleeping them in tents, drill 
shed, gj-mnasium, bowling alley, and gunnery 
school until more permanent tents were put up. 
These provided for the men to have, at least, 500 
cubic feet per man, and since 1914 this has never 
been reduced and is the minimum that should be 
allowed. The ventilation was improved and super- 
vised by frequent visits of a medical officer and a 
patrol of sick berth attendants during the night. 
(2) Disinfection. The room in which a case oc- 
curred was shut up, if possible, for two days. On 
the first day the windows, ventilators, fireplaces, 
etc., were closed up and formaldehyde vapor gen- 
erated for twelve hours. The room was then 
washed down with izal solution and left to air for 
twenty-four hours. Meanwhile the bags and ham- 
mocks were disinfected. (3) Isolation of con- 
tacts. All immediate contacts were sent to hos- 
pital for bacteriological examination and in ad- 
dition all men in the room were examined. 
(4) Frequent examination of men to detect car- 
riers. With a large number of men it is impossible 
to examine them all, but it is hoped that in a 
short time all men will have their naso-pharynx 
examined before they are sent on draft. (5) Spe- 
cial care of delicate new entries. All new entries, 
boy seamen, boy servants, and stokers, are ex- 
amined daily and any looking ill or anemic, or 
suffering from catarrh, are isolated in a special 
mess, are relieved from all duties, and generally 
cared for until their health improves. 

In the discussion that followed the reading of 
Surgeon Reade's paper Dr. Alfred Greenwood said 
that greater stress should be laid upon bad ventila- 
tion in favoring infection, than upon cubic space 
per ?e. He had met with many instances where 
it was clear that bad ventilation of huts, caused 

i through the deliberate blocking of ventilation 
openings by the soldiers, had been an important 

• predisposing cause in the spread of cerebrospinal 
meningitis. Among scores of carrier cases, proved 
positive by bacteriological tests, he had never 
found one to develop the disease subsequently. 
Referring to preventive measures he said that as 
the germ of the disease appeared to be easily 
killed it seemed unnecessary to adopt elaborate, 
e.xpensive methods of disinfection when a case 
had occurred, and a thorough wet cleaning of 



the room, with boiling of sheets, etc., would ap- 
pear to meet the circumstances satisfactorily. 

The Grave Form of Trench Foot. — In the 
Medicai Press, April 8, 1918, Dr. E. Chanvin ol' 
the French Army discusses the grave form of 
trench foot. With regard to treatment he sum- 
marizes as follows: Finally tetanus forms one of 
the classic complications of frost gangrene. It 
developed in one of his cases, in spite of two pre- 
ventive injections of serum. In presence of the 
array of serious complications, actual or prospec- 
tive, therapeutic practice requires to be very ener- 
getic. The use of cardiac tonics, camphorated oil, 
caffeine, sparteine, general tonics, alcohol, quinine 
extract, general antiseptics, local applications, 
antimycosic treatment, or use of hot air, all these 
are but methods of expectancy. The neuritic 
structures must be got rid of sooner or later. Is 
it well to wait for spontaneous separation, and 
then have recourse to an economic trimming of the 
wound, or is it better to amputate early and save 
the patient from the grave risks which always 
attend the most skilled expectant treatment? 

The ideal procedure would certainly be to await 
the separation of the eschar, while drying it up 
by application of hot air, and then embalming the 
part in pomades or antiseptic powders. After the 
separation to clean the stumps and asepticise it 
with appropriate dressings, and when we are at 
last in presence of a bone projecting from healthy 
soft tissues in a state of healthy granulation, to 
extirpate the projecting bone, and suture the 
edges of the wound. This is surely the method 
which enables us to preserve the maximum 
length of the affected limb, and it appears to us 
to be applicable in two groups of cases: (1) In 
those of congelation which are accompanied with 
grave general phenomena, but in which the 
sphacelus does not extend beyond the metatarsus. 
Here the tarsal articulations are intact. At the 
utmost, the tendons may infect their sheaths. 
There will be no deeply placed articular infection, 
and the maximum conservation of tissues can be 
secured, leaving the wound to be properly trimmed 
afterwards. (2) For the same reasons, this pro- 
cedure should be adopted in the "massive" lesions 
which involve the whole foot and necessitate a 
tibio astragaloid separation. The narrow sectional 
plane above the ankle joint presents little liability 
to infection. 

But in the intermediary types, where a groove of 
elimination has begun to form, a distant chopart 
or subastragaloid amputation should be promptly 
carried out; for temporization is, as previously 
said: (1) Dangerous. The separation of the gan- 
grened extremity by no means marks the termina- 
tion of the infective phenomena, and a grave sep- 
ticemia may carry off the patient. Any or all of 
the complications already indicated are liable to 
appear. (2'> Useless; the sole argument for its 
adoption being the prospect of securing a longer 
limb. But a secondary amputation, which is the 
form most frequently demanded in a highly in- 
fected case, must be carried out at a verj' high 
level on account of the propagation of purulent 
foci. On the other hand, on account of the prog- 
ress of prothesis amputations of the leg are now 
preferred by a large school of surgeons to any of 



20 



MEDICAL RECORD. 



[July 6. 1918 



the various disarticulations. Finally, early ampu- 
tation, on the fourth or fifth day, as soon as the 
spachelus has become clearly defined, is as econ- 
omic as the most ob.stinate and fortunate tempori- 
zation; for it enables us to exterminate the dead 
tissues completely before the appearance of any 
secondary phenomena. Personally, Chauvain 
says, in their practice they have adopted early 
amputation in their later cases, after the disap- 
pointing e.xperience of their first tentatives in 
conservatism. They have performed amputations 
of the leg, according to the extent and disposition 
of the lesions, either with an internal flap or, 
more frequently, a posterior one, reaching to a 
variable distance above the heel. A circular am- 
putation, with reunion of the edges is often made 
necessary by the gravity of the local infection and 
enables the avoidance of operation at too high a 
level. 

Bouchon's First Dressing. — Bouchon of the 
French medical corps contributes a brief article 
on his method of wound treatment to the Journal 
de Medecine et de chirurgie pratiques for March 
25. He devised the technique two years before 
the war and described it at the London Interna- 
tional Congress in 1913. It is adapted to recent 
wounds and amputation stumps and is practised 
only at the front. The wounded are then trans- 
ported to a base hospital and on the fourth day, 
when the dressing is removed, the wound should 
be found clean and the patient without fever. 
The wounded man may be dressed in the trench, 
on the stretcher, or in the subterranean dressing 
station. In these advanced localities there is no 
opportunity for asepsis. The substance used for 
antisepsis and hemostasis is a solution of formol 
in alcohol and ether. One liter of equal parts of 
the two solvents contains 30 c.c. of 40 per cent, 
commercial formol and 3 gm. of methylene blue. 
Applied directly to the raw surface this solution 
is a powerful hemostatic and antiseptic. The dark 
clot which forms is not molested and behaves 
somewhat like an application of collodion. A 
compress soaked in the same solution is now ap- 
plied and adheres intimately to the subjacent tis- 
sues; it is allowed to remain from three to six 
days. The method seems to be intended especially 
for amputation stumps in which suturing is not 
practised. 

Antidysentery Inoculation. — Prophylactic inoc- 
ulation against bacillary dysentery has, at last, 
promised to become a practical proposition. The 
organisms responsible for the disease known by 
this name are several and the difficulty has been 
to confer immunity against all these. The two 
main bacilli, those of Shiga and Flexner, have, 
however, furnished a vaccine, which in the hands 
of Captain H. G. Gibson, has given promising re- 
sults. Neutralization of the toxins by means of 
eusol was unsatisfactory, it being found that such 
vaccine became toxic on keeping, due to the break- 
ing down of the bacilli. Sensitized vaccines did 
not prove very satisfactory, as they failed to stim- 
ulate sufficiently the elaboration of protective sub- 
stances. Gibson, thinking that the defect was due 
to antibacterial substances of the serum employed, 
which rendered the bacteria inert as antigens, 
absorbed these substances from the serum and 



administered the vaccine with this absorbed 
serum. Such vaccines produce little or no re- 
action and have been proved to develop protective 
substances in the blood. Trials are now being 
made in the field and it is hoped that these will be 
successful. — The Prescriber, April, 1918. 



Canadian Hospital Bombed. — A despatch from 

London reports that on the night of June 24 the 
Germans bombed a Canadian Hospital and killed 
doctors, nurses, and patients. The Canadians have 
occupied the hospital for more than eighteen 
months. The roofs were painted with great red 
crosses and the buildings have never been used 
for military purposes. One operating staff, in- 
cluding the nurses, was buried under a mass of 
debris and in a few minutes the whole operating 
section was in flames. Bursting tubes of ether 
and hydrogen added to the horror of the scene. 
Two other surgical teams narrowly escaped, hav- 
ing just left a few minutes before to go to their 
midnight supper. 

Big United States Hospital in England. — Work 
has been begun on what will be the largest mili- 
tary hospital in Great Britain. It is located near 
Southampton and will accommodate 3,000. The 
site is a country estate of 200 acres which the 
Red Cross has purchased. It plans to erect nearly 
ten acres of buildings. The contract provides for 
the opening of 400 beds within six weeks. 

Fox Hills Hospital Ready.— The United State^^ 
Base Hospital at Fox Hills, Staten Island, was 
completed on June 26. Eighty-six buildings have 
been constructed in 100 days. There are three 
large wards in the large buildings which contain 
1,000 beds each. The transports will land their 
patients at Quarantine and they will then be taken 
to the hospital by motor ambulances. In connec- 
tion with the hospital the Red Cross has built u 
theatre that will seat 7,200 persons. It is planned 
to have entertainment for the wounded soldiers 
and sailors every afternoon and evening. The 
Government has acquired fifteen acres of land ad- 
joining the present site so that the capacity of 
the hospital can be doubled at any time. 

Army Has Enough Dentists. — The War Depart- 
ment has authorized the statement that the dental 
requirements of an army of more than 5,000,000 
men can now be met by the present force of the 
Dental Corps of the American Army. Examina- 
tions for dental officers have been closed and no 
more will be needed for at least six months. At 
the time that the United States declared that a 
state of war existed between this countr>" and 
Germany, the total number of dental officers was 
.58. The present force now numbers 5,810. Com- 
missions were offered to 5,467 dentists in all parts 
of the country and 95.1 per cent, were accepted, 
which speaks well for the patriotism of the dental 
profession. The Preparedness League of Ameri- 
can Dentists which a year ago had a membership 
of 5,000 to-day has 15,000 members. This organi- 
zation has been largely responsible for three den- 
tal ambulances that have been presented to the 
Surgeon General of the Army. 

Army School of Nursing Endorsed by General 
Medical Board. — The committee on nursing of the 
General Medical Board has given its hearty sup- 



July 6, 1918] 



MEDICAL RECORD. 



21 



port to the project of the Army School of Nursing 
and the facilities at the command of the commit- 
tee will be used in a recruiting campaign to se- 
cure suitable candidates for the school. The 
plan of the Army School of Nursing will be based 
on the methods that have been found to insure 
the best care of the sick in civil life. The stand- 
ard will be that of high class nursing schools, 
such as Johns Hopkins, the Peter Bent Brigham, 
the Lakeside of Cleveland, the Presbyterian, St. 
Luke's, etc. The plan provides that the head- 
quarters of the school will be in the Surgeon 
General's office and the course of training will be 
given in the various base hospitals assigned as 
training camps, each one of which is to be a com- 
plete unit. The plan provides that the course 
leading to a diploma is to extend over three years. 
The experience in the military hospitals is to pro- 
vide surgical nursing, including orthopedic, eye, 
ear, nose, and throat, and medical nursing. Ex- 
perience in children's diseases, gynecology, ob- 
stetrics, and public health nursing is provided 
through affiliations with civil hospitals and visit- 
ing nursing organizations. It is expected that 
schools will be opened early in July at Camp 
Devens and Camp Wadsworth. 

President Wilson Signs Rehabilitation Bill. — 
The bill providing for the vocational rehabilitation 
and return to civil employment of disabled sol- 
diers and sailors has been signed by President 
Wilson. 

Homes Offered as First Aid Hospitals. — At a 
committee meeting of the emergency unit of Har- 
lem, New York City, on June 25, it was learned 
that H. C. Frick, George J. Gould, and S. Lewisohn 
have offered their homes to the Police Depart- 
ment as first aid hospitals in the event of an air 
raid or other emergency. The emergency unit is 
composed of physicians who are training to be 
prepared to give aid in case of emergency and are 
instructing those desiring to take lessons in first 
aid treatment. 

Praise for Poets' Ambulance. — Arnaldo Fracco- 
roli, correspondent of the Corriere della Sera of 
Milan, writing from the Piave battle front, says 
that one of the most admirable episodes he has wit- 
nessed was the work of the ambulances inscribed 
"The gift of American poets." He says, "The 
courage of these young Americans doing their 
duty among the intense shell fire, this is indeed 
authentic living poetry." 

Dr. J. Breckinridge Bayne of Washington, who 
was believed to be dead, is in a German prison 
camp. Dr. Bayne was serving with the British 
Red Cross in Roumania and when the Germans 
invaded that country and the rest of the hospital 
staff fled he remained behind to attend to the 
wounded and was taken prisoner by the Germans. 

Americans in Fine Physical Condition. — At the 
weekly War Department Conference on May 25 
members of the House Military Committee were 
told that the soldiers of the American Expedition- 
ary Forces were freer from disease than the other 
armies and the troops training at home. 

Dr. George F. Nicolai, formerly professor of 
pathology at the Berlin University and the author 
of a book denouncing Prussian Militarism for 
which he was punished by imprisonment, escaped 



from Germany in an airplane and landed safely in 
Denmark on June 24. 

Mount Sinai Unit at the French Front. — The 
Mount Sinai Hospital Unit, designated as United 
States Base Hospital No. 3, has been established 
in a monastery near the front. On its staff are 
26 officers, 65 nurses, 150 enlisted men, and sev- 
eral untrained women. The hospital has accom- 
modation for about 1,500 patients. The surgical 
supplies are provided by Mount Sinai Hospital 
and the American Red Cross. The chief officers of 
the hospital are: Major Michael A. Dailey, com- 
manding; Major George Baehr, Major Howard 
Lilienthal, Major Herbert L. Celler, Major Ed- 
win Beer, and Major Walter M. Brickner. 

Park and Tilford Donate Paris Offices. — The ar- 
rival of increased numbers of troops in France 
has created a need for greater hospital facilities. 
To assist in meeting this need Park & Tilford have 
donated their Paris offices to be used as war hos- 
pitals and for other war purposes. 

Catholic War Council Builds Hospital. — Plans 
have been completed for the construction of a 
$300,000 hospital in Manhattan for soldiers and 
sailors by the National Catholic War Council. 
The site has been selected and arrangements made 
for the remodeling of one building and the erec- 
tion of another. The hospital will have 500 beds, 
and immediately upon completion will be turned 
over to the Government to be used in whatever 
way the War Department deems best. 

Give Home for Navy Hospital. — Commodore and 
Mrs. Morton F. Plant of Eastern Point, Conn., 
have given their large country home, the Watson 
House, to be used as a hospital for convalescent 
soldiers and sailors. The use of the residence is 
accompanied by a gift of 310,000 for its equip- 
ment. 

Camp Upton Base Hospital Issues Publication. — 
The enlisted personnel of the Medical Department 
of Camp Upton are editing and publishing a four- 
page news issue under the title of "The Cure.'' 
It is "published in the interests of the base hos- 
pital rather often" with the "largest high grade 
hospital circulation in Camp Upton." 

Osteopaths Not Admitted to the Medical Serv- 
ice. — At a meeting of the American Osteopathic 
Association in Boston, on Monday of this week, 
the president made a vigorous protest against the 
report made by the Surgeon General's Office to the 
Military Affairs Committee of Congress adverse to 
the acceptance of drugless healers in the Medical 
Corps of the army. He quoted from this report as 
follows: "The admission of osteopath physicians 
as such, and without the degree doctor of medicine, 
to the Medical Corps would have practically unani- 
mous opposition of the medical profession of this 
country and of all allied countries; would be re- 
garded, and justly so, as lowering the standards, 
educational and professional, of our Medical Corps, 
and would have a discouraging and detrimental ef- 
fect upon efforts to secure physicians for the corps, 
both now and in future, and upon the general morale 
of the corps." It certainly is difficult to imagine 
how an osteopathic practitioner, who is forbidden 
by the license law to give drugs, could treat the 
wounded at the front or those ill with trench fever. 
or the like. 



22 



MEDICAL RECORD. 



[July 6, 191? 



Medical Record. 

A Weekly Journal of Medicine and Surgery. 



THOMAS L. STEDMAN, A.M., M.D., Editor. 



PUBLISHERS 
WM. WOOD & CO.. 51 FIFTH AVENUE. 



See fourth page following reading matter for Rates of Subscription 
and Information for Contributors and Subscribers. 



New York, July 6, I9I8. 



THE PATHOLOGY OF THE CARDIAC LIVER 
IN PULMONARY TUBERCULOSIS. 

If there is a well-established fact in relation to the 
tuberculous heart, it is certainly cardiac atrophy 
going hand in hand with the general emaciation. 
Whatever theories may be brought forward to ex- 
plain the small size of the heart in phthisical sub- 
jects, it is, nevertheless, an established fact that 
the cardiac atrophy involves the entire muscle, and 
it may very well be that this general emaciation of 
the heart is the reason why the most trifling causes, 
acting on the weakened myocardium, result in dila- 
tation of the organ. In cases in which the right 
heart gives way under pressure from the obstacle, 
the right ventricle is flattened and somewhat soft- 
ened, and although the tricuspid valve is not in- 
volved in its integrity the auriculoventricular orifice 
is frequently dilated and insufficient. 

Hypertrophy of the heart is met with in fibrous 
phthisis, particularly mitral stenosis, in chronic tu- 
berculous interstitial nephritis, and when there is 
emphysema or pleural adhesion resulting in an in- 
crease of the heart work from respiratory difficulty. 
Under the term suprarenal asystolia Josue and 
Belloir have described a syndrome characterized by 
a considerable hypertrophy of the heart and a per- 
manent drop in the maximum and minimum blood 
pressure. In these circumstances the liver was 
found to be of the nutmeg type and the suprarenal 
glands small, and markedly sclerosed, with tubercles 
in the apices, either cicatrized or undergoing evolu- 
tion. It may be supposed that the suprarenal gland, 
after having undergone an exaggerated secretory 
function necessitated by the cardiac hypertrophy, 
finally gives out functionally, and there is likewise 
the possibility of direct action of the tuberculous 
process. 

A number of writers admit the possibility of 
sclerosis of the myocardium during fibrous phthisis, 
due to the action of the tuberculous toxin, while 
fatty overcharge is quite as common. No matter 
Avhat factor ia in play, when hypertrophy follows 
dilatation of the right ventricle this is merely a 
transitory phase in the process, and when compen- 
sation does not take place dilatation of the right 
auricle and tricuspid insufficiency ensue. In other 



words, cardiac hypertrophy is the defense of the 
heart against obstacles; secondarj' dilatation indi- 
cates the impotency of the organ. This impotency 
reach es i ts maximum in tuberculous cardiac sym- 
physis. Not only does the heart not increase in size, 
but it may even undergo atrophy. This process may 
occur without cardiac symphysis. 

The explanations which have been ofTered for the 
small size of the heart in cardiac symphysis, in . 
opposition to the production of pancarditis in rheu- 
matismal symphysis, is the rarity of the coincidence 
of tuberculous endocarditis with symphysis, the slow 
evolution, the absence of myocarditic reaction, and 
the torpid inflammatory reactions in the surround- 
ing structures. However, fibrocaseous or caseous 
nodules may be detected in the midst of the fibrous 
tissue; likewise gray granulations in the external 
leaf of the pericardium. 

The external surface of the pericardium may ad- 
here to the sternum and neighboring ribs, while 
adhesions may form between the mediastinal pleura 
and pericardium. The mediastinum may be trans- 
formed into a fibrous shell, in which case caseous 
lymph nodes will be found in the region of the 
hilum which have unquestionably played a part in 
the production of the surrounding fibrous tissue. 
On the other hand, the distribution of the neighbor- 
ing fibrous tissue, that of the pericardial adhesions, 
is very variable, and for this very reason it is quite 
evident that one cannot give to cardiac symphysis 
a settled nosological value. 

A cardiac liver in pulmonary tuberculosis has 
been merely mentioned as a possibility in fibrous 
phthisis. Nutmeg liver has been found in perhaps 
1 per cent, of the cases. But the very special inter- 
est of a cardiac liver in tuberculosis is that it is 
accompanied by either fatty degeneration or cir- 
rhosis. When the steatosis is slight it isolates the 
islands of localized blood stasis around the supra- 
hepatic veins. 

At the autopsy of tuberculous subjects no macro- 
scopic hepatic lesion may be found, but in other 
cases, and these are the more frequent, the gen- 
eral aspect is that of a fatty liver. Occasionally, 
the viscus assumes a congested aspect, or one may 
find red islands of suprahepatic stasis, as in the 
nutmeg liver, which are here very distinct against 
the pale and yellowish background offered by a state 
of steatosis of the parenchj-ma. 

But there are instances where the hypertrophy 
and congestion were marked, and on section of the 
hepatic gland the blood flowed out as in a tjTJical 
cardiac liver \vhere the fatty degeneration was so 
discrete that it was found only microscopically. 
This mixed condition of degeneration and conges- 
tion may be met with even in cases of tuberculous 
cardiac symphysis. But sclerosis may also be met 
with in these circumstances, and then it becomes 
the cardiotuberculous cirrhosis of Hutinel. The 
liver is hypertrophied and hard; it offers the nut- 
meg aspect, and upon section fibrous trabeculse, 
sometimes visible to the naked eye, and decolorized 
areas corresponding to the steatosis, may be seen. 



July 6, 1918] 



MEDICAL RECORD. 



23 



Histologically, islands of sclerosis around the su- 
prahepatic veins and portal spaces are found, along 
with tuberculous follicles and fatty degeneration. 
And still more, perihepatitis, ascites, and various 
tuberculous peritoneal processes, are present. 



INDUSTRIAL HEAT HAZARDS. 

The present day development of industries on a 
large scale has naturally created conditions of haz- 
ard which there has not been time yet either to 
study or to correct. That excessive heat produced 
in certain industries reacted badly upon the workers 
has long been noted, and recently Watkins (Public 
Health Reports, Vol. XXXII, No. 50) pointed out 
that these heat conditions and their effects are 
largely preventable, with the result that not only is 
the health of the worker improved, but the efficiency 
of the work is raised. The acute effect of excessive 
heat, heat exhaustion, is a comparatively minor con- 
sideration, because those who are so susceptible to 
it are soon eliminated from such occupations, but 
the chronic effects are the ones that create this in- 
dustrial problem. To the heat hazard can be as- 
cribed the general inefficiency of the worker, the 
loss of physical tone, and even a general physical 
deterioration, diminished resistance to fatigue, 
lowered resistance to disease, and a reduction of the 
period not only of usefulness but of length of life. 
The heat production of the body being such an 
important function, it goes without saying that any 
vital interference with it must react badly upon the 
organism. The normal temperature of the body is 
maintained within rather narrow limits by the bal- 
ance between heat production and heat loss. The 
production and the loss must be mutually propor- 
tioned, if not by one means, by another. In respect 
to heat loss, interference with one means usually 
provokes compensation by another. Body heat is 
produced by general muscular activity, gland activ- 
ity, and the metabolic processes. All bodily energy 
is converted into heat, and about 80 per cent, of 
the food ingested is for heat purposes. Muscular 
activity is probably the greatest factor in the heat- 
producing mechanisms, and, of course, has an im- 
portant bearing on the heat factor in the indus- 
tries. On the other hand, body heat is lost by 
conduction, by radiation, by convection, by evapora- 
tion, and to a lesser extent by the excretions. But 
the loss of body heat varies particularly with condi- 
tions external to the body, and it is these conditions 
that industrial hygiene, with respect to the heat 
hazard, proposes to remedy. More than 80 per cent, 
of the body heat is lost by radiation, evaporation, 
conduction, etc., and these means are retarded or 
accelerated according as industrial conditions are 
appropriate. The relative humidity of the air, the 
temperature, the rate of air motion, all influence 
the heat loss. As the temperature of the air rises, 
the rate of heat loss or the transfer of heat from 
the body diminishes. Likewise, the loss of heat by 
evaporation diminishes as the humidity of the air 
rises. The relative humidity of the air is one of 



the most important factors in the heat hazard of 
industrial establishments. Much higher tempera- 
tures can be tolerated and much more heat lost 
when the relative humidity is within reasonable 
limits. About 15 per cent, of the heat loss is through 
evaporation — the water output of the body varies 
inversely with the humidity. 

Most of the measures looking toward the eradi- 
cation of the heat factor in the industries has to do 
with the engineering features, in the way of isola- 
tion of the source of heat or the separation of the 
worker from it. Much can be done, however, by 
attention to proper clothing, diminution of mus- 
cular activity to the minimum, appropriate diet, the 
water intake, bathing, and, above all, frequent rest 
periods to the workers by means of short shifts. It 
would seem that the removal of the clothing would 
aid the loss of heat, but in fact the presence of 
clothing which is saturated by perspiration is a 
great factor in heat loss, because moisture is so 
good a conductor of heat. The clothing should be 
light, and capable of absorbing moisture. Cotton 
would seem to answer the purpose, except for the 
fact that it allows cooling off so easily, and is there- 
fore so likely to encourage internal congestion, with 
its possibilities. Wool does not have this objec- 
tionable feature, and woolen clothing is, therefore, 
best for this sort of work. 

Provision for and the encouragement of water ' 
drinking is helpful in the dissipation of heat, but it 
must not be taken at a temperature below 55° F., 
because of the tendency to gastric disturbances. 
Frequent bathing with showers at a temperature of 
about 85° F. is very beneficial. In respect to food, 
it must be generally reduced in these occupations. 
Proteins and fats cause the greatest amount of heat 
production, and should be reduced. The starches, 
green vegetables, and fruits should be increased. 



Effects of the War on the French Medical 
Press. 

Bardet contributes an article on this subject to 
the Bulletin General de Therapeutique for Febru- 
ary. He refers only to the medical press of France, 
but the periodical literature of the other warring 
countries, as well as that of some of the neutrals, is 
exposed to the same perils. From the very outset 
of the war the French journals have experienced 
great difficulties in getting out their issues. All 
of them ceased to appear for a few months, and 
not until the beginning of 1915 were certain among 
them able to reappear, but only a few on the original 
ante-bellum schedule. In regard to the Bulletin 
itself, it was hoped that two numbers could be issued 
monthly, beginning in January, 1915. This expec- 
tation was not realized, for two reasons. First, 
there was a great dearth of contributions, for the 
physician has time for neither writing nor research. 
Second, the printers are unable to issue more than 
one number a month. Scarcity of paper is a sepa- 
rate problem not included under the printer's short- 
comings. The price of paper has quintupled since 
1914. The amount of printed matter has been 
formally reduced by the Government, so that adver- 



24 



MEDICAL RECORD. 



[July 6, 1918 



tising matter can total only one-third of the text 
proper. But without this outside intervention much 
the same results would come about from intrinsic 
factors already mentoned. The cutting down of 
advertising matter occurs despite the fact that the 
subscriptions of the' readers fall far short of the 
cost of publication. Without its publicity columns, 
every medical journal in France would have to sus- 
pend. As it is, the subscription price may soon have 
to be doubled, and perhaps trebled. The publishers 
of medical journals will also be forced to withhold 
sample copies and exchange numbers. There has 
never been, with one or two exceptions, any profit 
in a medical periodical in France, and if publication 
must mean a total loss, then the outside world can 
no longer learn what French medical science is 
accomplishing. 



York seveial years ago, and later in other American 
cities. His own cases, while perhaps not the same, 
are similar to Brill's disease. Much stress is laid 
in the Paris cases upon failure of attendants to 
contract the disease, and until this occurs, he says, 
the question of contagion does not become a vital 
one. 



Is Migraine a Radiculitis? 

In migraine the presence of a meningeal reaction is 
but seldom alluded to by writers. Nevertheless, to 
this meningism may be attributed a number of 
migraine symptoms, such as flushing and pallor of 
the face, the peculiar pulse, photophobia, nausea 
and vomiting, and constipation. The tension of the 
cerebrospinal fluid is increased, and lumbar punc- 
ture often gives relief. These points are made by 
Babonneix and David in an article which appears 
in the Journal de medecine et chirurgie pratiques 
, for March 10. The writers also note the hitherto 
undescribed symptoms of return of pain as a result 
of coughing and sneezing, and of aggravation of 
pain during the course of the paro.xysm. This phe- 
nomenon has, however, been described in connection 
with radiculitis. If the brachial plexus is affected 
the severe arm pains following a sneeze are looked 
upon as pathognomonic. In radiculitis of the limbs 
the patients assume peculiar defense attitudes to 
minimize the effects of the sneeze. How explain 
the presence of this phenomenon in migraine? Is 
the latter a radiculitis of the trigeminus? In both 
migraine and radiculitis the increased tension of the 
cerebrospinal fluid may be a factor. 



Typhus Fever in Paris. 

Netter recently announced that a few cases of ex- 
anthematous typhus existed in Paris, which has not 
had a true visitation of the disease since 1893, al- 
though doubtless sporadic cases appear from time to 
time (Journal dt medecine et de chirurgie pratiques, 
March 10). Two miserable children, brothers, cov- 
ered with vermin, appeared to suffer from typhoid 
fever, but this affection was eliminated by hemo- 
culture. It was then learned that two other chil- 
dren and the mother had the same affection, which 
was shown to be true typhus through guinea pig 
inoculation. Triboulet, another pediatrist, has seen 
a similar family epidemic. If it is granted that 
such cases occur in Paris, what is their source? 
We need not go as far as Africa, for in Brittany a 
sporadic incidence has been noted since 1893. Net- 
ter believes, however, that the metropolis has never 
been entirely free from the disease since the Middle 
Ages, but there is a constant tendency to attenua- 
tion of virulence and diminution of contagion. He 
then cites Brill's disease, first described in New 



JN^ruiH of tJ|p Mnk, 

Influenza Epidemic in Europe. — The epidemic 
of so-called Spanish influenza which recently in- 
capacitated a large part of Spain is now in Paris 
and London and has also spread among the French 
and German soldiers. One report states that so 
many German soldiers have been incapacitated by 
this affection that it is delaying the drive that has 
been planned. 

Conference on Vocational Education. — The Fed- 
eral Board for Vocational Education, finding that 
the response to the request for a conference of 
the women interested in the supervision of the 
schools and the training of teachers under 
the Smith-Hughes Act for vocational educa- 
tion has been most gratifying, called a con- 
ference in Chicago, on June 26. The prob- 
lems that have arisen during the year in the 
development of vocational home economics were 
discussed as well as plans for the carrying out 
of the program of part time and evening school 
instruction proposed as a war time measure. 

American Association for Thoracic Surgery. — 
The first annual meeting of this association was 
held in Chicago, on June 10, 1918. The officers 
were: President, Dr. Samuel J. Meltzer. New 
York; Vice-President, Dr. Willy Meyer, New York; 
Secretary and Treasitrer, Dr. Nathan W. Green. 
New York; CouncUlors, Dr. Edward R. Baldwin of 
Saranac Lake. N. Y., Dr. Rudolph ilatas of New 
Orleans, La., Dr. Samuel Robinson of Santa Bar- 
bara, Cal., and Dr. Charles L. Scudder of Boston, 
Mass. An address was made by the president, Dr. 
Samuel J. Meltzer, and a "Review of the Evolution 
of Thoracic Surgery in the Past Fourteen Years" 
was presented by Dr. Willy Meyer. The treatment 
of empyema by the Carrel-Dakin method at the 
War Demonstration Hospital, the Rockefeller In- 
stitute for Medical Research, New York, was out- 
lined upon invitation by Maj. George A. Stew- 
art, M. R. C. "Remarks Concerning the Employment 
of the Dakin Solution in Cases of Empyema" were 
presented by Dr. Charles L. Scudder of Boston. As 
Dr. Scudder was unable to be present, the remarks 
were read by the secretary. A paper entitled 
"What Shall Be Done With the Open Chronic Sup- 
purations of the Chest Ca"ity?" (with presentation 
of patients) was read by Dr. Emil G. Beck of Chi- 
cago. "Post-Operative Thoracic Drainage" (exclu- 
sive of empyema) was the topic for discussion. The 
discussion was opened by Dr. Nathan W. Green, 
continued by Dr. Willy Meyer and Dr. Conrad 
Georg, Jr. Dr. B. Merrill Ricketts of Cincinnati 
presented many x-rays of partial and complete pneu- 
mothorax. A film of the skin sliding operation 
was presented by Dr. Emil G. Beck of Chicago. The 
following officers were elected for the ensuing year : 
President, Dr. Willy Meyer, New York; Vice-Presi- 
dent, Dr. Henry S. Plummer, Rochester, Minn.; 



July 6, 1918] 



MEDICAL RECORD. 



25 



Secretary and Treasurer, Dr. Nathan W. Green, 
New York ; Councillors, Dr. Samuel J. Meltzer, New 
York, one year; Dr. Rudolph Matas, New Orleans, 
two years; Dr. Samuel Robinson, Santa Barbara, 
Cal., three years; Dr. Charles L. Scudder, Boston, 
Mass., four years. The association has a member- 
ship of seventy-one at the present time. 

American Medical Editors' Association. — The 
forty-ninth annual meeting of the American Medi- 
cal Editors' Association was held at the La Salle 
Hotel, Chicago, on .June 10 and 11, under the presi- 
dency of Dr. George W. Kosmak of New York. 
One of the features of the meeting was the ban- 
quet on the evening of June 11, at which time 
Colonel R. E. Noble, M. C, U. S. A., spoke on the 
needs of the Medical Service; the Hon. Quinn 
O'Brien made an address choosing as his subject, 
"Is America Doing Her Best?" Colonel Charles 
Dercles of the French Army and A. Franklin 
Martin also made addresses. At the Executive 
Session resolutions were passed remitting the 
dues of members of the Associtaion who were in 
the service. Other resolutions adopted placed the 
organization on record as in favor of the Owen- 
Dyer bill and also in favor of granting appro- 
priate insignia and rank to women physicians who 
were giving war service equivalent to that of the 
men physicians. The Association relected its 
present officers for another year. They are Dr. 
George W. Kosmak of New York, president, and 
Dr. Joseph MacDonald, Jr., of New Jersey, secre- 
tary and treasurer. 

Physician Visits Convention in Airplane. — Cap- 
tain H. M. Strong, M. R. C, Post-Surgeon, Chanute 
Field, Rantoul, 111., made the trip to Chicago to 
attend the meeting of the American Medical Asso- 
ciation in an aeroplane. This is the first known 
instance of a physician being so anxious to get to 
Chicago that he could not wait for train or 
trolley. 

Cornell University Confers Degrees. — The com- 
mencement exercises of the Cornell University- 
Medical College took place on June 12, at which 
time the degree of Doctor of Medicine was con- 
ferred on thirty-two students. Major Charles L. 
Gibson made the address to the graduating class. 
Nine of the graduates have received commissions 
in the United States Navy and have entered the 
service. 

Ask Government to Stop Disorganization of 
Hospitals. — The Hospital Conference of the City 
of New York recently passed a number of resolu- 
tions among which was one advising that arrange- 
ments be made for the training of a large reserve 
of non-professional nurses. It was also resolved 
"that the President of the United States be urged 
to take such action as in his judgment will pre- 
serve the hospitals of the countrj- from the fur- 
ther disruption of their organizations and the 
abandonment of their indispensable public tasks." 

Opposition to Medical Enlistment. — At the an- 
nual conference of the Health Officers of New 
York State, Dr. Hermann M. Biggs, State Health 
Commissioner, according to newspaper reports, 
expressed the opinion that physicians should re- 
main at home in sufficient numbers to care for 
the civil population rather than to enlist except 
upon special demand for their services. He em- 



phasized the fact that no nation can produce a 
fit army unless its people are fit. 

Dinner in Honor of British Doctors. — About 
fiftj' physicians of New York City gave a fare- 
well dinner at the Metropolitan Club, on the 
evening of June 25, to Sir William Arbuthnot 
Lane, Sir James Mackenzie, and Colonel Herbert 
A. Bruce on the eve of their departure for Eng- 
land. All three of these men made brief ad- 
dresses. 

Dr. Edward H. Bradford, for six years dean of 
the Harvard Medical School and connected with 
the teaching staff for thirty-eight years, has re- 
signed. 

Dr. David Linn Edsall, since 1912 Jackson pro- 
fessor of clinical medicine in the Harvard Medical 
School, has been appointed dean of that institu- 
tion in succession to Dr. Edward H. Bradford. 

Dr. Walter James of this citj' has been appointed 
chairman of the new commission for the feeble- 
minded, which body, under an act of the last legis- 
lature, became effective July 1. 

Dr. Samuel E. Fletcher of Chicopee, Mass., has 
been appointed medical examiner for the Fifth 
Hampden District. 

Dr. Martin S. Budlong of Providence, R. I., has 
been appointed to the State Board of Health of 
Rhode Island to fill a vacancy caused by the 
death of J. Hillman Bennet. 

Dr. Joseph S. Neff, formerly Director of Public 
Health and Charities of Philadelphia, has been 
appointed by Governor Brumbaugh a member of 
the Advisory Board of the Pennsylvania State 
Department of Health. 

Dr. Elmer H. Funk has been elected Medical 
Director of Jefferson Hospital of Philadelphia, 
succeeding Dr. Henry K. Mohler, who has entered 
the military service of the United States with the 
Jefferson Base Hospital Unit No. 3. 

Another Anthrax Patient Cured. — A patient 
who was operated on for anthrax at Bellevue Hos- 
pital, New York City, on June 14, was discharged 
as cured on June 29. This is the fourth of a series 
of eleven cases of anthrax treated successfully at 
Bellevue Hospital. 

The New York and New England Association of 
Railway Surgeons will hold its twenty-eighth an- 
nual session at the Hotel McAlpin, New York City, 
on October 21, 1918. A symposium will be pre- 
sented on the ^Modern Treatment of Infected 
Wounds. The president of the association is Dr. 
J. S. Hill of Bellows Falls, Vt., and the secretary 
is Dr. George Chaffee of Little Meadows, Pa. 

Medical Society Elections. — The MAINE Medical 
Association, at its meeting in Portland, on June 7, 
elected the following officers : President, Dr. George 
H. Coombs of Waldoboro; First Vice-Preaident, Dr. 
John Sturgis of Auburn; Second Vice-President, 
Dr. Charles W. Bell of Strong; Secretary and Treas- 
urer, Dr. B. J. Bryant of Bangor. 

The Maine Homeopathic Medical Society, at 
its meeting in Bangor, on June 11, elected the fol- 
lowing officers: President, Dr. F. A. Ferguson of 
Portland; First Vice-President, Dr. W. A. Ratters 
of Pittsfield; Recording Secretary, Dr. E. S. Abbott 
of Bridgton; Corresponding Secretary, Dr. Carrie 
E. Newton of Brewer; Treasurer, Dr. W. S. Thomp- 
son of Augusta. 



26 



MEDICAL RECORD. 



[July 6, 1918 



The California State Homeopathic Society, at 
its annual meeting in San Bernardino, on June 5, 
elected the following officers : President, Dr. M. W. 
Kapp of San Jose; First Vice-Presideyit, Dr. H. A. 
Atwood of Riverside; Second Vice-President, Dr. 
Anna D. Chapin of Los Angeles ; Secretary), Dr. Guy 
E. Emming of San Francisco; Treasurer, Dr. T. C. 
Low of Los Angeles. 

The South Dakota State Medical Association, 
at its annual meeting, held at Mitchell on May 24, 
elected the following officers for the ensuing year: 
President, Dr. D. L. Scanlon of Volga; First Vice- 
President, Dr. H. T. Kennedy of Pierre; Second 
Vice-President, Dr. G. S. Adams of Yankton; Sec- 
retary-Treasurer, Dr. R. D. Alway of Aberdeen. 

The Vermont State Homeopathic Medical So- 
ciety held its annual meeting on May 30, in Mont- 
pelier, and elected the following officers for the 
coming year : President, Dr. E. D. Kirkland of Bel- 
lows Falls; VicerPresident, Dr. G. E. Morgan of 
Burlington; Secretary, Dr. G. L Forbes of Burling- 
ton; Treasurer, Dr. F. E. Steele of Montpelier. 

The Maine Medical Association, which held its 
annual meeting on June 7, elected the following offi- 
cers: President, Dr. C. M. Coombs of Waldoboro; 
Vice-Presidents, Dr. John Sturgis of Auburn and 
Dr. Charles W. Bell of Strong ; Secretary and Treas- 
urer, Dr. B. L. Bryant of Bangor. 

Obituary Notes.— Dr. Thomas Cook Stellwagen 
died of diabetes at his home in Media, Pa., on June 
7, aged 76 years. He was a graduate of the Medi- 
cal Department of the University of Pennsylvania, 
in 1868, a Fellow of the Philadelphia Academy of 
Surgery, and formerly a professor in the Philadel- 
phia Dental College and the Dental Department of 
the Medico-Chirurgical College. 

Dr. A. L HOLSONBACK, a graduate of the Mary- 
land Medical College, in 1860, died at his home in 
Graniteville, S. C, on June 8. aged 88 years. He 
formerly practiced medicine in Augusta, S. C. 

Dr. M. Osborne Christian, a graduate of the 
Harvard Medical School in 1878, died at his home 
in Irvington, N. J., on June 15, aged 69 years. He 
was connected with the Geological Survey and the 
Smithsonian Institute. 

Dr. Frank Chase Richardson, a graduate of the 
Boston University School of Medicine, in 1879, died 
in Roxbury, Mass., on June 20. He was for many 
years professor of neurology at the Boston Univer- 
sity School of Medicine. 

Dr. J. Hervey Buchanan of Plainfield, N. J., a 
graduate of Jefferson Medical College, in 1896, a 
Fellow of the American Medical Association, and a 
member of the Medical Society of the State of New 
Jersey, died on June 11 at the age of 45 years. 

Dr. Gwilym G. Davis of Philadelphia died of 
pneumonia at Kineo, Me., on June 16, aged 61 years. 
He was a graduate of the Medical Department of 
the University of Pennsylvania in 1879, and later 
professor of orthopedic surgery in that institution. 
He was a Fellow of the American Surgical Associa- 
tion and the American College of Surgeons, a mem- 
ber of the American College of Clinical Surgeons, 
the Pathological Society of Philadelphia, the Phila- 
delphia Pediatric Society, and other medical organ- 
izations. Dr. Davis was surgeon to St. Joseph's, 
the Episcopal and the Orthopedic hospitals, and to 
the ChiMron's Seashore House in Atlantic City. 



ROTARY MICROTOMES DESIRED FOR THE 
ARMY. 

To the Editor of the Medical Record : 

Sir: — At the present time there is a considerable 
scarcity of rotary microtomes, and a marked need 
for them at the various camps, where it is desired 
to make pathological examinations of lung tissue 
in differentiating the broncho from the lobar pneu- 
monias. A number of the firms who formerly made 
this apparatus are now working on signal corps and 
ordnance material, and we are, therefore, handi- 
capped. 

Might I ask you to make a request through the 
columns of your paper to the effect that the Medical 
Department is anxious to purchase a number of ro- 
tary microtomes for use on paraffin sections? Any 
one having a rotary microtome to dispose of should 
communicate with me at the address given below. 

I prefer not to borrow these instruments, as I 
would have to assume a responsibility for instru- 
ments which would pass out of my possession, and 
misunderstandings would doubtless occur. 

M. A. Reasoner, 
Lt. Colonel, Medical Corps, N.A. 



WOMEN PHYSICIANS AND WAR SERVICE. 
To the Editor of the Medical Record: 

Sir: — It ought to be a matter of regret that the 
admirable qualities now being displayed by women, 
and causing such unbounded surprise by their un- 
expected presence, were not allowed expression be- 
fore, for the qualities referred to are always desir- 
able and necessary. Women's present response to 
opportunity is a frequent topic of discussion. The 
medical women in the countries of our allies found it 
necessary to create even the opportunity. 

The Women's Hospital Corps, now established in 
the big military hospital of 600 beds in Endel Street, 
London, found their proffered service refused by 
the British Government in 1914, and it was not until 
this organization of women surgeons had demon- 
strated their ability in caring for wounded and 
dying Frenchmen that Britain invited them to re- 
turn home to care for their own wounded. The 
surgeon in charge of the Endel Street Hospital is 
Major Louisa Garrett Anderson, daughter of the 
second woman physician of modern times. Every 
member of Dr. Anderson's staff is a woman, and 
from the battlefields across the Channel ambulances 
of wounded men are brought to her and her aides 
to patch up and make over again. 

While in France the W. H. C. cared for wounded 
Tommies as well as Frenchmen, and it was said by 
one of them to Sir Alfred Keogh that word was 
abroad in the trenches that when a man was 
wounded the Woman's Hospital was the place to 
go to; "that women surgeons took more pains, and 
were less hasty about cutting off legs and arms, and 
that the women were quite all right." 

Another organization of British women is known 
as the Scottish Women's Hospitals, and it has won 
for itself world-wide fame. This organization was 



July 6, 1918] 



MEDICAL RECORD. 



27 



in charge of Dr. Elsie Inglis, who aimed to place 
a hospital wherever it was most needed. She has 
had as many as twelve operating simultaneously. 
These hospitals have had service on five battle 
fronts. It has sometimes been necessary to pack 
up the equipment and retire with the retreating 
army. They have even been captured. One of them, 
on its way to Serbia, was requisitioned by the Brit- 
ish Amiy at Malta to aid in caring for the wounded 
being brought in from Gallipoli. When they de- 
parted the military authorities at Malta wrote home 
for sixty more medical women to be sent to them; 
and when the Home Office read the report which 
accompanied this request they decided to send sixty 
to Malta and eighty more to other military hos- 
pitals. 

One of the Scottish Women's Hospitals in the 
Rue Archimede, Calais, in charge of Dr. Alice 
Hutchinson, had the lowest percentage of mortality 
in typhoid fever of any hospital in France. Another 
of these hospitals at Troyes, in charge of Dr. Louise 
McElroy, was one of the few hospitals to receive 
official command to pack up and proceed to Saloniki 
to be regularly attached to the French army, fur- 
nishing one of the few instances where a voluntary 
hospital was so honored. 

The S. W. H. faced almost insurmountable diffi- 
culties in Serbia. They braved dirt, infection, and 
cold; they found it necessary at times to carry 
the wounded themselves, and their endurance was 
put to the most severe tests. The chief of the Ser- 
bian command said of them: "Their capacity for 
work and for suffering seems incredible, and while 
they equal the Serbian soldier in endurance, in 
morale no one is equal to them." Dr. Inglis led 
an army herself through frozen passes in Serbia 
and Russia to safety a short time before she yielded 
up her life in the service of humanity. 

The French woman physician has also been win- 
ning laurels. Dr. Gerard-Mangin became an army 
doctor by stratagem, and necessity caused her serv- 
ices to be retained until she had proved her value. 
In the first three months of her service she per- 
formed six hundred open operations without losing 
a single patient. She afterward established a tem- 
porary hospital at Verdun, where she was under 
fire for seventeen months. At first, her hospital 
was without equipment or convenience, and she was 
almost destitute of assistance. For six weeks her 
clothes were not once removed from her body. One 
of her feet was frozen. A man was shot at her 
side one day, and she was slightly wounded. This 
woman was recalled from the front to take charge 
of the Hopital Militaire Edith Cavell, in the Rue 
Desmouettes, Paris, for Dr. Gerard-Mangin is an 
expert in tuberculosis. The rank of major has been 
conferred on this little, rosy-faced expert. Dr. 
Gerard-Mangin did a two-years' service at the front 
without an hour's absence from her post, and she 
is the only surgeon in the French Army of whom 
this statement can be made. 

Women physicians of the allied peoples have by 
their professional ability, initiative, resource, en- 
ergy, and endurance won from reluctant govern- 
ments a recognition long denied them, to the preju- 
dice of the people who might have been benefited by 
their ministrations. Women are now in charge of 



big London hospitals, where formerly no woman 
was permitted on the staff. Five of these hospitals 
are entirely staffed by women. Women have demon- 
strated over and over again professional skill 
and ability of the highest order, and during the four 
years of the World War no woman has ever been 
dismissed for professional incompetency or physical 
disability. 

Britain's change of heart on the woman-physician 
question has been so complete that she is now urging 
her eligible women to study medicine, and is even 
providing, when necessary, funds for this purpose, 
and an increased number of women medical stu- 
dents is now found in the medical schools. American 
women physicians are capable of rendering aid as 
valuable as that given by their sisters abroad. Over 
33 per cent., we are told, have already gone to the 
front or registered for war service. 

Although it is but a short time since we began 
to participate actively in the war, the shortage of 
physicians has grown markedly and is bound to in- 
crease. The fact that fewer students are entering 
medical colleges will, in the not far-distant future, 
still more affect the shortage. As, on account of 
the draft, women are available in larger numbers 
than men for medical study, eligible women should 
be urged to take up the study of medicine in order 
to be ready when the need for them arises. It is 
an error of judgment, as well as an economic waste, 
to urge women eligible for entrance to the higher 
professions to take up nursing, for the nursing 
material is relatively abundant, while the pre-medi- 
cal material is not. Physicians are needed quite 
as much as nurses, and are more valuable and more 
difficult to secure. 

It goes without saying that rank and salary should 
depend upon ability and service and not upon sex. 
It is a travesty on democracy to fight autocracy 
with one hand and carefully shield it with the other, 
as we so often do. That Prussian attitude should 
be swept away to make a place for the square deal 
to which every American citizen has a right. When 
burdens are laid without stint upon all, privileges 
should be dealt out equally. 

A committee of the Women's Medical Association 
of New York City has been formed to encourage 
and assist eligible young women to take up the study 
of medicine as a patriotic duty, and the broad- 
minded physician who realizes the country's need 
cannot do better than assist in this worthy object. 
Maude Glasgow, M.D. 

171 East Eightt-thikd Street. 



PRESCRIPTIONS FOR VENEREAL DISEASES. 

To THE Editor of the Medical Record: 

Sir : — The result of the recent amendment to the 
public health law to which the State Commissioner 
of Health has publicly called attention will be to 
hamper, if not to penalize, both doctor and drug- 
gist in their professional relations with patients 
using medicinal agents which may be construed to 
be remedies for venereal disease. Already the New 
York State Department of Health has made itself, 
under the law, the sole executant of the right to 
advertise either remedies or forms of treatment for 



28 



MEDICAL RECORD. 



[July 6, 1918 



these diseases, even to the exclusion of reputable 
medical journals. It has even gone so far in this 
respect as to appropriate the publicity privileges 
hitherto exclusively enjoyed in public lavatories by 
quacks. If this be a form of "public service" at the 
expense of the taxpayers, the sooner it is proclaimed 
from the more reputable places, now so generally 
impounded for public service of all character, the 
better. As a friend and well wisher, no less than 
a coworker with the members of the profession of 
pharmacy, I would advise them for their self-pro- 
tection to disregard certain provisions of this law. 
For a druggist to refuse either a copy of a pre- 
scription or to renew a prescription containing a 
remedy for venereal disease, unless ordered to do 
so by the physician, is to stigmatize those pre- 
senting such a prescription for compounding which 
may have no such purpose. This is an act for which 
the druggist could be held responsible, as tending by 
implication to degrade the purchaser with whom he 
is dealing. Both by the ethics of his profession and 
by the law the druggist is not to take cognizance 
of the character or purposes of the remedies he 
dispenses, or to use the knowledge thus gained, ex- 
cept under process of criminal law when compelled 
to do so by the court. 

If the law under consideration demands this serv- 
ice it should be exacted of the physician, not the 
druggist. The latter alone can decide whether his 
prescription is intended for a case of venereal dis- 
ease. This the framers of the law could not demand 
of the physician, but they felt from past experience 
that they could accomplish the same purpose by 
making a cat's paw of the druggist. Before the 
druggist thus discriminates he should demand this 
protection from the doctor, in writing, on his pre- 
scription. Despite the threats and penalties held 
over his head by the State Department of Health, 
his refusal otherwise to stigmatize this one class 
of patients would be upheld by any court or jury in 
this State. 

John P. Davin, M.D. 

117 W. 76th Street, New York. 



STUDY OF CEREBROSPINAL LOCALIZATION. 

To THE Editor of the Medical Record: 

Sir: — I should like to suggest a determination of 
the distribution of cerebrospinal lesions and locali- 
zation of structural changes by the study of vascu- 
larity through injection of blood and lymph vessels. 
The method has, to my knowledge, been applied to 
the study of lesions in various organs, as, for in- 
stance, the kidney and liver. Injections very fre- 
quently show in these organs the vascular changes 
and their localization, and even permit of a quan- 
titative estimate of them and a comparison of ves- 
sel and tissue volume. The work is of distinct inter- 
est and value. 

It certainly seems that in the case of an organ 
such as the brain or cord, in which each unit plays 
an important part, and vascularity is of the highest 
importance, the same method must yield results 
equally interesting and of real interest. In point of 
fact, I have seen very little in the way of reports 
on such work. 

Results are certainly to be expected in sclerosis, 
such as multiple sclerosis and the atrophies, and 



vascular scleroses, such as senile psychosis and arte- 
riosclerotic conditions. Such work must also throw 
light, whether the results be positive or negative, 
upon the wide array of psychoses, choreas, epilep- 
sies, etc., which invite pathological investigation. 

Such work, when correlated with clinical mate- 
rial, would afford a method of cerebral and cord 
localization. If, by chance, it affords any knowledge 
of unmapped areas, the time spent at it might even 
be regarded as entertainingly spent. 

Emanuel Josephson, M.D. 

2132 Daly Avence, New York. 



OUR LONDON LETTER. 

(From Our Own Correspondent.) 

THE CALLING UP OF MEDICAL MEN FOB MILITARY 

SERVICE — A NEW MEDICAL DIRECTOR IN FRANCE — 

TRENCH FEVER INFECTION — HONOR FOR HARVT:Y 

CUSHING. 

London, June 13. 1918 

Medical men, though liable, of course, to ordinary 
conscription, practically are never taken now for 
purely military service, the gross waste of scientific 
material implied in such an action being fully 
recognized. It being on all hands allowed that the 
right duties for a medical man to perform are 
medical duties, the question of exemption from 
medical military service has to be decided on two 
grounds only: (1) Is the medical man physically 
able to undertake the responsibilities which a com- 
mission in the army may entail? And (2) is the 
medical man, exemption not being claimed on phys- 
ical grounds, doing more valuable service to the 
state by remaining in a civilian capacity than could 
possibly be expected from him if he were with the 
colors? A Central Tribunal decides questions of 
exemption for the whole country and for all classes, 
but it is in the nature of a supreme appeal court, 
and so far as medical men are concerned is asked to 
give no decisions until every individual case has 
been thoroughly sifted by bodies chosen for the 
purpose. Regulations or instructions which have 
been recently published dealing with applications by 
medical men for exemption make it jKissible that 
this central tribunal will have more work to do. 
especially as the Ministry of National Service is 
considering the whole question of man power in the 
country and its proper employment. The new in- 
structions which have just been issued with refer- 
ence to the calling up of medical men institute a 
special medical tribunal to which in future all ap- 
plications for exemption are to be made, but this 
tribunal is simply "The Local Arrangements Sub- 
committee" of the Central Medical War Committee 
renamed "The Medical Tribunal." In my letter of 
February 23* I explained the elaborate constitution 
of the Central Medical War Committee and its af- 
filiated bodies, to whom the recruiting of the medi- 
cal profession have been intrusted by the War Of- 
fice almost since the outbreak of hostilities. .\s 
each area of the country now comes under review. 
notification will be sent by the Ministry of National 
Service to the practitioners affected, informing 
them of the time within which they may apply for 
exemption if they desire it. The Medical Tribunal, 
in association with the Committee of Reference of 
*MEnicAi, Record. March 10, 1918, p. 469. 



I 



July 6, 1918] 



MEDICAL RECORD. 



29 



the English Royal Colleges will give every applicant 
for exemption an opportunity of being heard before 
a report on his case is made, and if it is decided by 
the Medical Tribunal that it is the duty of a medical 
man to accept a commission, he can still appeal to 
the Central Tribunal, like any other citizen, on 
grounds of serious hardship, of ill health, or of con- 
scientious objection. But it is not intended that 
cases should come before the Central Tribunal un- 
less important questions of principle are involved 
or unless some special reason can be fairly alleged. 
The Medical Tribunal is representative, through the 
various local war committees of the Central Medical 
War Committee, of the whole of the medical pro- 
fession of the country, and is now in possession of 
full and detailed information of the professional po- 
sition of every medical man on the register, and of 
the local professional needs of every area. The 
Committee of Reference which acts with the Medical 
Tribunal has been selected by the Royal College.< 
in order to deal with the institutional needs of 
various areas. It is the duty of this body to pro- 
vide that the hospitals, general and special, and all 
infirmaries shall not be unduly depleted of their 
medical officers, and along these lines the work of 
the Committee of Reference is partially militarj-, 
for there is not one of these institutions which has 
not since the outbreak of war put its beds and the 
services of its honorary staff at the disposal of the 
sick and wounded of the war. The demand for 
medical practitioners is now so great both for 
military' and civilian purposes that it is only by 
carefully considered distribution of the available 
medical men that the requirements of the coun- 
try- can be met. The special position of the medi- 
cal profession has been recognized by granting its 
members, for exemption purposes, a court com- 
posed of themselves. Great trust in the patriotism 
and bona fides of the profession has thus been 
shown by the nation, and the result in times of 
unthinkable stress has been on the whole satis- 
factory. The new instruction will be administered 
consistently with the national interests, but with 
a consideration for particular medical cases which 
could not possibly have been extended to candi- 
dates for exemption by any tribunal composed of 
laymen. 

At a moment when the German offensive has 
recommenced with particular vigor against sec- 
tions of the Western line held bj- British troops, 
either alone, or in conjunction with the American 
contingents, the retirement of the Director 
General of Medical Sei-vices on the Western Front 
appears to be inopportune. Sir Arthur Sloggett 
has been the Medical Director General in France 
since the outbreak of the war and although he 
has reached the age limit for active service, there 
are undoubtedly many who would have liked to 
see him remain at his post during these particu- 
larly critical times. He has discharged his mani- 
fold and far-reaching duties well, he has been 
quick to see where developments were needed and 
willing to trust the right men to carry them out. 
He has made intelligent use of the different 
branches of expert medical service which have 
been placed at his disposal ; and — crowning dis- 
tinction for an officer in a supreme position — he 
has earned the reputation of fairness in his vari- 



ous selections and promotions. Lieutenant Gen- 
eral Burtchaell who succeeds him has, it will be 
admitted, the strongest possible claims to the 
office which circumstances have made vacant. He 
is at home with army administration in the War 
Office and in foreign lands both in times of peace 
and times of activity. He has been a staff officer 
in Indian Commands and in the South African 
War. He has had an appointment under the Irish 
Command, and for the period immediately pre- 
ceding the war he was employed by the War Office 
as Assistant Director General of the Army Medi- 
cal Service. Since the war broke out General 
Burtchaell has been in France and closely asso- 
ciated under Sir Arthur Sloggett with the re- 
organizations required to meet the needs of a 
growing army. In this way to a knowledge of the 
medical needs of the British soldier he has added 
close association with the Over-seas Forces — 
American and Colonial — to whom his appointment 
is noticeably welcome. His appointment to the 
supreme command on the Western Front at this 
juncture of the war will entail upon him immense 
responsibilities, but his record shows that he will 
be able to meet them and that he can rely upon 
the hearty cooperation of his professional col- 
leagues. 

Trench fever, after having been identified under 
a good many names and after the name had been 
applied to a good many varving conditions and 
phases of numerous diseases, is now recognized 
as an entity and the latest investigation carried 
out on behalf of the War Office has thrown light 
on the mechanism of its infection. The work has 
been carried out by Major Byam, Captain J. E. 
Carroll of the United States Army Medical Serv- 
ice, Captain L\ti Dimond, and an enthusiastic band 
of volunteers and the result is an important chap- 
ter in the epidemiology of parasite-borne disease. 
Lice as carriers of the infection had been identi- 
fied, of course, long before this latest investiga- 
tion was undertaken, but some points have now 
been established of great scientific interest. The 
voluntary workers, to whom allusion is made, 
were the subjects who submitted themselves to 
the bites of infected lice, and the first point es- 
tablished was that trench fever could not be pro- 
duced by the bite alone of infected lice. One man 
who received no less than 9,518 bites by lice fed on 
trench fever cases did not sicken, nor did another 
who was bitten 13,224 times over a period of fif- 
ten days. It was noted that while the younger pa- 
tients with lice upon them always yielded to the 
desire to allay irritation by scratching, the older 
volunteers, in whom infection more frequently 
missed, were tho.se who did not scratch. This ob- 
servation led to the suggestion that infection 
might be due to the scratching in of the lice or 
of their excreta, and the successful result of the 
experiment of scarifying the skin and rubbing in 
crushed lice or the excreta of lice fed some time 
before on trench fever patients at once confirmed 
this view, the volunteers so treated developing 
the disease after an incubation period averaging 
eight days. The lice appear not to be infected 
immediately after feeding upon a patient with 
trench fever, but to become so after the lapse of 
a week, and in no case was infection carried by 



30 



MEDICAL RECORD. 



[July 6, 1918 



excreta which had been passed within a few days 
after the feeding of the louse. These facts sug- 
gested to Major Ryan and his coadjutors that the 
parasite might complete its life-cycle within the 
body of the louse. That the louse is the carrier 
and that spontaneous infection cannot be consid- 
ered, is proved by the fact that with the crushed 
bodies of normal lice, as with their excreta, no 
evidence of infection or its spread could be ob- 
tained. It is an important point to note with re- 
gard to prevention that in these experiments the 
infective louse excreta remained virulent for more 
than a fortnight when dried at the ordinary tem- 
perature of the room, and retained that virulence 
after exposure not only to direct sunlight but to 
a temperature of 56° C, whereas it is usually as- 
sumed that dry heat at this temperature suffices 
to prevent infection by lice. Lastly the conclusion 
curious, even if it has no pathological bearing, 
was arrived at that the louse cannot transmit in- 
fection to its own offspring. At the last meeting 
of the Society of Tropical Medicine, when Major 
Byam presented the report of his experiment Sir 
William Leishman stated that the conclusions 
reached by the work of the Trench Fever Com- 
mittee in France were similar to those arrived at 
by Major Byam. One clear message of this work 
is that civilian populations run the risk of infec- 
tion from soldiers discharged from the army or 
returning on leave, unless hygienic precautions 
are rigidly taken. 

The Royal College of Surgeons in Ireland has 
conferred on Prof. Harvey Cushing, Harvard Uni- 
versity, the honorary Fellowship of the Corpora- 
tion, imitating thereby the action already taken 
by the Royal College of Surgeons of England. The 
Irish College is particularly chary of presenting 
anyone with their honorary diploma of the highest 
rank. 



OUR LETTER FROM PARIS. 

(From Our Own Correspondent.) 

FIGHTING TUBERCULOSIS — JIU-JITSU AGAIN — THE RED 

CROSS EVERYWHERE. 

Paris, May 11. 191S. 

One more sanatorium to help meet the problem of 
tuberculosis in central France will be estab- 
lished as the result of a gift of 200,000 francs, 
just made by the Tuberculosis Bureau of the 
American Red Cross to the French Comite de 
Secours aux Blesses Militaires at Tours. This 
contribution, together with a fund raised by the 
local committee, makes possible the purchase of a 
large property known as "Bel Air," which the 
French society will convert into a large sanator- 
ium for tuberculous civilians and r6formes. 

The Red Cross has already established tubercu- 
losis hospitals of its own at Yerres and Plessis- 
Piquet, near Paris; at Lyons and elsewhere; has 
made a gift to St. Joseph's Hospital in Paris, 
which enabled it to remodel a building acquired 
by it for a tuberculosis sanatorium of 125 beds at 
a cost of 285,000 francs, and is constantly aiding 
tuberculosis hospitals in almost every department 
of France. In February alone it made grants of 
furniture, food, clothing, and medical supplies 
valued at nearly 100,000 francs to scores of hos- 



pitals outside Paris. Its grants of this kind from 
November through February total 575,000 francs 
and were made to 188 hospitals, with a total capa- 
city of 15,385 beds. Its representatives are con- 
stantly in the field visiting tuberculosis hospitals 
and studying their needs. 

Its diet kitchens erected in the yards of Paris hos- 
pitals serve more than 650 people a day. Since Sep- 
tember, when it undertook the work of providing ex- 
tra comforts — games, phonographs, colored bed- 
spreads, books, and supplementary food rations — 
the total number of the voluntary exiles, many of 
whom entered the pavilion without hope of cure, 
merely to avoid the risk of spreading contagion, 
has increased 258 per cent. 

One of the most interesting tuberculosis hos- 
pitals operated by the Red Cross is in the Hos- 
pital Sainte-Eugenie at Lyons, in a chateau pre- 
sented to the city of L3'ons by the Empress Eu- 
genie and loaned by the city for the period of the 
war to the American Red Cross. This hospital is 
solely for tuberculous women repatriates sent 
back by the Germans as useless mouths. Until 
this hospital of 200 beds was opened there wa.*; 
very inadequate hospital provision for tubercu- 
ous women. Forlorn relics of undernourishment 
and depression, for the first time in three years 
they find at Lyons comfortable beds and adequate 
care. 

Through the generosity of Mrs. Robert Woods 
Bliss two wagonloads of hospital equipment and 
supplies have been donated to the Bureau of Tu- 
berculosis. The gift includes an cc-ray machine, 
anesthetizer, autoclave, dental chair, etc., and the 
things are being distributed to the three hospitals 
operated by the Tuberculosis Bureau in and about 
Paris, the Edward L. Trudeau Sanatorium at 
Plessis-Robinson, the Chateau de la Fontaine 
Bude, Paris, and the Hospital Benevole 19 bis, at 
46, rue Docteur Blanche, Paris, and a certain 
amount of surgical equipment is being turned 
over to the general Red Cross supplies. This was 
part of the equipment at a hospital now discon- 
tinued. 

When Lieutenant Desouches of the French Mis- 
sion attached to the American Army, was in Paris 
last, he expressed surprise that Dr. McCurdy, 
head physical instructor of the Y. M. C. A. for 
the American Army, was not aware that jiu-jitsu 
was taught in both the French and British Armies. 
He said: "Go to the Ministere de la Guerre and 
see Commandant, or, as you say, 'Major,* Royet, 
directeur de I'infanterie. He is at the head of the 
physical instruction." 

Commandant Royet received me courteously 
and at once spoke of jiu-jitsu in the French Army. 
"Why, we have had this going on for more than 
half a year, and all the men in the French Army 
have to learn jiu-jitsu, adapted to our require- 
ments, and the feature is an enormous success. 
We encourage the men in every way to perfect 
themselves in what we call "corps-a-corps fight- 
ing," and this feature is of immense use. Before 
the war the method of combat was with the 
bayonet and was simply a system reduced to 
movements, manual exercises, and fencing. But 
since the war we have gone into the thing with 
entirely new motives. We have adopted real 



July 6, 1918] 



MEDICAL RECORD. 



31 



hand-to-hand fighting, such as is imposed by 
the circumstances of this war. We require our 
men to kill their adversaries in this new corps- 
a-corps work. The bayonet is all right, but sup- 
pose you have no bayonet — which sometimes 
happens — well, a man can clutch his knife and at- 
tack his adversary. But suppose he has no knife, 
or, for some reason, cannot make use of it, at the 
psychological moment? What then? Why, he sim- 
ply relies on his knowledge of jiu-jitsu. Jiu-jitsu 
is an art which takes time to learn thoroughly, but 
a soldier can learn enough in a month to give him 
complete confidence in himself when he has noth- 
ing but his hands, head, and feet to help him out, 
minus his gun, bayonet, grenade, or sword, as the 
case may be. What we teach enables our men 
to master their adversaries in almost all circum- 
stances — even when the adversary is armed. He 
can disarm his adversary. You can see this in our 
schools. You simply kill a man with this jiu-jitsu 
properly applied. 

"The one thing above all, in this jiu-jitsu work 
is that a soldier has complete confidence in him- 
self. We have found it a splendid thing for the 
morale. When they advance at the front they are 
sure they can grapple with their adversary. Is 
not this a good thing to learn? The English Army 
has taken this up and it has found its value, and I 
can heartily recommend it to all the Allied Armies. 
The Minister of War is getting out a brochure 
containing this system of instruction and it will 
soon appear with illustrations and at the same 
time our Ministry will issue an English transla- 
tion. 

"Boxing is all right, so is the savate, or French 
substitute for boxing, so is wrestling, and so is 
also, of course, the Japanese jiu-jitsu. All come 
into our system of instruction. Let us take an ex- 
ample: Suppose a man boxes his adversarj^ 
knocks off his helmet. There is a fraction of a 
second of surprise. Then is the time to disarm 
him and finish him off with jiu-jitsu. Our system 
does not give jiu-jitsu the monopoly to the ex- 
clusion of all other means of getting rid of one's 
enemy, but it is an adaptation to our require- 
ments. We use bayonet, knife, savate, boxing, and 
jiu-jitsu, all combined for practical purposes. 
When I say one month is sufficient for a man to 
learn our army physical development exercises, I 
do not mean any one at random; I mean a man 
who has had some physical development to start 
with. A man who never had physical develop- 
ment exercises cannot be expected to pick up jiu- 
jitsu in a short time. He takes longer to get the 
required skill. But he gets it. Believe me, our 
men are delivering the goods all right." 

Recent air raids at Nancy have given the 
American Red Cross another chance to show its 
eagerness to make as bearable as possible the 
difficult living conditions of the women and chil- 
dren in the villages behind the army lines. The 
organization has just sent 2,000 francs to M. 
Mirman, Prefect at Nancy, for the emergency 
fund for victims of the last raid, in addition to 
providing twenty-two cases of clothing and sev- 
eral cases of foodstuffs to relief societies which 
were meeting the emergency. Members of the 
Red Cross staff at Nancy were the first to come 



to the rescue of the victims caught in the debris 
of a cafe on which a bomb had fallen. 

The proprietress of this cafe lived in Belfort 
until 1914, when all the members of her family 
except two baby daughters lost their lives in an 
aerial bombardment. She made her way to Nancy 
and finally succeeded in getting a little capital 
together and starting this business to support the 
children. The bomb which struck this cafe killed 
the two little daughters and destroyed everything 
she had in the world, leaving her completely alone 
and penniless. The Red Cross is helping her make 
a third start. 

Cooperation between M. Mirman and the Ameri- 
can Red Cross in work for the harassed civilian 
population of Meurthe-et-Moselle has been car- 
ried on since last July, when almost the first work 
of the department of Civil Aft'airs was to help the 
French authorities in the direction of a refuge for 
350 young children and mothers suddenly ordered 
out of the villages where there was continually 
danger of gas attacks. The refuge established 
in a former barracks near Toul is now sheltering 
about 500 childi-en, too young to be trusted to wear 
gas-masks, and mothers of young babies, and the 
American Red Cross and the American Fund for 
French Wounded, acting together, have estab- 
lished in connection with the refuge a general dis- 
pensary, a children's hospital of 110 beds, of 
which 40 are reserved for maternity cases, and 
traveling dispensary service which carries Ameri- 
can doctors and nurses to fourteen villages of 
Meurthe-et-Moselle. Some idea of the service 
which America is rendering to these unfortunate 
little French citizens can be obtained from the 
figures showing the work done in the month of 
February, when 189 children were treated in the 
hospital, 4,310 in the clinics, held in factories, 
schools, and town halls. 



The Boston Medical and Surgical Journal. 

June 20, 191S. 

1. The Massachusetts Medical Society, Annual Discourse— 
The Socialization of the Practice of Medicine. Myles 
Standish. „ ^^ » , 

2 Massachusetts Anti-Tuberculosis League, Fourth Annual 
Meeting, Boston. April 11, 1918. . ,,. ^ ^ 

Introductory Remarks by the President. Vincent Y. 

Bowditch. , „ ,^. _, 

Adequate Community Organization for Health I:.duca- 

tional Work. Mary A. Abel. , . ,„ , „ ,, 
Relative Values in Anti-Tuberculosis Work. C. M. 

Hilliard. . «, , , ■ 

Annual Report of the Massachusetts Anti-Tuberculosis 

League. 191S. Ethel M. Spofford. 
Follow LTp Work in Tuberculosis in the Small Towns 

and Villages in Massachusetts. Bernice M. Billings. 
War and Tuberculosis. Charles J. Hatfleld. 
Conservation of Man Power in Industry. Anna M. 

3. Idiopathic Epilepsy a Sympathicopathy. Edward A. 
Tracy. 



New York Medical Journal. 

June 22, 1918. 

1 . Some Unusual Surgical Experiences. Albert Van Der Veer. 

2. The Relation Between Lupus Erythematosus and Tuber- 

culosis. Fred Wise. . . „. »,«, _ 

3. Prognosis in Pulmonary Tuberculosis. Maurice Fishberg. 

4. Diagnosis and Treatment of Anthrax. Nathan Schwartz. 
.5. Otogenous Temporal Abscess with Hemiplegia. Otto 

Glogau. _ , , ■., ,, J TT 

6. X-ray as a Diagnostic Aid in Backache. Mulford K. 

7 A Plan for the Prevention of Venereal Diseases in New 
York State. E. H. Marsh. 



32 



MEDICAL RECORD. 



[July 6, 1918 



S. Occupational ilercuiy I'oiHDi 

gert 
9. Treatment of Coini)oun<l Kr; 

ualty Clearing: Stations. 



ing. George Schuyler Ban- 
:ture of the Femur at Cas- 



Journal of the American Medical Association. 



Jiinr 



I'JIS. 



1. Investigations of Swimming PooLs at the Univer.sily of 

Minnesota. H. A. Whittaker. 

2. Removal of Brain Tumor ; Report of a Case in Which the 

Patient Survived for More than Thirty Years. W. \V. 
Keen and AUer G. ICUis. 
:',. Chronic Myocarditis : A Clinical Study. Henry A. ( "hri.s- 
tian. 

4. Hypertrophic Pyloric Stenosis in a Two-Year Old Cliilil : 

Report of a Case. Alfred J. Scott. 

.'). Report of a Case of I'seiuloleukemia Infantum Cvon 
Jaksch's Disease). David A. Roth. 

G. Agglutinin Response After Army Triple Typhoid Vaccina- 
tion. Eric A. Fennel. 

7. The Psychoneurotic Factor in the Irritable Heart of 
Soldiers. B. S. Oppenheimer and M. A. Rothschild. 

5. Prophylactic Treatment in the Prevention of Venereal 

Diseases. Morris C. Thrush. 

3. Chronic Myocarditis: A Clinical Study. — Henry A. 
Christian presents the results of a clinical study of 230 
cases of chronic cardiac disease carried out in the 
wards of the Peter Bent Brigham Hospital in 1917. 
Of these 120 were positively diagnosed as chronic myo- 
carditis and 5 questionably so, while 150 were regarded 
as cases of chronic valvular disease. The figures in 
1916 were proportionately the same, being 1.56 of 
chronic myocarditis and 141 of chronic valvular dis- 
ease; and in 1915 these cases were respectively 91 and 
113 in number. The author summarizes the results of 
his observations as follows: There is a common chronic 
cardiac condition, in a general hospital for adults equal 
in frequency of occurrence to chronic valvular disease 
of the heart, which, for want of a better term, may be 
called chronic myocarditis. By this term is meant 
cardiac insufficiency from myocardial disturbance with- 
out organic lesion of the heart valves. A very large 
proportion (366 out of 407) of these patients or admis- 
sion to the hospital are over forty years of age, and 
somewhat more are men than women. The heart is 
nearly always enlarged, and usually there is a cystolic 
murmur at the apex; but whatever its intensity or trans- 
mission, thickening or distortion of the valve flaps or 
chorda tendinese is rarely found. Acute rheumatic 
fever and syphilis are both relatively uncommon in 
these cases, and neither plays any considerable part 
in the etiology. Chronic use of alcohol occurs in 
about one-third of the cases. High blood pressure is 
often found, but is absent in more th^n half of the 
cases. Chronic nephritis is often present, as is hyper- 
tension; but in seventeen out of forty-one cases at 
necropsy, the kidneys showed no chronic nephritis. 
Coronary sclerosis is an important factor in only about 
half of the cases. Increase of interstitial connective 
tissue is the lesion most found in the heart muscle, but 
in numerous cases the heart muscle seems practically 
normal except for hypertrophy of the fibers. Electro- 
cardiography often gives evidence of disturbed muscle 
function. About half the cases show auricular fibiilla- 
tion or flutter or the distortion of the ventricular com- 
plex, indicating some disturbance in the conduction sys- 
tem; but in even advanced cases the electrocardiogram 
often shows no significant disturbance. As to treat- 
ment, digitalis in the earlier breaks in compensation is 
a very efficient drug, and diuretics produce marked 
diuresis. He adds, however, that we have no certain 
knowledge of what really produces this type of cardiac 
insufficiency, and further study of these patients during 
life and after death is needed before we can have any 
adequate understanding of the mechanism and the 
causes of this condition. 



The Lancet. 

Mail 2.T. IfllS. 



The Mljroy Lectures (Ahstracts nf) on the Teaching; 

Training in Hysiene : Some Criticlsnis and Sugges 

Lecture III. H. K Kenwood. 
A Contribution to the Tichni<iuo of Infected Wound 

tiro, More Especially roiiiiinund Fr.ictures. Ca 

Fraser B. Gurd. KemMrUs In- Sir n<iliort Jones 
Two Fatal Cases of Kstivo-Autunmal Malarial Fevoi 

curring in England. Ma.ior .Vrlliur .1 Hall. Ca 
Fgerton H. Williams, and Captain ,T, Stiolto C I>..i 



4. A Method for the Drainage of Deep Wounds of the Thigh. 

Captain W. Sampson Handley and Dr. P. J. Hanlon. 
i>. Skin Grafting in the Treatment of War Bums. Surgeon 

C. P. G. Wakeley. 

6. Three Cases of Epidemic Stupor — I.. J. Anderson Smith : 

II., F. Parkes Weber ; III., T. H. Parke. 

7. A Ca-se of Congenital L'eformity of Hands and Feet. 

Barbara G. H. Crawford. 

2. A Contribution to the Technique of Infected Wound 
Closure, More Especially Compound Fractures. — Cap- 
tain F'raser B. Gurd believes that a more aggressive and 
direct method of treatment of infected compound frac- 
tures than is commonly employed in English hospitals 
is indicated. The techniques introduced by Rutherford 
Morison and Carrel, when properly employed, have 
each proved their usefulness in the hospitals in France. 
In a series of thirty characteristic cases. Captain Gurd 
has applied a modification of these methods with grrati- 
fying results. He describes in detail his method and 
divides the cases to be treated into: (1) Acute suppura- 
tive cellulitis with slough formation; (2) Open granu- 
lating wounds communicating freely with exposed bone 
and discharging purulent material in moderate quan- 
tities; (3) More or less quiescent bone inflammation 
communicating with the surface by means of one or 
more sinuses. In the first class of case, he employs 
substantially the technique suggested by Morison with 
the addition of the paraffin-gauze pack. In the second 
type of case, as soon as the infectious process has be- 
come localized an effort is made to approximate the 
tissues and skin edges and so mirimize the ultimate 
formation of new tissues with its accompanying .=e- 
quela of adherent scars and nutritional disturbances. 
This is done by insertion of mattress .-utures of heavy 
silk (No. 12-16) smeared with B. I. P. P. and protected 
by small rubber tubes or buttons. The wound is dressed 
with spirit or Dakin's solution. At each dressing, at 
six to twelve days' intervals, new sutures are inserted 
and the tissues gradually approximated. Invagination 
of scar is avoided by undercutting the skin. At each 
dressing the bone edges are carefully palpated with tl:e 
B. I. P. P. pack brought in accurate contact with bare 
bones. Loose white bone fragments are removed and 
bone ends not covered with granulations within six 
weeks from time of injury are nibblad a'u-ay. f)nce the 
bone is obscured by velvety granulations, the granula- 
tion tissue and as much as is deemed advisable of the 
scar tissue is excised and the wound tightly closed by 
means of superimposed layers of mattress sutures after 
B. I. P, P. has been carefully applied to the surface. 
In cases of the third type, the author advises excision 
en masse of as much scar tissue as possible. In the 
treatment of sinuses the value of passive hyperemia is 
emphasized and the danger of meddlesome packing with 
inert gauze. He points out that in the majority of 
these cases either bleeding has interfered with proper 
vision so that examination of bone is impossible or the 
wound edges are not easily approximated. In such 
cases he recommends that the exposed bone and soft 
tissues be mopped with alcohol and an excess of B. I. 
P. P. applied; paraffin gauze packs are pressed into 
position and the wound closed, as completely as may be, 
by means of protected mattress sutures. Such wounds 
are not dressed. In five or ten days the patient is 
anesthetized and sutures and packs removed. The 
wound surface is found clean, bright-red in color, and 
covered with granulations. There is no bleeding, ex- 
amination is easy, and further interference readily 
carried out. The wound is again dried, "re-bipped," and 
closed by mattress sutures in layers. The author points 
out that, as Morison showed, frequent dressings of 
wounds, after closure, are unnecessary and harmful. 
Sutures should be left in position, if possible, for three 
weeks. The advantJtges of the method described are: 
Lessening of discomfort and pain to the patient, as a 
result of increase in interval between dressings and 
shortening of open wound period; improvement in 
functional result in consequence of less frequent dis- 
turbance of bone fragments during the dressing stage 
and earlier application of complete immobilization in 
cases in which this is indicated, a diminution in the 
number of adherent painful scars and nutritional dis- 
turbances, and earlier opportunity for secondary op- 
erations, such as nerve and tendon suture and mas- 
sage, etc.; early transformation of patients from the 
"dressin.g" to "observation" class of men; shortening 
of hospital days per patient and consequent increase 



July 6, 1918J 



MEDICAL RECORD. 



33 



in the usefulness of hospital beds; economy of dress- 
ing material, both by reason of the infrequency of 
dressings and shortening of the dressing period. Com- 
menting on Captain Gurd's article, Colonel Sir Robert 
Jones points out the value of such a method as that 
described in that the rapid and successful closure of 
wounds, which otherwise might persist as sinuses for 
months, simplifies to some extent one of the greatest 
problems with which the army medical authorities are 
faced — the provision of hospital beds for the large 
numbers of wounded transferred to England. 



The Lancet. 



June 1. 191 S. 

1 .\ Contribution on Blood Transfu.sion in War Suiter, \ 

Ij. Bruce Robertson. 
-■ On the Acidosis of Shock and Suspended Circulation 

Colonel Sir AIniroth E. Wright and Captain Leonard 

Colebrook 
■i. Pulmonary Fibrosis. Tuberculous and Non-tuberculous. 

G. H. Hebert. 
4 Intrapelvic Abscess, a Complication of Gunshot Wound.-; 

of the Buttock. Colonel W. Thorburn and Captain (i. 

Richardson. 
', A Xote on Anaerobes in Soil Infected Wounds. Captain 

Henry Goodale. 
h A Case of Amebic Abscess of the Liver and Brain with 

No Previous Historv of Dvsentery. Major T. D. M. 

Stout, D S.O., and Captain D. E. Fenwick. 
7 .\. Case Illustrating an Extreme Modification of T.,o<';iI 

Tetanus. Captain Cecil Wor.'^ter-Drought. 

o. A Note on Anaerobes in Soil Infected Wounds. — 

Captain Henry Goodale reports the conclusions reached 
in regard to anaerobes from evidence collected from a 
large number of cases in the Bacteriological Laboratory 
of Dartford War Hospital for Sir David Bruce's Tetanus 
Committee. He has found (1) That anaerobes or their 
spores persist in the deep tissues around bone and in 
scars after wounds have healed, or when they are 
covered with healthy granulations that give nothing but 
staphylococci on culture. (2) That anaerobes can find 
their way from an infected wound of the e.xtremities 
to the serous cavities of the brain and pleura, and are 
found in these localities in connection with meningitis 
and pleurisy. (3) That anaerobes are found in me- 
tastatic abscesses of the lung resembling in type the 
organisms found in the soil-infected wound of the 
patient, and the symptoms of these patients are those 
of general septicaemia. He states that he has not 
entered into any speculations as to the precise way by 
which anaerobes find their way from one part of the 
body to another; it appears certain that they produce 
a substance that paralyzes the polymorphonuclear leu- 
cocytes and inhibits phagocytosis, this being one of the 
factors which accounts for the rapid progress of acute 
bacillary gangrene. Nor has he spoken of symbiosis, 
which is another important factor in dealing with 
anaerobes. He hopes, however, that in view of the 
importance of the subject the few observations he 
has made may be of some value. 



The British Medical Journal. 

June 1. 191S. 



Hort( 



' The Care of the Tuberculous Soldier. Maj<j 

Smith Hartley. 
: Remark.s on Roentgenographic Pelvimetry. W. R. >lac- 

Kenzie. 
: The Part Played by Concomitant Infection with Anaerobic 

Organisms (other than B. tetani) in the Causation of 

Tetanus. Captain William .1. Tulloch. 
4 .Aneurysm of the Third Part of the Left Subclavian -Ar- 
tery. Successfully Treated by Ligature of the Second 

Part. Herbert H. Brown. 
" A Case of Cerebral Toxemia — '' "Botulism." James Law 

Brownlie. 

3. The Part Played by Concomitant Infection With 
-Vnaerobic Organisms (Other than B. Tetani) in the 
Causation of Tetanus. — Captain William J. Tulloch 
points out that (1) There is good ground for believing 
that the ancillary part played by B. welchii in the 
causation of tetanus is clearly defined. The capacity 
of this organism for doing harm in the connexion under 
consideration can be almost eliminated by the use of 
the antitoxin for B. welchii. (2) The capacity shown 
by the toxin of Vibrion septique for stimulating the 
growth of tetanus spores in vivo is more variable than 
is that of B. welchii. Experiment VII indicates, how- 
ever, that it too may play a part in the causation of 



tetanus. (3) It follows from conclusions 1 and 2 that 
antibodies to the toxins of B. tetani, B. ivelchii, and 
^'ib>•ion septique should be included in all serum em- 
ployed for the prophylaxis of tetanus. (4) While such 
a polyvalent serum promises to reduce still further the 
incidence of tetanus it would be too optimistic to assume 
that it would absolutely eliminate that disease, for in- 
fections other than those dealt with in this communica- 
tion may also play a part in stimulating the growth 
of B. tetani in wounds. One of these, B. oedematiens, 
the writer proposes to investigate immediately. 



Berliner klinische Wochenschrift. 

Aliiil 1.-.. I'.US 

The Disturbances of the Internal Secretions in Eunu- 
choids. — E. Voelckel gives a genera! survey of the 
question of testicular insufficiency and then gives the 
case history of a male aet. forty years, with hypoplastic 
testes. His secondary se.xual characteristics were in- 
sufficient; in height he was below the average in rela- 
tion to body weight, while lymphocytosis was insuffi- 
cient. Voelckel was unable to find any change in the 
sympathetic or autonomous excitability. Likewise, he 
was able to note that the conditions of metabolism were 
normal by the following tests: (1) A mixed diet, at 
the rate of 3000 calories by weight, maintained the sub- 
ject at his normal weight. A diet of 1800 calories le- 
.sulted in a loss of weight, rapidly compensated by a 
return to the diet of 3000 calories. There was, con- 
sequently, no disturbance in oxydation. (2) There was 
no alimentary glycosuria nor hyduria. This subject can, 
therefore, demonstrate either theory concerning the re- 
lationship of the endocrine glands between themselves. 

Is There a Disease of Aviators? — W^. Hirschlaff comes 
to the conclusion that there is no clinical picture be- 
longing properly to aviators. The phenomena that they 
may offer is quite as well met with in the case of moun- 
tain sickness. The writer mentions, among others, the 
following phenomena: pain in the ears in rapid changes 
of altitude, particularly in the descent. The aviator 
automatically deals with them by making movements 
of deglutition or yawning (the presence of a tubotym- 
panic or sinunasal obstruction may cause violent pain 
in the blocked-off cavity). The want of oxygenation 
does not usually give rise to any trouble, as the aviator 
is provided with a tank of oxygen. The blood pressure 
is usually increased by about 20 mm. Hg. at the end of 
the flight, as compared with the initial pressure. Like- 
wise, the pulse rate increases from 20 to 30 per minute. 
Organic cardiac disturbances are unusual. The most 
frequent, and at the same time the most serious dis- 
turbances, are of a nervous nature: restlessness, in- 
somnia, functional cardiac disturbances. Aviators easily 
become the prey of neurasthenia, while on the other 
hand, psychopathic disturbances (for example, traumatic 
neuroses) are rarely encountered among them, this fact 
being explained by the selection of the men taken into 
the air service. 



Deutsche medizinische Wochenschrift. 

April 4, 191S 
The Diagnosis of Fluid Collections in the Knee Joint. 

— Pels-Leusden has come to the conclusion that the 
present methods of diagnosis which, as far as he is 
concerned, are limited to the patellar shock, are wanting 
in "finesse" and are insufficient, and in this we agree. 
This procedure, which, according to Pels-Leusden, is 
the only one resorted to (in his country), but can very 
well be completed by a method more apt for detecting 
small fluid collections in the knee. This consists in 
placing the leg in complete passive extension, and in 
this position the hands of the examiner being placed 
one above the other below the knee joint, can produce 
fluctuation of the fluid contents on either side of the 
patella. 

The Cure of Cutaneous Ulcers and Bone Fistulse Fol- 
lowing Wounds from Missiles, by Immunized Skin 
Flaps. — M. Katzenstein has noted that grafts of healthy 
skin often die in their struggle with the infected wound 
which they covered. Katzenstein proposes to overcome 
this difficulty by immunizing the flaps, and to attain 
this end he treats the skin which shall serve as a graft 



34 



MEDICAL RECORD. 



[July 6, 1918 



by the application of the dressings coming from the 
wound. An inflammatory process ensues which ren- 
ders the skin more apt to grow over the grafted area. 
This procedure has been utilized in cases of cutaneous 
ulcers treated in the first place by Thiersch's grafts, 
a fixation of the epidermic bits occurs in spite of the 
local suppuration; the pus can be given exit through 
the graft, or may even be eliminated spontaneously. 
The pedunculated flaps destined for closing the musculo- 
cutaneous ulcers or bone fistulje will likewise hold 
much more readily if they are first treated by the septic 
products of these ulcerative processes. The writer in- 
sists on the fact that numerous wounded men who 
had undergone long and varied hospital treatments 
rapidly recovered after the application of the method 
advised. 



Deutsche medizinische Wochenschrift. 

April 11, 1918. 

Sealed Dressings. — F. Hartel, taking into considera- 
tion Bier's researches on the conditions of tissue re- 
generation, criticises the absorbing dressings which are 
almost universally employed. These viciate the condi- 
tions of e.xistence of the deeper tissues which habit- 
ually live in a fluid medium. 'The absorption by aspira- 
tion of the gauze dressings interferes with the develop- 
ment of the granulations, without mentioning the in- 
conveniences attendant upon change of dressings (pain, 
tearing of the wound tissues, etc.). In certain condi- 
tions, pus is a useful adjuvant to the process of 
cicatrization. The technique employed by Hartel con- 
sists in the use of impermeable material which covers 
the wounded surface completely. The surrounding 
skin is covered with a dermatol-zinc oxide ointment, 
after which the impermeable dressings are held in place 
by gauze, and the whole retained by a roller bandage. 
If retention of fluids is too great, di'ainage of the 
declivitous parts of the wound cavity may be resorted 
to. The result of this method is, that after a few days 
under the free production of pus will be found granu- 
lations in full development. This procedure is to be 
used in all cases of clean, open wounds, but in irregular, 
doubtful wounds it is contraindicated. 

The Presence of Virulent Tubercle Bacilli in tha 
Blood After the Exhibition of Tuberculin, in Cutaneous 
and Other Tuberculoses. — W. Schonfeld finds that the 
passage of bacilli into the circulation in cutaneous 
tuberculosis is infrequent. The production of this 
bacillemia was not made evident by injections of tuber- 
culin or the intravenous use of cyanide of gold. Finally, 
Schonfeld considers as doubtful the attribution of an 
atypical tuberculous reaction to a tuberculosis in the 
given subject. These conclusions have been come to from 
results derived from a series of injections made in 
the guinea-pig of blood taken from patients before and 
after treatment with tuberculin. 



Hunchener medizinische Wochenschrift. 

April 9, 191S. 

The Cause of Essential Night-Blindness. — L. Koeppe 
again brings up the question of hemeralopia on ac- 
count of its present importance in military medicine. 
In opposition to those who attribute this v'sual defect 
to lesions of the nervous system, retinal malformations, 
circulatory disturbances, etc., the writer places the 
cause in a diminished transparency of the cornea and 
lens. Evening light produces cecity, because the rela- 
tive opacity of these structures intercepts the light 
rays, so that the point of retinal excitation is not 
reached. Koeppe has been able to demonstrate these 
anomalies in transparence by means of a Nernst lamp 
provided with a slit thus giving a centuple enlargement. 
Hemerolopic patients frequently offer these changes, 
while by an ordinary visual examination no change of 
the cornea or lens will be detected. The writer believes 
that his method is a means of verifying hemerolopia 
in subjects who claim to have night-blindness and that 
any simulation on the part of the subject can be de- 
tected. 

Frenuent Diagnostic Mistakes, Particularly in Phys- 
ical Diagnosis. — A. Heinecke, who is the director of an 
observation clinic to which all doubtful cases or those in 



which the diagnosis is difficult are sent, as well as 
soldiers requinng expert opinion as to their militarj' 
aptitude, oflers this paper. He has been able to send 
back to active service 77.*3 per cent, of the cases sub- 
mitted to his examination, 47.9 per cent, returning to 
the front. He has been able to note that the most 
general diagnostic error has been that of puhnonarj- 
tuberculosis which did not exist. He has become very 
critical in regard to the physical diagiiostic means gen- 
erally employed. Thus, of all findings by ausculta- 
tion, he looks upon rales as the only certain sign (when 
all characteristic evidences of pulmonary tuberculosis 
are absent) of tuberculosis. Comparative percussion of 
the apices may cause erroneous interpretation when 
there exists a slight scoliosis, even when the spinous 
apophyses are perfectly in line. Asymetry of the 
claviculae and ribs is also a source of ei'ror in physical 
diagnosis. To conclude, the writer opposes the modem 
tendency to make a too fine physical examination as this 
only tends to increase the number of mistaken diag- 
noses. 



Correspondenz-Blatt fiir Schweizer Aerzte. 

March 2, 1918. 

Epidemic of Diphtheria in Basle. — Massini refers to 
an epidemic which prevailed during the late winter. 
A number of the victims were treated by the author in 
the Civil Hospital. The incidence was rather cumu- 
lative than epidepiic, and in the last month five of the 
interned children died from larjiigeal diphtheria. There 
were no deaths from the pharyngeal and nasal localiza- 
tions. All the recovered children received their serum 
either early (pharyngeal cases 2.5 days) or late (nasal 
cases 20 days). The dead children did not receive 
serum until an average of more than 6 days had ex- 
pired; while in children who recovered from laryngeal 
diphtheria the interval was but 2.3 days. It is very 
rare for death to occur in diphtheria when the mem- 
brane has been expelled in the first two or three days, 
and this result we see when serum is given early. 
Serum sickness in the form of a rash was seen 12 times, 
while anaphylactic phenomena were quite absent. The 
author would not term this epidemic a severe one, for 
the measure of severity is high morbidity and mortality 
in adults. It is, of course, conceivable that in such 
cases virulence can attain such a pitch that the action 
of serum becomes problematical. 

Is Salvarsan of Value in .Amebic Dysentery? — Heim 
asks if salvarsan may not be the equal of emetine as 
an antiprotozoan remedy. A study of recent litera- 
ture shows that this practical subject seems to 
have received little attention. The author having 
treated a patient, without success, with emetine, 
obtained his chance to test arsenobenzol. The case 
was eminently amebic in clinical characters, re- 
lapses occurring from time to time over a period of 
years. The Wassermann was negative, so that no 
claim could be urged of a syphilitic substratum. Ame- 
bus were present in the stools in small numbers only. 
The patient, whose relapse had at first been mild 
and controllable with emetine, had become much worse, 
and was confined to his bed with many daily evacua- 
tions. The author chose to use neosalvarsan in the 
form of an enema, and benefit was at once apparent. 
After six of these enemas during a fortnight the pa- 
tient was practically well. He had a mild relapse 
six months later which yielded to a single enema of 
neosalvarsan. Similar results were obtained in other 
cases, so that the author does not hesitate to use 
salvarsan whenever emetine proves unequal to the 
task of controlling the disease. 



Night Blindness in Troops. — Landott has separate*! 
these into three classes. In false hemeralopia or noc- 
turnal amblyopia we have to deal with refractive errors 
including lesions of the cornea. In true hemeralopia 
we have to deal with retinochoroiditis, retinitis pigmen- 
tosa, choroiditis, etc., the effects of which on visual 
acuteness had been latent before the night life of the 
war. The first class may require only glasses, while the 
second should be transferred to the auxiliary services. 
Finally we have the hemera'onia due to poor food and 
malhv.irione which yields rapidly to regimen. — La Press* 
M^dicale. 



July 6, 1918] 



MEDICAL RECORD. 



35 



look ^vutos. 

Blood Transfusion, Hemorrhage and the Anemias. 
By Bertram N. Bernheim, A.B., M.D., F.A.C.G., 
Instructor in Clinical Surgery, the Johns Hopkins 
University; Captain, Medical Officers' Reserve Corps, 
U. S. Army; Author of "Surgery of the Vascular 
System," etc. Price, $4.00. Pniladelphia and Lon- 
don: J. B. Lippineott Company. 
Bernheim has rendered a genuine service to the pro- 
fession in writing this book at the present time. The 
work is the logical outcome of the author's large prac- 
tical experience in blood transfusion during the past 
few years; in fact, since the procedure became recog- 
nized as an invaluable adjunct to the therapeutic 
armamentarium in the treatment of the anemias. He 
begins with an introductory note containing an inter- 
esting historical resume of transfusion from the 
earliest times dovm to the present. Four periods are 
demarcated. The first comprises the early abortive 
attempts of archaic interest only. The second is the 
period initiated by Carrel's work on blood vessels, 
which was the beginning of modern research into the 
problem. This period includes Crile's arteriovenous 
direct transfusion technique. The third period is that 
of indirect transfusion of whole blood by means of the 
syringe-cannula technique, introduced by Lindeman, 
and which is in reality a revival of von Ziemssen's 
old method long forgotten. The fourth period is just 
beginning, according to the author, and may well be 
termed the Period of Anticoagulants. The book con- 
tains twelve chapters with the following captions: 
Blood and the phenomenon of bleeding; diagnosis of 
hemorrhage; control of hemorrhage, factors involved 
in a determination of danger limits, blood pressure; 
indications for transfusion; dangers of transfusion, 
hemolysis and agglutination ; selection of donor for 
transfusion, dangers to donor, treatment of donor after 
transfusion; methods of transfusion, technique; trans- 
fusion for acute hemorrhage and shock, etc., etc.; 
transfusion for anemic and debilitated conditions in 
general; primary pernicious anemia; transfusion for 
hemophilia, melena neonatorum, purpura, jaundice; 
leucemia, splenic anemia, certain toxemias. Each sub- 
ject is treated in a thorough manner without dwelling 
upon irrelevant details. "The indications for transfu- 
sion are considered at length and numerous clinical 
citations are included to emphasize its value. A list 
of references is given at the end of each chapter, per- 
taining to the topic under discussion. The book is 
concluded by an appendix containing hemolysis and 
agglutination tests to be carried out before transfusion. 
To anyone interested in the subject of blood transfusion, 
Bernheim's work will appeal as being a sound, prac- 
tical treatise well worth perusal. 

The Medical Clinics of North America. New York 
Number. November, 1917. Vol. 1, No. 3. Published 
Bi-monthly. Price, $10.00 per year. Philadelphia 
and London : W. B. Saunders Company. 
This number of the Medical Clinics is replete with 
much valuable and up-to-the-minute information on 
a well selected list of subjects. A few of the more 
important ones might be mentioned as illustrating the 
general high level of the contents. Dr. Warfield T. 
Longcope, in his clinic at the Presbyterian Hospital, 
adds a case of Vaquez's Disease to the literature of 
this rather rare malady. Prof. Graham Lusk gives 
a very practical dissertation on "Calories in Common 
Life," being an estimate of food requirements in health 
and disease. Dr. Warren Coleman has a contribution 
on typhoid diet with an exposition of the high calory 
principle, rules for calculation of such a regimen, 
menus for the different stages of the infection, cau- 
tions to be observed, and the question of hemorrhage 
in its relation to diet. The writer states that he be- 
lieves the principle underlying the high calory diet is 
applicable to other febrile diseases than typhoid fever. 
Dr. Rufus Cole contributes an excellent article on the 
treatment of lobar pneumonia, in which the impoi'tance 
of identifying the type of infecting organism is empha- 
sized. Detailed directions are given by Cole regarding 
the use of antipneumonic serum. Dr. Alfred E. Cohn 
on the clinical pharmacology of digitalis gives many 
useful suggestions as to the use of this all-important 



drug. The newer ideas on protein sensitization in the 
human is considered by Dr. Robert A. Cooke in two 
lectures, during the course of which he takes up the 
diagnosis of bronchial asthma and hay fever, and dis- 
cusses the value of protein injections in these condi- 
tions. The value of the fluoroscopic method of diag- 
nosis in digestive diseases by Dr. Arthur L. Holland, 
and a symposium on diabetes by Dr. H. R. Geyelin are 
two conti-ibutions of decided merit 

Vagotonia. A Clinical Study in Vegetative Neurology. 
By Dr. Hans Eppinger and Dr. Leo Hess of Vienna. 
Authorized translation by Drs. Walter Max Kraus, 
A.M., M.D., and Smith Ely Jelliffe, M.D., Ph.D. 
(Second, revised and corrected edition.) Nervous 
and Mental Disease Monograph Series, No. 20. Price, 
$1.00 net. New York: The Nervous and Mental 
Disease Pub. Co., 1917. 

Just as the broad term "epilepsy" is coming to be 
applied to a smaller and smaller group of patients, 
so increasing knowledge of the obscure regions of 
neuropathology will decrease the ranks of patients 
whom we have been in the habit of labelling simply 
"nervous." The autonomic nervous system is probably 
the least understood of any part of the human body, 
and the existence of a disease syndrome consisting of 
abnormal irritability of this system is little enough 
appreciated by the large majority of the profession to 
make the present volume very welcome. The first edi- 
tion was rapidly exhausted, and this one is practically 
a reprint, although some minor changes have been 
made. It is a remarkably clear presentation of the 
known facts of the subject, with suggestions for future 
research, the whole bound in the Continental method — 
that is, heavy paper covers, a custom at which many 
American doctors are wont to carp. 

A Treatise on Regional Surgery by Various 
Authors. Edited by John Fairbairn Bin.xie, A. M., 
CM., F.A.C.S., Kansas City, Mo. Vol. III. Octavo 
of 830 Pages with 521 Illustrations. Price $7.00 net. 
Philadelphia: P. Blakiston's Son & Company, 1917. 

This is the final volume of this set and while, accord- 
ing to the announcement opposite the title page, it is 
supposed to cover only the surgery of the extremities, 
there is also a section on thoracic surgery which 
should have appeared in the first volume along with 
the articles covering the surgery of the heart, pericar- 
dium, diaphragm, and breast. Lilienthal and Ger- 
ster's section on thoracic surgery, although hidden 
away at the back of the book, is not only one of the 
most important, but one of the most scholarly in the 
volume. 

The standard set by the articles in the second volume 
perhaps led us to expect too much of this one, and 
possibly that is one reason why this seems somewhat 
disappointing. In this volume particularly there is 
entirely too much overlapping of material. There 
seems to be no good reason why such subjects as 
traumata (exclusive of fractures and dislocations, 
which require individual consideration), osteomyelitis, 
tumors, and numerous other subjects could not have 
been covered by one author, who might point out any 
occasional differences arising when one or the other ex- 
tremity was concerned, rather than for one author to 
describe, for example, boils, carbuncles, bone cysts, etc., 
etc., as affecting the upper extremity and then for an- 
other author to duplicate the process for the lower ex- 
tremity. A great deal of space could have been saved 
without loss of anything essential. 

The following authors have contributed to this vol- 
ume: Drs. James F. Mitchell, J. W. Perkins, A. F. 
Jonas, Dean Lewis, E. H. Bradford. Robert Soutter, 
J. F. Binnie, W. J. Frick, Charles Herbert Pagge, 
Emmet Rixford, Stanley Stillman, David McCrae Ait- 
ken, Howard Lilienthal. John C. A. Gerster, Sir W. 
Arbuthnot Lane and Sir Robert Jones. Among th« 
sections that deserve special mention are those on frac- 
tures and dislocations, both of the upper and lower 
e.\tremities, by Perkins, Jonas, Lane, and Fagge; the 
long section on diseases of the upper extremity by 
Dean Lewis; the sections on deformities of the lower 
limbs, congenital dislocation of the hip, and infantile 
paralysis by Jones and Aitken, and the section on 
thoracic surgery by Lilienthal and Gerster. 



36 



MEDICAL RECORD. 



[July 6, 1918 



AMERICAN MEDICAL ASSOCIATION. 

Si-rty-itinih Annual Meeting Held in Chicago, June 

10-14, 1918. 

(Special lieport to the Medical Record.) 

SECTION ON THE PRACTICE OF MEDICINE. 

First Day — Wednesday, J^ine 12. 
{Continued from Vol. 93, page 1149.) 

Neurocirculatory A.sthenja. — ^Drs. William H. Robev, 
Jr., of Boston and Ern.st Boas of New York presented 
this communication, which. was read by Dr. Robey, and 
in which they said that the condition to which the name 
"neurocirculatory asthenia" had been recently given 
had been previously described under the names of "sol- 
dier's heart" and "effort syndrome." The symptoms of 
this condition were breathlessness on exertion, tachy- 
cardia, palpitation, precordial pain, vertigo, fatigue on 
slight exertion, lassitude, high blood pressure, and gen- 
eral nervous instability. AH the symptoms were exagger- 
ated by a slight amount of exercise. The condition was 
known in civil practice, but because the individuals suf- 
fering from it spared themselves and took up certain 
work compatible with the condition it was not so fre- 
quently observed by the civil physician; but in the 
Army, where everyone must do the same work and must 
adapt himself to the work, it was quite frequently ob- 
served and was responsible for a certain degree of in- 
validism. The condition was often diagnosed as or- 
ganic heart disease, because of the precordial pain 
usually present and the elicited thrills which suggested 
mitral stenosis. The thrills, however, in the condition 
described, were systolic in time. In some soldiers the 
condition was present before entering the service, in 
others it occurred after entering the service, and in still 
others only the greatest stress gave rise to that condi- 
tion. Until recently there had been no category of light 
work in the army and the men presenting the symptoms 
described had been usually discharged. Lewis treated 
these cases with calisthenic exercises, progressing 
slowly from one form of exercise to another, and those 
that could not go through with the entire series were 
discharged. In the essayist's experience that form of 
treatment had no value as a cure, but was of some diag- 
nostic value. They had become convinced that the con- 
dition was due to an inherent nervous instability. A 
vast number of the patients gave a family history of 
nervous disease and their personal histories indicated 
that they had always been somewhat unstable ; they 
could not stand any extra strain and could not meet con- 
ditions requiring special effort; many gave a history 
of enuresis in childhood, objectively they showed twitch- 
ing of the fingers and emotional instability, and were 
subject to crying. Some writers mentioned hyperthy- 
roidism in connection with that syndrome, but the 
authors had not observed any changes in the thyroid. 

Sir James McKenzie of England, who was introduced 
by the Chairman as the man who had made the study of 
cardiovascular disease popular here and abroad, said 
he wished to preach the gospel of clinical investigation. 
Instead of spending so much time in studying what hap- 
pened when the patient was dead, the time should be de- 
voted to the study of the patient's symptoms. The sen- 
sations of the patient should be studied accurately. 
Such symptoms as fever and pain had not been studied 
sufficiently. Pain was often described as diffu.se. In 
his opinion, however, there was no diffuse pain, but il 
was governed by definite laws. During the Civil War 
he had read descriptions of "soldier's heart." but when 
he had visited the hospitals nobody was able to demon- 
strate that condition to him. In England he had grouped 
500 soldiers who were discharged from the service be- 
cause of valvular disease of the heart and disordered 
action of the heart, and in 90 per cent, of the cases 
there was no organic disease. The murmurs which had 
been elicited were functional or, better, physiological. 
When a murmur was found the question should be, 
What deficiency did the murmur produce"? The entire 
problem was that of the myocardium and not murmurs. 
He liFid foll()Wi.'(l ;i im.H' witli m presystolic- miii-mur for 



eighteen years and then the murmur had disappeared. 
He had never been able to hear a Flint murmur nor a 
Steel murmur. He did not object to the name of effort 
syndrome or the new name neurocirculatory asthenia, 
but the trouble was that many stopped at names, as 
soon as a condition was labeled that seemed to solve the 
problem. The symptoms should be more carefully 
studied. The asthenia was not confined to the ner\'ous 
system, but the entire system was asthenic. In many 
cases of functional heart condition, by careful ques- 
tioning of the patient, one frequently elicited a history 
of cough, diarrhea, malaria, etc., a week or ten days 
previously, and these patients were simply convalescing 
from some form of an infection. He had sent a man 
with an aortic murmur into the trenches with a certifi- 
cate that he was able to do easy work, and whenever 
that soldier wanted a rest or a little vacation he would 
go to the division surgeon and the latter, upon listening 
to his heart, would shake his head and immediately send 
him to the hospital. .\ny man when subjected to 
strong physical exertion gave way somewhere — some 
got tired in their legs while others got short of breath. 
The symptoms of exhaustion, in his opinion, deserved 
very careful study. He did not suggest the particjlar 
exercise Dr. Lewis was using in the heart conditions 
mentioned ; all he wanted was that the patients should 
do something in which they were interested. Any man 
who was able to take exercise and enjoy it was doing 
his heart good and not harm. 

Dr. Warfield of Milwaukee said he was very much 
interested in this subject. He had been in Camp Jack- 
son, where 50,000 men passed. He had seen all the 
heart cases and he wished to know how the condition 
described could be determined. The exercises given 
were in many cases sufficient only to bring out the gross 
lesions; many patients could perform various exercises, 
return to normal easily, and still have a murmur. He 
thought such men should be retained in the service. He 
wished to know if there was a way whereby in the re- 
cruiting station it could be told who was going to break 
down. He had only seen one case that he was able to 
diagnose as "effort syndrome." Some were cases of 
hyperthyroidism, some cases were called by the psy- 
chiatrist psychoneurosis, and some turned out to be 
tuberculosis, but there were many cases with trivial 
heart lesions. The question was an important one for 
those who were doing recruiting (!uty. 

Dr. Litchfield of Pittsburgh wanted Sir James 
MacKenzie to say something about the influence of 
tobacco on the heart. With the outbreak of the war 
the tobacco trust, through adroit advertising, ha>l im- 
pressed the public with the importance that tobacco 
played in keeping the soldier in good spirits, and as a 
result everybody — from friend, relative, to various chari- 
table organization — had made a special effort to see 
that the soldier was well supplied with tobacco. The 
excessive supply of which the soldier found himself to 
be the possessor resulted in its excessive use, in con- 
sequence of which various functional heart conditions 
had developed. When the smoking was stopped, as upon 
admisision to a hospital, the condition quickly disap- 
peared. 

Sir James Mackenzie said that at the beginning of 
recruiting in England many young men were shocked 
to know that they had murmurs; many had consulted 
him because they had been turned down by the recruit- 
ing officer. He wished to impress upon the hearers that 
perfectly physiological hearts might have murmurs and 
a murmur systolic in time might be perfectly normal. 
If there was no enlargement of the heart, if the rhythm 
and rapidity were normal, and there was good response 
to effort, one should forget about the murmur. In his 
opinion there was no such thing as mitral regurgita- 
tion of first or second degrees; he had kept records of 
the rejected cases and had become convinced of the 
harmlessness of niurnuirs. One man who had had a 
rough systolic murmur at the apex had been rejected 
by the army six times, but upon Dr. MaeKenzie's per- 
sonal recommendation had been finally accepted and, 
after three years' hardest work in the trenches, was as 
vigorous as ever. Hyperthyroidism was another craze. 
He had examined three hundred cases that were diag- 
nosed so and in none was he able to find an enlarged 
thyroid. Tobacco in many cases might be a predis- 
posin'r i-.niise, hut was only .mo symptom and one should 



July 6, 1918] 



MEDICAL RECORD. 



37 



never depend on one symptom alone. In his book he 
had described an X type. He called it X because he 
did not know what the condition was due to. Patients 
suffering with that type of heart condition were poorly 
nourished, their peripheral circulation was poor, they 
did not respond to cold, were afraid of a cold bath, were 
red-nosed, and of an irritable temper. Such people had 
irritable hearts and under army life would easily bi'eak 
down. Some would call them psychasthenia, but it was 
more probable that the condition was due to an ileostasis 
or some other gastriointestinal condition. 

Dr. Oppenheimer of New York said that last sum- 
mer the Surgeon-General had sent six American officers 
of the Reserve Medical Corps to the British Military 
Heart Hospital, with which Sir James MacKenzie had 
been connected since its inception. After serving there 
for several months they had written an independent 
report in which they suggested the new name, neurocir- 
culatory asthenia, for the now familiar symptom com- 
plex. After the completion of the report Dr. Thomas 
Lewis had written a brief but valuable foreword show- 
ing its military bearing in relation to the young Ameri- 
can forces. By some mistake, however, the paper was 
printed in the April issue of The Military Surgeon, with 
Dr. Lewis as the author; the names of the six American 
officers really responsible for the report and also for 
the introduction of the name were entirely omitted. 
This explanation he thought might make certain parts 
of that paper more intelligent. Several other names had 
been used, such as "disordered action of the heart," 
"irritable heart of soldiers," "effort syndrome," "ath- 
letes' heart," "cardiac neurosis," etc., but the use of any 
term which directed the soldier's attention to his heart 
handicapped him and the officer who dealt with him. 
Neurocirculatory asthenia overcame that objection ; 
moreover, the name was not meant to imply any theory 
of the fundamental pathology, which was still unknown. 
It was purely a descriptive term, indicating that in this 
syndrome there were nervous and circulatory syniptoms 
associated with an increased susceptibility to fatigue. 
Since returning to America there had been an oppor- 
tunity to compare the cases among the American re- 
cruits who had broken down in training with such sjTnp- 
tem with the British soldiers who were invalided fx'om 
the front with "D. A. H." The condition as seen in 
England and America was identical, but the cases here 
were milder and, as Major Robey and Captain Boas 
pointed out, belonged almost entirely to the constitu- 
tional group; i.e. to the group that had symptoms prior 
to entrance into service. The question of fundamental 
pathology, especially that of hyperthyroidism, was here 
complicated by the great prevalence of thyroid enlarge- 
ment in the "thyroid belt" of the Great Lakes. Some of 
these men had a simple thyroid enlargement, some 
suffered from thyreotoxic hearts, but it was exceptional 
to find a typical case of Graves' disease. As to the 
question of nervous instability which Major Robey had 
emphasized. Captain Rothschild and the speaker had 
taken in detail the family and the personal histories of 
one hundred soldiers in Colchester, and found that 4G 
per cent, had predisposing neuropsychic factors in their 
family and previous histories, but that thirty-nine had 
absolutely negative histories and had given valuable 
military service before breaking down. Dr. Warfield 
had asked a very important question. In answer, one 
might say that only a certain percentage of cases could 
be picked out in the initial examination of drafted men, 
for the disorder might not develop uutil the soldier was 
exposed to the conditions of modern warfare. In view 
of the abundance of perfectly normal recruits in this 
country, every man who was sent overseas should be 
fit, and, for the present at least, it was sound to reject 
doubtful or borderline cases. 

Dr. Jacobi of New York said in addition to the 
mitral murmur the presence of hypertrophy or dilata- 
tion, or both, was also necessary in order to make a 
diagnosis of organic heart disease. Some murmurs 
were changeable, they were present one day and not the 
other; some appeared only after exertion. Many con- 
ditions called myocarditis were due to nervous irritabil- 
ity as a result of excessive use of tobacco. In some 
patients murmurs appeared after running up and down 
stairs, but disappeared after ten minutes' rest. Such 
people could very easily do a certain amount of good 
work and need not be rejected from the service. 



Dr. Robey, in closing the discussion, said that out of 
26,000 men examined only a few cases of organic disease 
had been found; the entire question was that of mus- 
cular efficiency. Out of the 26,000 men examined only 
200 were diagnosed as subjects of circulatory asthenia, 
and as they had not been pressed for men and it was a 
real condition, it was thought best to reject them. 
There was no way of telling at the recruiting station 
who would break down as a result of such a condition. 

Newer Aspects of Digitalis Therapy. — Drs. Joseph 
H. Pratt and Hy.man Morrison of Boston presented 
this communication, which was read by Dr. Pratt. They 
stated that the usefulness of digitalis was not appre- 
ciated until recent times, although in 1785 Withering 
cMlled attention to its therapy in a very exhaustive 
paper called "The Truth About Fox Glove." His thesis 
was to continue administi'ation until the drug acted on 
the heart, kidney, pulse, or stomach and MacKenzie 
a hundred years later recorded the same postulates. 
The essayists stated that most of the digitalis on the 
market was of poor quality and variable in strength, 
of thirty samples tested, twenty-four of which were 
native grown, seventeen were below U. S. P. strength 
and the extreme of variation was 700 per cent. Physi- 
cians feared unjustifiably large doses of this drug; weak 
preparations were given and the use of the infusion 
should be condemned. One c.c. of a good tincture of 
digitalis produced a physiological effect in three days. 
Regarding strophanthin they considered the drug in- 
travenously a life-saving measure. Unpleasant results 
which followed its administration were due to large 
doses; they never gave more than one-half milligram 
per dose. They were convinced that in some cases 
strophanthin produced therapeutic effects which could 
never be obtained by digitalis. They emphasized the 
importance of using an active preparation and in suffi- 
ciently large doses to obtain results. 

Sir James MacKenzie said he could give support to 
everything Dr. Pratt had stated; he, however, never 
found a weak preparation in England. It grieved him 
in years bygone to see medical men from the United 
States pass through England jump over to Germany 
and come back with some kind of an instrument, carry- 
ing it as a false-god. They might have waited a little 
to see what England was doing. Undue importance was 
given to laboratory investigation and the clinical side 
was neglected. In England they had followed more 
the system of clinical investigation and inen like Hun- 
ter and others who were known in this country as 
surgeons were primarily clinicians. Withering, under 
the system of clinical observation, had been able to 
write a better paper one hundred and twenty years ago 
than anyone had written since with all the laboratory 
methods at hand. 

Second Day — Fridaij, June 14. 

Symposium on Pneumonia : Unique Findings Gathered 
from the Observation of Eleven Hundred Cases of 
I'neumonia in a Base Hospital. — Dr. .\rthiir A. Sm.4LL 
of Chicago presented this paper. The cases studied 
comprised 857 lobar and 208 bronchial pneumonias. 
The ordinary lobar type, as seen in civil practice, pre- 
vailed during September and October, but in November 
and December the incidence became greater with pro- 
portionately more bronchial cases and a higher mor- 
tality. Thus in the last two named months the mor- 
tality was 29 per cent, and this continued during 
January, and during that month the mortality of the 
lironchial cases rose to 5-3 per cent. This high 
mortality was difficult to account for unless it was 
attributed to the fact that many of the cases were 
secondary to measles. \ surprising feature of the so- 
called streptococcic bronchial pneumonia cases was the 
paucity of sj-mptoms both subjective and objective. A 
slight cough, a few rales, and perhaps no subjective 
complaint often formed the entire clinical picture at 
first, twelve to twenty four hours later there would be 
a small consolidated area with tubular breathing, usu- 
ally in the scapular region. A malignant type some- 
times occurred, the patient would be slightly ill in the 
morning, admitted to the hospital in the evening, and 
a fatal result would occur the following morning. 
Post-mortem findings would reveal lymphadenitis, acute 
pleuritis, bronchial and lobar pneumonia in the same 
patient. Empyema had occurred in i).25 per cent, of 



88 



MEDICAL RECORD. 



IJuly 6, 1918 



all cases. The condition was very hard to diagnose. 
AT-ray pictures revealed pocket formation of pus in 
locations that could not be detected by exploratory 
puncture or from physical signs. Forty-eight per cent, 
of the empyemas were due to streptococci, ilany cases 
were diagnosed as meningitis on account of the pres- 
ence of Koenig's sign, stiffness of the neck, and head- 
ache. Others presented symptoms of appendicitis. Jaun- 
dice was not infrequent especially in the negro; another 
frequent complication was pericarditis. The high mor- 
tality might be attributed to the fact that during the 
first four months the physical condition of the men 
was poor, there was a great deal of dust in the camps, 
the men frequently went to bed with wet clothes on, 
the prevalence of measles. Tonsils were enlarged in 
many cases, which in turn predisposed the men to many 
respiratory infections as coryza, bronchitis, etc., which 
in turn contributed to the development of pneumonia. 

An Epidemic of Streptococcus Pneumonia and Em- 
pyema at Camp Dodge. — Drs. Joseph L. Miller and 
Frank B. Lusk of Chicago presented this communica- 
tion which was read by l3r. Miller. They stated that 
they had observed 740 cases of pneumonia of both types 
in Camp Dodge between the months of September and 
April. Between the months of September and March 
the pneumonias were mostly of the pneumococcic type 
with the same mortality as observed in civil life, but 
along the month of March the streptococcic type devel- 
oped. This type of pneumonia gave an unusual high 
mortality and in a large per cent, of cases developed 
empyema in which the mortality had reached about 60 
per cent. The colored troops, however, were less liable 
to empyema but the mortality from uncomplicated pneu- 
monia was higher in the colored than in the white. 
The patients appeared very ill. Marked toxemia was 
present but physical signs were less definite. The 
rapidity of the occurrence of empyema was remarkable, 
frequently following within twenty four hours after 
patient's admission to the hospital. The greatest diffi- 
culty was encountered in the detection of fluid. Physical 
signs would show good breath sounds, bronchial breath- 
ing with some rales, the patient frequently dying 
twenty-four hours later and presenting upon autopsy 
large amounts of fluid which was due to the peculiar 
pocket formation, rendering it almost impossible of 
detection by means of physical signs and even by ex- 
ploratory puncture. The a;-ray was resorted to fre- 
quently, every case admitted to the ward was a'-rayed 
within the first twenty-four hours and every five days 
while the temperature continued to show any elevation. 
Many cases of bronchitis with a temperature of 101°, 
under r-ray examination proved to be pneumonia ; but 
while the rr-ray was of value in detecting consolidation 
it was of far less value for the detection of fluid, and 
frequent aspiration had to be depended upon in order 
to make a diagnosis of fluid. Empyema developed in 
33 per cent, of the pneumonia cases and many empyemas 
were complicated by peritonitis, suppurative pericar- 
ditis, and arthritis. While the mortality from non- 
complicating pneumonia was higher in the negro than 
in the white, the mortality from empyema in the negro 
was lower than in the white. The contributing causes 
of the epidemic were the dry, warm, and exceedingly 
dusty month of March, the frequent drills, the preval- 
ence of coryza and bronchitis, overcrowded condition 
of the sleeping rooms, cots being too near one another, 
and the fact that the windows were not kept open, 
which was especially true of the colored troops who in 
addition to closing the windows frequently covered up 
their heads with their blankets. The treatment during 
the epidemic consisted in the administration of 1 c.c. 
of a carefully standardized tincture of digitalis every 
three hours until the crisis occurred, the administration 
of morphine for cough or restlessness and the admin- 
istration of camphorated oil in bad heart cases. The 
streptococcic empyemas did not respond well to early 
surgical interference; the first thirty-two cases were 
operated upon early with quite disastrous results. Re- 
peated aspirations until the fluid became purulent 
when operation was resorted to was the plan later on 
adopted and better results were obtained. The im- 
provement in the results, however, was only appai-ent, 
as of the thirty-two cases operated on early fi(i per 
cent, resulted fatally, and of eighty-one cases with later 
operations 51 per cent, were fatal. The patients op- 



erated on early, however, died much sooner than the 
cases of later operations. The death in manv cases 
was due to the intense toxemia and not empyema. 
When localized pockets of pus remained undiscovered 
the patients died eventually. Whenever the pus was 
localized in one pocket he got well no matter what 
manner of treatment was followed. 

A Clinical Study of Eight Hundred Cases of Pneu- 
monia. — Drs. WiLLARD J. Stone of Toledo, Oh.o; Bruce 
G. Phillips and Walter P. Bliss of New York pre- 
sented this communication, which was read by Dr. 
Stone. The study embraced all cases of pneumonia 
treated during the period of eight months, of which ap- 
proximately (JSO were primary lobar pneumonia and 
150 pneumonias following measles. The infection had 
been of a seveie type. In only a small number of cases 
was the Pneumococcus Type 1 present. In a far larger 
number of cases the Streptococcus hemolyticixs pre- 
vailed. The occurrence of empyema was unusually fre- 
quent and the mortality as a result of that complication 
was high. The pneumonias following measles were of 
both the lobar and bronchopneumonic type. Empyema 
occurred in twenty-one per cent, of all cases. The mor- 
tality of empyema due to the pneumococcus was 25.8 
per cent., while that due to the streptococcus mortality 
was 74.2 per cent. Early operations for empyema re- 
sulted in a high mortality which had been reduced by 
preliminary aspirations and intrapleural lavage until 
the pneumonic process had subsided when operation fol- 
lowed. 

Streptococcus Pneumonia. — Dr. James G. Cummings 
of Ann Arbor, Mich., read this paper. He stated that 
during the winter months at Fort Sam Houston they 
had a large number of cases of pneumonia which was 
of a severe type complicated very frequently with em- 
pyema. The investigation showed Streptococcus hcmo- 
lyticus was the cause of the epidemic. The germ was 
isolated from the throat sputum and from pleural 
fluids. The germ was frequently spread through the 
use of milk into which it had gotten from the udder 
of the cows infected by humans. This organism was 
frequently found in tonsillitis and in areas to which 
the tonsils had been removed and the swabs from 
throats of patients suff'ering with measles showed a 
large percentage of Streptococcus hcmolytinis, and of 
those many developed pneumonia of the streptococcic 
type. Out of 12 per cent, of pneumonias which de- 
veloped following measles 90 per cent, were carriers of 
the hemolytic streptococcus, while in healthy people 
this organism was present in only six per cent. The 
hemolytic streptococci prepared the way for measles 
and later on for pneumonia. Sixty-one per cent, of 
the pleural exudates following contained the hemolytic 
streptococcus. In thirty-four autopsies of patients who 
died of pneumonia nine cases were of lobar and twenty- 
eight of the bronchopneumonic type. The hemol>'tic 
streptococcus w-as found in about eighty per cent, and 
was obtained in pure culture from bronchial pneumonia 
cases. In the lobar pneumonias the streptococcus was 
found in pure culture or combined with pneumococcus 
Type I. In only one pneumania case following measles 
was the pneumococcus Type I found alone. In pneu- 
monia due to hemolytic streptococci the mortality was 
82 per cent. It w-as important therefore to determine 
in a given case of pneumonia whether the cause of the 
organism was the pneumococcus or the streptococcus. 
Instead of dividing the pneumonias in the lobar and 
bronchial pneumonic types we should speak of pneu- 
mococcic and streptococcic pneumonia. .'Ml patients 
who were carriers of .streptococci should have their 
tonsils removed ; the milk supply should be sterilized 
and patients should be isolated or protected from one 
another by masks. The development of a streptococ- 
cic vaccine off'ered vast hopes for the successful treat- 
ment of that form of pneumonia. 

The Pathology of the Pneumonia of the Army Camp. 
— Dr. William G. MacCallum of Baltimore read this 
paper. He said a study of pneumonia in an army 
camp was undertaken during February and March. 
There were numerous cases of lobar pneumonia due to 
one or other typo of pneumococcus. There were, how- 
ever, still more cases of a peculiar bronchopneumonia 
due to infection with a hemolytic streptococcus. This 
condition frequently followed directly on measles which 
was very prevalent, but occurred also after scarlet 



I 



July 6, 1918] 



MEDICAL RECORD. 



39 



fever and in many cases in which there was no history 
of measles. The rapid interstitial infiltration of the 
tissues and organization of the exudate suggested the 
name interstitial bronchopneumonia for this type. Modi- 
fications of this lesion were found in cases of over- 
whelmingly violent infection. Combinations of lobar 
pneumonia and interstitial bronchopneumonia occurred. 
No septicemia had been found in the interstitial type 
of pneumonia except a few hours before death and 
after death. During life the germ was found in the 
sputum, in pleural effusions, and frequently in peri- 
cardial fluid. Streptococcic infection produced a 
marked congestion and inflammation of the respiratory 
tract; laryngitis with ulceration and tracheitis were 
common. Infection was rather localized, distant 
regions becoming involved by extension. Empyema was 
of extremely frequent occurrence. The conclusion as 
a result of the pathological studies was that though the 
infection caused by the hemolytic streptococcus was 
due to some predisposing cause such as measles, so far 
as pneumonia was concerned it was a distinct disease 
with as distinct a pathology as the primary pneumonia 
due to the pneumococcus. 

Practical Consideration of Epidemiology Drawn from 
a Classification of Streptococci. — Dr. Ralph A. Kin- 
SELLA of St. Louis read this paper, in which he stated 
the previous work on classification of non-hemolj'tic 
streptococci indicated that this variety was highly vari- 
able. This variability seemed to depend on the exist- 
ence of two opposite elements in the group, the indi- 
viduality of any one member being determined by how 
much of one or the other element it displayed. Recent 
work on the classification of hemolytic streptococci indi- 
cated lack of variability, all strains studied being iden- 
tical. The complement fixation reaction was the cri- 
terion on which the classifications were based, it being 
considered that the best basis for classification was an 
immunologic one, since bacteria owed their importance 
in medicine to their presence in man and their patho- 
genicity. His studies of the various groups of strep- 
tococci had demonstrated that no disease was shown to 
be due solely to one type of non-heniolytic streptococci, 
which lived under many conditions and were widely 
distributed, while the hemolytic streptococcus was rare 
in normal man, had a highly invasive capacity, was 
milk borne, and its presence in empyema was demon- 
strated in pure culture. The more widespread a bac- 
terium was the greater was its variability and the less 
was its pathogenicity. This was best illustrated by 
the colon and typhoid bacilli. Of the pneumonias Type 
I had little variation, was not found in normal man, 
and was therefore highly pathogenic, while Type IV, 
which was widely distributed, was frequently found in 
norma! man and was least pathogenic. The conclusion 
was that widespread heterogeneous bacteria were least 
invastive and rarely spread infection. 

Dr. Welch of Baltimore said one year ago such a 
discussion would have been an impossibility; a new 
problem had arisen ; a new knowledge had come. When 
many cases of pneumonia appeared in camps they were 
thought to be entirely secondary to measles or due to 
other predisposing causes, as lack of warm clothing, 
cold weather, overcrowding, a great amount of dust 
and wind. Such was then the conception of the etiology 
of pneumonia; physicians were aware as to the pecu- 
liarities of pneumonia, but the experiences in the camps 
was something new. In this connection he wished to 
emphasize the importance of laboratory methods with- 
out which the problem could not have been solved. He 
wished especially to emphasize that it was the coopera- 
tion of the clinician, anatomical pathologist, and bac- 
teriologist which formed the best method for the study 
of disease. The relationship of the streptococcus in- 
fection to the antecedent measles was not known yet. 
It was known that the same type of infection occurred 
in camps where there had been no measles. There was 
a great field open for further study, and the Surgeon 
General had appointed a pneumonia board which was 
to act as a clearing house for all the information ob- 
tained on the subject. The Streptococcus hemolyticus 
was still very little known; it was not known whether 
the germ, like the tubercle or the typhoid bacillus, was 
a definite type vsdth a definite pathogenesis, or whether 
it had acquired a. virulence by having passed through 
susceptible individuals. Measles might have enhanced 



its virulence, but now it was highly virulent by itself. 

Dr. Russell of Washington, D. C, said that the 
study of the mortality in the various camps presented 
many interesting features. Next to meningitis pneu- 
monia was the principal cause of death. In Camps 
Pike, Beauregard, and Wheeler there was a mortality 
of 22 per cent, and over, while in other camps the mor- 
tality had been under 8 per cent. If, however, we con- 
sidered the mortality with relation to the localities 
where the men came from it would be found that the 
high mortality camps were composed of men who came 
from Georgia, Arkansas, Alabama, and other Southern 
States, while the camps with the low mortality were 
composed of men coming from the Northeastern States. 
In camps where the death rate was low the rural popu- 
lation was low, as instanced in New England States, 
while where the mortality was high 78 per cent, of the 
men had come from rural communities. Pneumonia 
had occurred in troops who had not come from thickly 
settled cities. The picture was so clear that the con- 
dition was almost self-evident. Another interesting 
feature brought out was the fact that the more men 
were put on the sick list the lower was the mortality; 
hunting out light cases and caring for them early re- 
duced the death rate. Camps Upton, Mead, and Logan 
had about the same mortality as New York, Baltimore, 
and Chicago, the cities where most of the men came 
from. In Southern camps the mortality had been higher 
than in the nearby cities. The explanation was that 
men coming from the country contracted various dis- 
eases very easily, while the men from the large cities 
appeared to be immune to measles and other disease 
and therefore had a low mortality. During the Civil 
War the same had been observed. Northern troops 
were healthier in Southern camps than the Southern 
troops no matter where located. 

Dr. Cole of New York said he wished to emphasize 
one point about the two tjT)es of pneumonia: one was 
due to the pneumococcus and was endemic; the other, 
to the streptococcus, was epidemic, prevailing at a cer- 
tain time and then disappearing. In animals strepto- 
coccus infection was a secondary disease and, fortu- 
nately, self-limited. The .streptococcus was a variable 
organism and could become very virulent under certain 
conditions. Measles was a predisposing condition to 
streptococcic infection, after which the streptococci be- 
came more virulent. To prevent the spread of the in- 
fection early diagnosis and caieful isolation of patients 
harboring streptococci were important, which in turn 
would tend to prevent the spread of measles. It was 
necessary to have hospitals for infectious diseases in 
every camp. Infectious diseases could not be treated 
successfully in a hospital organized on general basis. 
The two hospitals should be separate with separate 
personnel, should have observation wards and sufficient 
wards to be able to care for various kinds of infection. 
It was not so much a question of building as of organi- 
zation. 

Dr. Bliss of New York said that the subject had been 
very exhaustively discussed and his experience had been 
the same as in all camps. The percentage of empyemas 
was great, the mortality high, being usually due to 
pocket formation. The diagnosis for empyema had to 
be revised. Physical signs, blood counts, a--ray exami- 
nations could not be depended upon. If high tempera- 
ture, pulse, and respiration continued after five or six 
days they looked for fluid, they did not spare the ex- 
ploratory needle. High mortality after operation was 
often due to the spreading of the infection to the oppo- 
site side. They found daily irrigation of the pleural 
cavity with Dakin's solution following operations for 
empyema of great value. Costectomy was much prefer- 
able to thoracotomy. The treatment of pneumonia was 
along the customary lines but they used a standardized 
tincture of digitalis of which every 0.17 c.c. per pound 
of body weight produced the desired physiological effect 
within forty-eight hours; thus a man weighing 120 
pounds received 20 c.c. of that tincture within the first 
forty-eight hours. Serum therapy for Type I pneumo- 
coccus was very beneficial in his experience, but with 
the other sera he did not have sufficient experience to be 
able to pass judgment. There appeared, however, to 
be a considerable lessening of toxic symptoms. 

Dr. McKenna discussed this question from the surgi- 
cal standpoint. He stated that after fourteen days 



40 



MIDICAI. RECORD. 



!July 6, iyi8 



every case was examined with the i-ray and if pus was 
present surgical interference was resorted to. He had 
used the method of draining the pleural cavity instead 
of opening it and the results were very satisfactory. 
The draining of the pleural cavity was performed by 
the introduction of a No. 14 French catheter, by means 
of a trocar and cannula; if the fluid was found to be 
too thick a small quantity of Dakin's solution would 
dissolve it; as much as possible of the pus was removed 
and a corresponding amount of Dakin's solution was 
introduced. This procedure was repeated every three 
hours during the day and several times during the 
night. The fluid obtained from the pleural cavity was 
examined every day and cultures were made in order 
to determine the occurrence of mixed infections. This 
operative procedure minimized the danger of infecting 
the pleural cavity and prevented the collapse of the 
lung which occurred in the older operations. It could be 
repeated with ease and the fluid could be under constant 
bacteriological examination. Out of nineteen cases 
treated by this method all cleared up without sinus 
formation. In the presence of a lung abscess treatment 
with this method resulted in a sudden cough and a 
taste of the solution in the mouth. Out of 130 cases 
treated with the old method 42 per cent, died; the last 
nineteen patients treated with this method were still 
living. This form of treatment was not going to save 
all empyema cases, as a certain percentage were going 
to die no matter what the treatment was; but was of 
great value and had many advantages over the older 
methods. 

Dr. Dick of Chicago said that he had had an oppor- 
tunity to observe the case information in Camps Pike 
and Dodge; in the latter the nonhemolytic streptococcus 
was present in many lobar pneumonia cases. In Camp 
Dodge many patients suffering from pneumonia gave a 
history of exertion, as long hikes. Many cases of strep- 
tococcic pneumonia had suff'ered previously from coryza 
and bronchitis. The disease had not been carefully 
watched. The severity of the epidemic differed at differ- 
ent times, though the treatment was the same and one 
should not therefore lay too much stress on the methods 
of treatment because apparently more favorable results 
had been obtained by changes in treatment. 

Dr. LiCHTY of Pittsburgh said that he had observed 
two types of pneumonia during the past winter at the 
Mercy Hospital at Pittsburgh. One occurred in colored 
people who had come from the South; it was a typical 
lobar pneumonia. The patients were admitted to the 
hospital during the later stage of the disease and the 
mortality was very high. The social service should be 
informed S9 that they might instruct people who were 
moving from one part of the country to another. The 
other group of pneumonias occurred when cold began 
to break up and corresponded with the streptococcic 
cases observed in the Army camps. The course of the 
disease was atypical, there were many empyemas and 
the mortality was very high. This disease developed 
among the more intelligent part of the population but 
the people considered it grippe and did not take enough 
interest in it until too late. He thought laymen should 
be instructed as to the importance of the early signs 
of pneumonia just as they were taught in reference to 
cancer and appendicitis. 

Dr. Lo\'EWELL of the Army said that his experience 
had been similar to that of the various authors of papers 
read. In Camp Snelling they had a number of cases of 
pneumonia during December, but nothing unusual was 
observed until during the month of February 800 cases 
had come on from Texas, after which he had seen 
respiratory diseases he had never seen before. Every 
physical sign obtained had been disproved by autopsy. 
In many cases the pleuritic exudate was of a gelatinous 
type making it impossible to obtain any by puncture. 
A large percentage of the cases developed tuberculosis. 
Another interesting point was the occurrence of puru- 
lent peritonitis and empyema in the same case. 

Dr. Ryan of Des Moines wished to call attention to 
the usefulness of intravenous injections of glucose in 
cases of pneumonia. The subject had been discussed 
during the early part of the session by Dr. Litchfield, 
but his experience had been with 10 per cent, glucose 
to which sodium bicarbonate was added. Many excel- 
lent results were obtained by this form of treatment in 
])ncumonia. 



Later Result.-s of Intraspinous Treatment of Cerebro- 
spinal Syphilis Based on Four Years' Observation. — 

Drs. Clyde L. Cu.mmer of Cleveland and Richard Dex- 
ter of Toledo, Ohio, presented this communication which 
was read by Dr. Cummer. They said that their ex- 
perience during the period of five years with the method 
of intraspinous treatment of neurosyphilis as suggested 
by Swift and Ellis was of great benefit in a certain 
type of cases. Careful clinical observation, together 
with laboratory findings, had convinced them that re- 
sults could be obtained by the intraspinous method 
which could not be obtained in any other way. Some 
patients could not stand intravenous injections very 
well and tabetics often developed severe gastric symp- 
toms under that form of treatment. Such cases fre- 
quently responded to the intraspinous method. They 
did not claim that the intraspinous method had done 
everything that was expected of that method nor was 
the method indicated to supersede other methods, but it 
was merely a good addition for certain types of cases. 
In the experience of the essayists, cases of tabes and 
of syphilitic meningitis were specially amenable to that 
form of treatment. Anatomical cure was not claimed 
in cases of tabes, but in the best cases the ataxia com- 
pletely disappeared, they were free from gastric pains, 
and were able to attend to their previous occupations 
without any difficulty. In cases of paresis where de- 
generative changes had taken place this form of treat- 
ment was of no avail. In the early stages, however, it 
might be of benefit. 

Dr. FORDYXE of New York said that the subject of 
neurosyphilis was a very important one. When the 
nervous system was involved during the floral stage of 
the disease it was very important to recognize the con- 
dition early, as. during that time, it responded well to 
the intraspinous method. Obser\'ation of twenty groups 
of familial and conjugal neurosyphilis had proven that 
a highly virulent spirochete was present which frequent- 
ly affected the meninges during the early stage of the 
disease and even during the administration of salvarsan 
and mercury. In one case 960 cells per c.mm. were 
counted in the spinal fluid, in another 400 cells. Both 
patients had received intravenous and other form of 
syphilitic treatment; they were in a staire of delirium 
as a result of meningeal involvement; both recovered 
•under intraspinous treatment. Early meningitic syphi- 
lis was specially favorably influenced by the intra- 
spinous method, while the degenerative type of cases 
responded to the treatment less favorably. Dissemi- 
nated and localized cerebrospinal types which did not 
respond well to other methods of treatment in his ex- 
perience had responded well to the intraspinous treat- 
ment. Cases of optic atrophy might be arrested by the 
intraspinous method. There were no untoward effects 
as a result of that treatment if a proper technique was 
carried out. During the past four years he had had no 
bad results from this method. 

The Relation of Mastoiditis to .\cute Infectious Con- 
ditions. — Dr. George H. Lathrope of Morristown, N. J., 
read this paper. He said that during the past winter 
Camp Shelby was invaded by an epidemic of pneumonia 
which was caused by the Streptococcus hcmoliiticm'. 
Empyemas were few. but out of 300 pneumonia cases 
123 cases of mastoiditis developed, on either one or 
both sides. The onset was rapid, beginning with pain 
one night, bulging of the drum the next morning, which 
was followed by incision; but within 72 hours the mas- 
toid was involved and filled with thick pus. In some 
cases development of the disease was even n)ore rapid. 
There seemed to have been a virulent type of germ 
which had a spcial predilection for the mastoid. The 
epidemic of mastoid disease seemed to have followed 
the epidemic of measles. Measles alone appeared to 
have been responsible for :iS per cent, of the mastoid 
cases. Bacterial examinations showed that of 1S2 cases 
SI gave positive cultures. The cultures were from 
pus taken from the mastoid and not from the middle 
ear. The Strciitococnis riridaxs predominated. Many 
patients with streptococcic infection died from a com- 
plicated basilar meningitis, which was proven also by 
culture. Twenty-seven cases were complicated by 
measles, respiratory disease, and otitis media. Contrary 
to the experience of other camps the streptococcus 
found in the cases which had followeil measles was of 
the v'ridans type and not of the hemolytic. The obser 






July G, 1918] 



MEDICAL RECORD. 



41 



vation of those cases led to the conclusion that Camp 
Shelby suffered from an epidemic of mastoiditis which 
was the result of a streptococcic infection, which, in 
turn, was the expression of a streptococcic invasion of 
other Southern camps. The predominating organism 
was the Streptococcus viridaiis and not 6'. Iiemolyticus, 
and measles apparently started the epidemic and con- 
tributed to its development. 

Dr. Fowler of the Army said that during a period 
of six months approximately 140 cases of mastoid dis- 
ease had been operated upon at Camp Shelby, of which 
number very few were free from pus. It was his ex- 
perience in the surgical department during four months. 
that when the patients were operated upon very early 
the results were good. Later cases developed complica- 
tions, severest of which was basilar meningitis. There 
did not appear to be any definite pathway for the infec- 
tion to travel from the mastoid to the basal meninges. 
Preventive treatment consisted in the early incision of 
the drum of any case of otitis, isolation, and disinfec- 
tion of the wards. His opinion was that the occurrence 
of basal meningitis in cases of mastoid was probably 
accidental. The cumulative evidence of the cases ob- 
served was that a special virulent organism was present 
which was communicable and had a specific tendency to 
involve the mastoid. 

Dr. Small of Chicago said he saw many cases of 
mastoid developed in Camp Pike. Quite a number de- 
veloped after pneumonia and they were specially charac- 
terized by the absence of objective and subjective symp- 
toms, being discoverd mostly upon autopsy. Middle-ear 
disease in pneumonia gave little pain until suppuration 
occurred. Complications following a careful operation 
for mastoid were frequent. 

Dr. Scott of Iowa said the cases discussed resembled 
those frequently observed in children. Mastoiditis in 
children was usually diagnosed when the ear stood out 
too prominently. There was usually no pain and the 
otitis media was frequently overlooked. It seemed quite 
likely that the middle ear and the mastoid normally con- 
tained bacteria, but only under certain conditions the 
bacteria developed and produced disease. 

Dr. Potts of the Army said he was in Camp Shelby 
when the epidemic had developed and the experience in 
camp had been different from that he had seen in civil 
life. Formerly the onset was called to the attention of 
the physician by a great deal of pain which was usually 
followed by a reddened ear-drum, and which was an 
indication for a paracentesis of the drum, and a case 
was frequently obtained as the result. In Camp Shelby. 
however, the onset of mastoid disease was very rapid, 
frequently without any appreciable symptoms. In his 
opinion there was no question that the mastoid infec- 
tion in Camp Shelby was of an epidemic type. The 
meningitis which frequently occurred in these cases was 
in his opinion due to general toxemia and was not trans- 
mitted from the mastoid. 

Dr. Lathrope, in closing, said that the pathway from 
the throat to the meninges had not been definitely 
proved. There was a direct path from the throat to the 
mastoid. He did not think that there were dormant 
bacteria in the middle ear or mastoid as Dr. Scott had 
suggested. In one case of basilar meningitis nothing 
was found except an infection of the ethmoid cells. 
The relationship of the meningitis to the mastoid de- 
serv-ed further study. 

\ Study of Diaphragmatic Movements in Acute .Ab- 
dominal Inflammations. — Dr. Llewellyn Sale of St. 
Louis read this paper, in which he said that the limita- 
tion of the movements of the diaphragm had been pre- 
viously recognized as an important sign, which bore a 
relationship to various inflammatory conditions in the 
neighboring- organs. His first attention to that sign 
was called by a case following an appendical opera- 
tion. There was absence of breath sounds on the left 
lower side which disappeared in several hours. A study 
of value of the limitation of diaphragmatic movements 
had been undertaken. All abdominal cases admitted to 
the surgical ward were examined for that sign. It 
was noted that in 16 cases of appendicitis the move- 
ments of the diaphragm on the right side were dimin- 
ished and breath sounds were absent. In some cases 
where the diaphragmatic sign was positive, though 
diagnosis of appendicitis was doubtful, the cases turned 
out to be appendicitis, while in cases were a diagnosis 



of appendicitis was made but the diaphragmatic sign 
was negative, a normal appendix was found upon opera- 
tion. In normal conditions there was practically no 
difference in the movements of the diaphragm on the 
two sides, but their continued investigations had shown 
them that there was a limitation on the right side of 
the diaphragm in cases of appendicitis, gall-bladder 
disease, and other inflammatory abdominal conditions. 
All the cases were studied by physical diagnostic 
methods and were verified by the fluoroscope. As to 
the cause for the limitation of diaphragmatic move- 
ment the essayist thought it might be due to the volun- 
tarj' inhibition of the diaphragmatic muscle similar to 
the muscular contractions of the other abdominal 
muscles. The actual mechanism, however, of this phe- 
nomenon was by no means certain. 

Dr. Guthrie of the Army said the new application 
of the diaphragmatic sign was very interesting; x-ray 
workers were used to look for it in thoracic diseases. 
They usually took it to be due to the disturbances of 
the phrenic reflexes. He thought there was nothing 
mysterious in the limitation of the movement of the 
diaphragm. It was due to a spastic reflex limitation 
similar to the reflex limitation of muscles in the case 
of an infected joint. He was satisfied that that was 
the proper explanation, but application of the diaphrag- 
matic signs to abdominal conditions was a very useful 
and helpful procedure. 

Dr. PoTTlNGER of California said that whenever there 
was any inflammation of the lungs the diaphragm was 
limited in its movements. In inflammation of the liver 
such a limitation of motion might be due to the phrenic 
nerve. In abdominal cases, however, he thought this 
was due to the lower intercostals which helped to 
innervate the diaphragm. Internal reflexes were very 
important and he hoped that more attention would be 
paid to them. 

Dr. McDonald of Detroit stated that he had come 
across five or six eases which were operated upon for 
appendicitis but in which a normal appendix had been 
found, though typical symptoms of pain, tenderness, 
and rigidity of the abdominal muscles were present. In 
some cases basilar pleurisy was found. In one case a 
limitation of the diaphragm was observed in the screen, 
but he had also noticed a shadow and became suspi- 
cious of pleural effusion which later proved to be the 
fact, and he thought this should be remembered in con- 
nection with the positive diaphragmatic sign. 

Dr. Sale, in closing, said he was glad of the infor- 
mation he had obtained through the discussion. He 
thought Dr. Pottinger's explanation as to the cause of 
the diaphragmatic phenomena had a great deal of 
value, though not explaining it completely. Dr. Mc- 
Donald's point was very well taken, and he felt that in 
such conditions the diaphragmatic sign would be of 
very little help in making a diagnosis. 

The Control of Cross Infections by Masking of Pa- 
tients. — Dr. Joseph A. Cafps of Chicago presented this 
communication, which was read by Dr. James S. Mo- 
lester of Birmingham, Alabama. The epidemic of 
pneumonia and other streptococcic infections which had 
occurred in various camps raised the question of the 
prevention of the spread of respiratory diseases. It 
had been discovered that milk, cream, and ice cream 
were as important in spreading streptococcic infection 
as in spreading typhoid fever. In Camp Grant many 
diseases were traced to the milk, and when that was 
boiled the number of infections was decreased. The 
streptococcus caused more diseases than any other 
organism and certainly deserved active preventive 
measures. Many respiratory diseases were transmitted 
by nasal secretions, coughing and sneezing, and crowd- 
ing in camps, receiving wards and ambulances. The 
best remedy for this was individual isolation by means 
of masks. They had carried out this experiment in 
Camp Grant with very satisfactory results. During 
the epidemic of grippe they flrst isolated the patients; 
later, due to lack of accommodations, they had placed 
some of the patients in the general wards. The result 
was that everyone developed grippe. Later on, under 
the mask system, they placed a number of grrippe cases 
in the psychiatric department and no grippe cases had 
developed. Dr. McLester himself, who had carefully 
followed out the plan of the mask, had escaped g^ippe, 
though he had attended hundreds of cases and was 



42 



MEDICAL RECORD. 



[July 6, 1918 



rather susceptible to this disease. In Camp Grant 
every case of contagious disease was masked. Every- 
one entering an ambulance or receiving ward was 
masked. 

Dr. Molester further added that his personal ex- 
perience had been the same as that of Dr. Capps. He 
had used the method at Camp Sheridan with very sat- 
isfactory results. They had an unusually large num- 
ber of cases of coryza and bronchopneumonia. When 
the masked system was adopted these diseases were 
checked. 

{To be continued.) 



STATE BOARD EXAMINATION QUESTIONS. 

New York State Board of Medical Examiners. 

January, 1918. 

(Concluded from Vol. 93, page 1014.) 

OBSTETRICS AND GYNECOLOGY. 

1. Give the symptoms and the signs of pregnancy. 
Define positive signs. 

2. Name the fontanels of the fetal head. How are 
they determined before birth? State the significance 
of the position in which they are found. 

3. What is determined by urinary analysis during 
pregnancy? 

4. Give the etiology and the treatment of inflamma- 
tion of the mammary glands. 

5. What gives rise to an atonic condition of the 
uterus? What conditions may be dependent on it? 
How should it be managed? 

6. Give methods of resuscitation of an asphyxiated 
infant at birth. 

7. Describe kraurosis vulvae. What are the sequelae 
of this disease? Give treatment. 

8. Give the treatment of gonorrhea in the female. 
What are the sequelae of this condition? 

9. With what conditions may inversion of the uteras 
be confused? Give the differential diagnosis. 

10. Name the constituent structures of the perineum. 
Of what importance is the structure as a whole? 

11. What are the various forms of new growths of 
the uterus? How are the benign growths differentiated 
from the malignant growths? 

12. What is endometritis? Name the varieties of 
endometritis, giving the microscopic appearance of 
each. 

SURGERY. 

1. Give the signs and the symptoms of psoas abscess. 
State where it usually points. 

2. Describe the treatment by posture and saline drip 
of a severe case of purulent peritonitis. 

3. Differentiate femoral hernia from other condi- 
tions simulating it. 

4. Give in sequence the symptoms of fracture of the 
skull with rupture of the middle meningeal artery. 

5. What surgical procedure may be instituted in 
chronic pancreatitis? 

6. Give a clinical picture of palmar abscess. State 
the precautions to be used in making incision for 
drainage in palmar abscess. 

7. Discuss spinal anesthesia, naming the agents em- 
ployed and giving the teehnic. 

8. What are the special dangers to be avoided in 
treating burns near joints? 

9. What is ectropion? Describe an operation for its 
relief. 

10. Give the symptoms and the treatment of acute 
otitis media. 

11. What are the serious objections to breaking up 
an impacted fracture of the femur? When should 
this be done? 

12. What are Lane's kinks? 

HYGIENE AND SANITATION. 

1. What purposes are served by the registration of 
deaths? 

2. Describe in detail the tuberculin test and explain 
its application in public health work. 



3. What is a deodorant? Name two reliable deodor- 
ants. 

4. What measures are necessary for the prevention 
of diphtheria in an orphan asylum? 

5. Give in detail a method for the prevention of 
rabies in a person bitten by a mad dog. 

6. Give in detail a method for determining the sani- 
tary quality of well water. 

7. Name three sanitary methods for the disposal 
of garbage on a farm. 

8. What parasitic conditions may be produced by 
the ingestion of raw beef? 

9. Give in full a list of the reportable diseases as 
established by the New York State Sanitary Code. 

10. Name five metallic substances that may become 
factors in occupational diseases. 

11. Name a disease that may be transmitted by the 
rat flea. 

12. How may the presence of a typhoid carrier be 
detected? 

ANSWERS. 

OBSTETRICS AND GYNECOLOGY. 

1. Subjective signs of pregnancy, in the order of their 
appearance, are: Cessation of menstruation, morning 
sickness, increased frequency of urination, active fetal 
movements. 

Objective signs of pregnancy, in the order of their 
appearance, are: Softening of the cervix, changes in 
the mammary glands, discoloration of the vulva and 
vagina, pulsation in the vaginal vault, Hegar's sign, 
active fetal movements, ballottement, palpation of the 
fetus, intermittent uterine contractions, hearing the 
fetal heart beat, rate of growth of the uterine tumor. 

The positive signs of pregnancy are such signs as are 
found in pregnancy only, and which are absolutely 
diagnostic of that condition. 

Positive signs of pregnancy : (1) Hearing the fetal 
heart sound; (2) active movement of the fetus; (3) 
ballottement; (4) outlining the fetus in whole or part 
by palpation, and (5) the umbilical of funic souffle. 

Doubtful signs of pregnnncy: (1) Progressive en- 
largement of the uterus; (2) Hegar's sign; (3) Brax- 
ton Hick's sign; (4) uterine murmur; (5) cessation of 
menstruation; (6) changes in the breasts; (7) discolo- 
ration of the vagina and cervix; (8) pigmentation and 
striae; (9) morning sickness. 

2. The fontanels of the fetal head are: (1) The 
anterior, or frontoparietal; (2) the posterior, or oc- 
cipito-parietal. There are four other fontanels, two 
on each side, situated at the inferior angles of the 
parietal bones, but they are unimportant. They are 
determined before birth by the touch of the examiner's 
finger against the presenting fetal head. 

In L. O. A. positions the small, posterior fontanel 
is found towards the left acetabulum. In R. O. A. 
positions the small, posterior fontanel is found towards 
the right acetabulum. In R. O. P. positions the large, 
anterior, fontanel is found towards the left acetabulum. 
In L. O. P. positions the large anterior fontanel is 
found towards the right acetabulum. 

3. "The urine should be examined at regular intervals 
throughout pregnancy. This examination should be 
both chemical and microscopical, and made at least once 
a month for the first six months, and once a week dur- 
ing the last four. The presence of albuminuria, the 
evidences of toxemia, edema, renal insufficiency, or 
nephritis, demand daily examinations. This examina- 
tion should determine the amount of urine passed in 
twentv-four hours, its specific gravity, the total amount 
of urinary solids, the percentage of urea, the presence 
or absence of albumin or sugar and of tube casts.— 
(Polak's .Manual of Obstetrics.) 

4. Inflammation of the mammary glands. Etiolo- 
gy: Infection, generally due to handling; cracked or 
sore nipples and overactivity of the gland with retained 
secretion are predisposing causes. 

Treatment : Prophylactic measures consists in not 
touching the breasts (by doctor or nurse or patient l 
without thoroughly clean hands; by washing and dry- 
ing the nipple before and after nursing, and by proper 
attention to hygienic conditions before labor, and the 
nipple and breasts being preserved from pressure. 
Treatment before suppuration occurs consists in sup- 



July 6, 1918] 



MEDICAL RECORD. 



43 



porting the breast with a bandage, emptying the gland 
regularly with a breast pump, and applying a bella- 
donna plaster over the gland to stop the secretion and 
allay the pain. Nursing from the aftected breast should 
be stopped at once. When pus is present an incision 
should be made at once, or the abscess may burrow 
extensively and riddle the breast. The incision should 
be made in a line radiating from the nipple, so as not 
to cut the ducts; it should be free, and all pockets 
opened up with the finger. Then a large drainage tube 
is inserted and shortened daily, as the wound heals by 
granulation. If necessary, several incisions are 
made. 

5. Aiitonic condition of the utents may be caused by: 
Debilitated constitution, exhausting disease; uterus 
weakened because of congenital malformation, inflam- 
mation, or too frequent child-bearing; tumors of the 
uterus or neighboring tissues; displacement of the 
uterus; age (pregnancy in an old primipara), hy- 
dramnios; twin pregnancy; fright or mental emo- 
tion. 

It may predispose to delayed labor, prolonged labor, 
lacerations, infection, post-partum hemorrhage, and 
subinvolution. 

Treatment consists in removing the cause if possible ; 
the bladder and bowel should be emptied; opium, mor- 
phine and chloral may be given so that the patient may 
get a little sleep, at the same time food may be admin- 
istered; the uterus may be massaged through the ab- 
dominal walls; hot vaginal douches are sometimes help- 
ful; the vagina may be distended with a rubber bag; 
if the membranes are ruptured a Champetier de Ribes 
bag may be placed in the lower part of the uterus; an 
anesthetic may be necessary; quinine, strychnine, and 
ergot have been recommended by some, and condemned 
by others; the newest remedy is pituitrin, which may 
be injected into the muscles in doses of from one to 
one and a half cubic centimeters, provided that the 
cervix is dilated and that there is no obstruction to 
delivery. 

6. Methods of resuscitation of an asphyxiated infant 
Kit birth. — In every case, foreign matter must be re- 
moved from the air passages; then any of the follow- 
ing may be tried: (1) Holden's method of direct in- 
sufflation with oxygen. (2) The use of the pulmotor. 
(3) Direct (mouth to mouth) insufflation. (4) 
Schultze's Method — For inspiration the child should be 
suspended by the shoulders, face from the operator, by 
placing an index finger in each axilla, holding the 
thumb in front and two fingers extended over the 
posterior aspect of each shoulder, expanding the chest, 
while the head is kept steadied and extended between 
the ulnar surfaces of the hands. For expiration the 
position is inverted by swinging the trunk and lower 
limbs upward and toward the operator's face, flexing 
the body in the lumbar region. The first movement 
should be one of expiration, which helps to rid the 
trachea of mucus. The objections to this method are, 
first, the chilling of the body; second, the shock in- 
volved, so that in feeble infants, if used at all, it 
must he done with g^reat caution. This, and direct 
insufflation with oxygen, or by mouth to mouth, are 
the most effectual methods in asphyxia of the new- 
born. (5) Sylvester's Method.— The child is placed 
in a supine position, with the head well extended by a 
fold of blanket under its neck. For inspiration, the 
arms are drawn well above the head; for expiration, 
they are placed by the sides and the thorax gently com- 
pressed. The value of this method is increased by 
making forward traction on the tongue during inspira- 
tory movement. (6) Bj/rd's Method.— The child is held 
supine upon the hands of the operator at right angles 
to the forearms. For inspiration the radial borders of 
the hands are lowered. For expiration they are raise^d. 
The child is successively folded and unfolded. (7) 
Laborde's Method.— With the child lying in a supme 
position on a table, or in a warm bath, with the head 
extended, gentle intermittent traction is made o" the 
tongue about eighteen times to the minute. (8) When 
respiratory movements have been established but re- 
main persistently feeble, a weak Faradic current, one 
pole of which is applied to the nuchal region and the 
other over the epigastrum, combined with the continued 



inhalation of oxygen, may induce deeper and stronger 
respiratory efforts. (9) Should all of the foregoing 
methods fail, and the fetal heart, however slow, con- 
tinue to beat, an injection into the umbilical vein of 
30-50 cm. of sterile normal salt solution, containing 0.5 
per cent, of fructosate of sodium, may be given. The 
salt solution dissolves CO.-. — (From Polak's Manual of 
Obstetrics.) 

7. Keausosis vulv^ is a condition in which the 
tissues of the vulva undergo atrophy and contraction. 
The patient may suffer little or no inconvenience, but 
as a rule she complains of itching, burning, pain, im- 
possibility of coitus; there may be a discharge, or the 
parts may be dry. The vulvovaginal orifice is nar- 
rowed, the pubic hair is dry and broken, and the parts 
look shiny and smooth. The sequelx are dyspareunia, 
dystocia, extensive lacerations in labor, and general 
discomfort. Treatment consists in the application of 
sedative and cooling lotions, or an ointment containing 
opium or cocaine; nitrate of silver and phenol have 
been recommended. Operative procedures, such as 
forcible dilatation, cauterization, and excision, have 
afforded relief. 

8. Treatment of gonoi~rhea in the female: Rest, if 
possible, in bed; freedom from alcoholic or sexual ex- 
citement; a mild and unirritating diet; salines and 
diuretics; plenty of water to drink; a warm sitz bath; 
douching of vagina with about a gallon of a 1:5000 
bichloride solution, or of borax (1 dram to the quart), 
or of potassium permanganate (1 per cent, solution) ; 
the douche is to be taken in the recumbent position. 
Sequelte: Cystitis, urethritis, vulvitis, endometritis, 
salpingitis, septic peritonitis, sterility, condylomata of 
vulva, abscess of Bartholin's glands. 

9. Inversion of the uterus may be confused with: 
Procidentia, or polyps, or myoma of the uterus. 

The differential diagnosis is shown in the following 
tables (from Dudley's Principles of Gynecology) : 



COMPLETE INVERSION OF 
UTERUS. 

1. No pedunculated at- 
tachment to uterus. 

2. Uterine cavity being 
obliterated, sound can be 
passed but short distance, 
in incomplete and not at 
all in complete inversion. 

3. Vaginal or rectal 
conjoined examination 
shows a ring or depres- 
sion where the uterus 
should be, and fails to 
show the uterus above the 
vagina. 

4. The inverted uterus 
is a symmetrical pyriform 
body. 

5. Orifices of the Fallo- 
pian tubes usually de- 
monstrable. 

6. Muciparous glands 
of the uterus present and 
microscopically demon- 
strable. 



UTERINE POLYPUS OK 
MYOMA 

1. Attached to uterine 
wall by broad surface or 
by narrow pedicle. 

2. Sound passes by the 
side of the mass through 
external os far into 
uterine cavity. 



3. Uterus 
vagina. 



felt above 



4. Not usually sym- 
metrical and may be very 
asymmetrical. 

5. Not present. 



6. Not present, or if 
present less perfectly de- 
veloped. 



INCOMPLETE INVERSION OF 
THE UTERUS 

1. The uterine cavity as 
measured by the sound 
will be diminished. 

2. Development sudden. 

3. Bimanual examina- 
tion shows rig-like depres- 
sion in wall of uterus. 

4. Usually dates from 
parturition. 



INTRA-UTERINE MYOMA 



1. Cavity enlarged. 

2. Development gradual. 

3. Uterus symmetrical 
or asymmetrical, but no 
ring-like depression. 

4. No parturition. 



44 



MEDICAL RECORD. 



July 6, 1918 



INVERSION OF UTERUS. 

1. The protruding mass 
is wider below than above. 

2. External os uteri ab- 
sent and tubal orifices 
present at lower end of 
mass. 

3. Sound in urethra goes 
upward into bladder. 

Exception. — When the 
vagina is concurrently in- 
verted the sound may pass 
down wa id. 



COMPLETE PROCIDENTIA 

1. Mass wider above. 

2. External os present 
nil tubal openings absent. 



;!. Sound goes down- 
ward into anterior por- 
tion of mass. 



10. The perivciun or pelvic floor is composed chiefly 
of fascia, muscles, and connective tissue. Its superior 
surface is lined by peritoneum. Next below, and in 
close contact with the peritoneum, comes the "internal 
pelvic fascia." Immediately below the internal pelvic 
fascia are two thin muscles, viz.: (1) The levator ani, 
each half of which arises from the body and horizontal 
ramus of the pubes and from the arcus tendineus, and 
passes downward and inward to meet its fellow of the 
opposite side in the median line, where it is inserted 
into a tendinous raphe extending from the coccy.x to 
the rectum, while some fibers pass between and to the 
sides of the bladder and rectum, and to the vaginal 
and rectal sphincters. (2) The coccygeus, vk-hich is a 
narrow, triangular slip, situated parallel with and pos- 
terior to the levator ani, closing in a little space which 
the latter muscle failed to cover. Below these muscles 
the pelvic floor is further strengthened by the perineal 
fanciii. Its posterior portion consists of a single layer, 
while its anterior part is divisible into three layers. 
Within these latter layers are lodged the pudic vessels 
and nerves, and the superficial muscles of the perineum. 
These mu.scles are the constrictor vagime, the spliincter 
atii, and the transversiis pcrinei, and to these .struc- 
tures must be added the integument and the very 
numerous interstitial layers of elastic connective tissue, 
which latter weld the parts together and add strength 
and elasticity to the whole fabric. — (From King's Ob- 
tetrics.) 

The perineum helps to support and compress the 
pelvic viscera, enabling them to maintain their normal 
relationship. It also surrounds and supports the lower 
end of the rectum, the vagina, and the urethra, and so 
enables them to perform their functions properly. 

11. New growths of the uterus: Cysts, adenoma, 
polyps, myoma or fibroid, sarcoma, carcinoma, endo- 
thelioma, papilloma, deciduoma malignum. 

Malignant growtlis of the uterus are diagnosed by 
the history, symptoms, physical signs, and microscopic 
examination. It is a disease of advancing years, and 
generally occurs after the menopause; nullipara and 
multiparje are equally liable. The chief symptoms are 
hemorrhage and discharge with an offensive odor, pain, 
and cachexia. The cervix is soft, the uterus enlarged, 
and tender. The uterus must be curetted, and the 
scrapings examined by the miscroscope. 

12. Endometritis is an inflammation of the uterine 
mucosa. The varieties are: Acute and chronic; non- 
infectious and infectious; the latter are septic, gonor- 
rheal, tuberculous, and syphilitic. 

Septic endometritis: There is a necrosis of the 
superficial endometrium and a barrier of granulation 
cells in the deeper layers of the mucosa. The necrotic 
endometrium is exfoliated, the microorganisms peri.sh 
(except in the puerperium, when the cocci may pene- 
trate the lymph channels, blood spaces and myo- 
metrium). Gonorrheal endometritis is an inflammation 
of the mucous membrane in which gonococci are found 
in and under the epithelium, and penetrating the myo- 
metrium perhaps to the perimetrium. The surface 
epithelium is exfoliated or shows a transitional stiige 
to the many layered squamous type. The glands are 
unaltered except that they are di.stended with secre- 
tion, and the cells may be increased in number. There 
is edema and a round cell infiltration of the inter- 
glandular tissue with a few pus cells. There is also 
a cellular infiltration of the myometrium, which may 
lead to abscess formation in the uterine wall. Tuher- 
rnlons endometritis may be miliary, interstitial or 



ulcerative. Tubercle bacilli are the infecting agents, 
but their pre.sence is difficult or impossible to demon- 
strate. The interior of the uterus may be covered 
with a caseous material. The underlying layer of sur- 
face cells is unbroken. Beneath them are masses of 
epithelioid cells, occasionally giant cells, or round cell 
infiltration, and possibly typical tubercles. There may 
be a caseous mass in the myometrium. 

Chronic hyperplastic endometritis. The glands may 
be increased in number, acquiring a corkscrew form, 
and display a dilatation of the gland-spaces, with ex- 
ci-e.scences of epithelium in their lumen. There is also 
a proliferation of epithelium upon the surface of the 
endometrium, but nowhere a duplication of the single 
epithelial layer in the glands or on the surface, except 
in elderly women. In the interstitital form there is at 
lirst a round cell infiltration of the interglandular coi.- 
iiective tissue. The glands are widely separated and 
compressed ; there may be exfoliation of the surface 
epithelium; in the later or chronic stage the round cells 
are converted into spindle cells; scar tissue is formed: 
the glands are so compressed that they atrophy and 
disappear; the uterine mucous membrane is reduced t<i 
a single layer of epithelial cells on the surface of the 
uterine cavity. There is frequently a mixed form of 
interstitial and glandular endometritis, and varyin;; 
gradations may be observed between the purely glandu- 
lar and the interstitial hypertrophy. — (From Hirst's 
Gynecology.) 



1. Signs and syinpiums of psoas abscess: "There may 
l)e none, old unususpected psoas abscess being often 
found at the autopsy. Early symptoms depend upon 
irritation of the lumbar nerve roots — namely, sciatica, 
cruralgia, or neuralgia of the anterior crural. Aching 
across the hip and back and the base of the sacrum; 
cramp, and at times paralysis. Inability to extend the 
thigh. Children merely complain of a pain down the 
thigh, and always carry it flexed. Deep pressure in 
the abdomen, along the semilunar line, reveals a ver- 
tical, sausage-shaped, tender, fluctuating, elastic tumor 
(mistaken for loaded bowels, but which does not roll 
from under the fingers). It may or may not reach 
Poupart's ligament and may be accompanied by a 
tumor of similar character in the iliac fossa. The 
abscess may run its course without any subjective 
symptoms, the extra-abdominal tumor first attracting 
attention. When extra-abdominal the usual physical 
signs show it to be abscess; and the impulse on cough- 
ing that it has intra-abdominal connection; combined 
pressure above Poupart's ligament and over the tumor 
in, e.g., the thigh, reveals fluctuation. Psoas abscess is 
most likely to be overlooked when symptoms of spinal 
or sacroiliac disease are not coexistent" — (Heath's 
Dictionary of Surgery.) 

I'soas abscess usually points in the upper and an- 
terior part of the thigh, below Poupart's ligament, 
external to the femoral vessels; but occasionally it may 
point above Poupart's ligament, or over the great tro- 
chanter of the femur, or over the iliac crest into the 
gluteal region, or elsewhere. 

2. hi case of serere purulent peritonitis, "the patient 
is placed in the 'Fowler position,' that is, with the 
head of the bed raised about eighteen inches, or he is 
propped up on pillows in the sitting posture, so that 
any fluid in the abdomen may gravitate into the pelvis. 
Saline solution should be introduced in sufficient quan- 
tity to restore the blood pressure and to increase the 
excretory action of the kidneys and skin. It may be 
run continuously into the rectum through a catheter 
and rubber tube connected with a douche-can placed 
at a level of about six to twelve inches above the pelvis; 
the solution at a temperature of 100' Fahr., is allowed 
to flow at the rate of about three-quarters of a pint per 
hour." — (Thom.son and Miles' Manual of Surgery.) 

3. A Femoral Hcrxia may be mistaken for an inguinal 
hernia, an enlarged lymphatic gland, a lipoma (espe- 
cially in women), a psoas ab.scess, and a varix of the 
saphena vein. 

From an enlarged gland diagnosis is made by the 
absence of an impulse on coughing, by the increased 
feeling of resistance, and by the irreducibility of the 
gland. .\n enlarged gland is, however, often found 



July 6, 1918J 



MEDICAL RECORD. 



45 



associated with a femoial hernia. In a fat subject 
diagnosis between a gland and an omental hernia may 
be very difficult. 

The lipoina is differentiated by its mobility and ab- 
sence of attachment. There is no impulse on coughing, 
and it is dull to percussion. Again the difficulty is 
increased in cases of omental hernia. 

A psoas absccas is reducible, and has an impulse on 
coughing. It returns to the abdomen much more slowly 
than the hernia, and never with a gurgle. It lies to the 
outer side of the femoral artery, while the hernia is 
internal, and fluctuation can often be felt between it 
and the iliac fossa. If there is doubt the spine .should 
be carefully examined. 

.4 varix of the sapluua vein has an impulse on 
coughing, and disappears on recumbency. The impulse 
on coughing is, however, quite different to that of a 
hernia. A varicose saphena vein is generally associated 
with varicose veins belou- the knee, the thigh being 
free. — (Aids to Surgical Diagnosis.) 

An inguinal hernia has its neck above Poupart's^ 
ligament; a femoral liernia has its neck below- it. 

4. Fracture of the skull with rupture of the middle 
meningeal artery. — "After the injury there is gen- 
erally a 'free interval,' in which the patient recoveis 
to some extent from the concu.ssion, and may even 
appear to be well. If there has been no concussion he 
may even have gone about his work for a time, and 
severe bodily or mental excitement have caused recur- 
rence of the bleeding. If shock is a prominent sign, it 
generally diminishes with cessation of bleeding, on ac- 
count of circulatory weakness and formation of throm- 
bus in the vessel, or of excess of intracranial pressure. 
This recovery may set up bleeding again, and the same 
series of symptoms are repeated. As effusion increases 
symptoms of compression begin, with unconsciousnes.s. 
slowing of the pulse, and stertor. The most common 
local signs are paralysis of the head and upper limbs, 
and, in left-sided injuries, aphasia. Owing to the small 
size of the branches of the middle meningeal artery. 
hemorrhage is not so severe over the upper Rolandic 
area, hence the trunk and leg muscles are less severely 
implicated. Impairments of sensation are not as a rule 
easily determined, on account of the mental condition 
of the patient, but they are useful when positively 
noted. The general course is that of progressive com- 
pression of the brain." — (Buchanan's Handbook of 
Surgery.) 

.5. Surgical proeedurea in chronic pancreatitis may 
include: Removal of gallstones if any are present: 
cholecystostomy (for indirect drainage of the pan- 
creas), cholecystenterostomy. 

6. In jxilmar abscess the hand is swollen, both on the 
dorsum and on the palmar aspect. The fingers are 
bent and stiff. The pain is severe, and constitutional 
symptoms are marked. If the thumb and little fingei 
are involved (or their synovial sheaths) the forearm 
may be affected as well as the hand. 

In making incision, the cut should be below the 
palmar arches, in the line of the metacarpal bones. 
and the sides of the fingers should be avoided if pos- 
sible. If incision has to be made above the palmar 
arches these latter are to be avoided. 

7. "Spinc[l anesthesia is produced by the injection of 
a local anesthetic into the subarachnoid space. Cocaine 
and eucaine are seldom used at the present time. 
Stovaine has a strong affinity for the motor nerves, 
and may, in high anesthesia, cause paralysis of the 
respiratory muscles. Tropacocaine and novocaine 
possess less of this affinity, hence are safer ; the u.sual 
dose is from one-half to one grain. The solution is 
prepared by dissolving the drug selected (previou.^ly 
sterilized) in cerebrospinal fluid, which is drawn into 
the syringe containing the anesthetic, after the intro- 
duction of the needle into the .subarachnoid space. In 
order to make the solution of a higher specific gravity 
than the spinal fluid and so remain in the lower part 
of the spinal theca. Barker uses distilled water 1 c.c. 
glucose 0.05 gram, and stovaine 0.1 gram. The syringe 
.should be boiled in plain water, as the soda solution 
employed for other instruments may diminish the 
efficacy of the anesthetic. The patient lies on the 
side, or assumes the sitting posture; in either ca.se the 
back should be bent forward in order to increase the 

space between the vertebral arches. The operator 



places one finger upon the spine of the fourth lumbar 
vertebra, which is on a line between the two iliac 
crests, and enters the needle fitted with a stylet, just 
below and to the right of this point, in a slightly up- 
ward and inward direction, until the dura has "been 
punctured, which in the adult is usually at a depth of 
two and one-half inches. The stylet is withdrawn and 
1 dram of the cerebrospinal fluid allowed to escape. 
The anesthetic solution is then slowly injected, the 
needle withdrawn, and the puncture sealed with col- 
lodion. The patient is then placed in proper condition 
for operation, but never should the head and shoulders 
be on a lower level than the lumbar vertebra, as the 
fluid may gravitate towards the medulla and cause 
respiratory paralysis. Anesthesia results in about five 
minutes and lasts from one to three hours or longer. 
No attempt should be made to induce anesthesia above 
the diaphragm. Headache, nausea, and vomiting are 
frequent sequels, and evidence of transient and perma- 
nent cord injuries has been noted. The chief dangers 
are infection, injury to the cord, and poisoning from 
the anesthetic employed. The mortality has been esti- 
mated at 1 in 200. From what has been said it may 
be gathered that the method is destined to pass into 
desuetude." — (Stewart's Manual of Surgery.) 

8. In treating burns near joints, the special dangers 
to be avoided are: The formation of cicatricial con- 
tractions, deformities, loss of motion of the joint. 

9. "Ectropion is an eversion of the lid with exposure 
of more or less conjunctival surface. It may affect the 
upper or the lower lid, or both. The V-Y operation 
{Wharton Jones). — A V-shaped incision is made with 
the apex directed away from the palpebral margin, the 
incision including the cicatrix. The skin is freed from 
underlying parts, not only in the V-shaped area, but 
also to either side. The V-shaped area is slid upward 
until slight inversion of the lid margin is produced. 
The margins of the incisions are then brought together 
by sutures in such a manner that the figure Y results." 
— (May's Diseases of the Eye.) 

10. .icute catarrhal otitis media is frequently caused 
by acute coryza and the infectious fevers. There is a 
painless obstructed sensation in one or both ears, im- 
pairment of hearing, and tinnitus. The inflammation 
causes closure of the eustachian tube. Inflation and 
aspiration of the middle ear and syringing and douch- 
ing the nares and nasopharynx must be avoided. A 
moderate spray of Dobell's solution may be used. If 
pain is present, dry heat, in the form of hot-water 
bottle, hot stone wrapped in flannel, etc., may be ap- 
plied. A few drops (100), w-armed, of a carbolic acid 
solution (1:40), or one of formalin (1:2000), may be 
instilled into the ear. 

11. The objectiotis to breaking up an impacted frac- 
ture of the femur are: (1) Such a procedure might 
cause a gap between the fragments, and so hinder 
repair; (2) it might cause undue mobility between the 
fragment, which would also hinder repair. The im- 
pactions should be broken up only when the patient 
is young and healthy and active; and if the deformity 
is great, and there is excessive shortening. 

12. Lane's kinks are bends or twists of the intestine 
which are due to the upright position maintained by 
the body and also to the descent of the cecum from 
its early embryonic position: adhesions attached to the 
lower end of the ileum, or accessory peritoneal bands, 
are often responsible for the condition. 

HYGIENE AND SANITATION 

1. Purposes served by the registration, of deaths. 
"Death registration serves a number of highly im- 
portant purposes. Its functions are legal, econornic. 
and social. Death registration is useful in preventing 
and detecting crime through the restrictions placed upon 
the disposal of dead bodies. It sei-\-es as evidence in 
the inheritance of property and in the settlement of 
life insurance contracts and policies. Death registra- 
tion makes it possible to show by mathematical com- 
putations and statistical methods the extent and rate 
of change in population produced by deaths; the aver- 
age duration of life, and, to the extent that the 
certified causes of death have been correctly stated, 
the relative frequency with which the several causes 
produce death. Death statistics by comparison with 
birth statistics give useful information regarding popu- 



46 



MEDICAL RECORD. 



[July 6, 1918 



lation increase or decrease." — (Rosenau's Preventive 
Medicine and Hygiene.) 

2. "The tuberculin reaction has been made a cardinal 
feature in the diagnosis of tuberculosis in cattle, and 
to some extent in man. Its chief practical application 
is in detecting the disease in dairy cows. The test on 
cows is made by injecting subcutaneously from 20 to 
40 centigrams of tuberculin and noting any change in 
the temperature of the suspected animal. The normal 
temperature should be taken every two hours on the 
day prior to the injection, and after the injection 
should be taken on that day and on the following day 
at least every two hours. The normal temperature of 
the cow may vary considerably, and should always first 
be determined; a rise of from 1.5° to S" C. warrants the 
inference that the animal is tuberculous; the tuberculin 
reaction has been often controlled by autopsy, and for 
all practical purposes is specific and unequivocal. The 
information afforded by a positive outcome, as a rule, 
can be relied on implicitly, but a negative reaction is not 
always proof of the absence of infection. Failure of 
the test is most likely to occur in advanced and clinically 
recognizable cases." — (Jordan's Bacteriology.) 

3. A deodorant is a substance which is able to de- 
stroy or to neutralize the disagi-eeable odors which 
result from the putrefaction or fermentation of organic 
matter. Two reliable deodorants: Charcoal and for- 
malin. 

4. Measures necessary for the prevention of diph- 
theria in an orphan asTjlum : The isolation of all cases 
and carriers; all who show cultures containing organ- 
isms which morphologically resemble the diphtheria 
bacillus should be isolated, whether the strains are 
virulent or not. Cultures should be taken from both 
nose and throat. Convalescents should not be released 
from quarantine until at least two cultures taken from 
"both nose and throat are negative. All persons within 
the institution, both inmates and administrative force, 
should then be tested to the Schick reaction. Those 
reacting positively should be given a prophylactic dose 
of diphtheria antitoxin (1000 units). The immunizing 
dose may be repeated every ten days or two weeks as 
long as the danger persists. Those who react posi- 
tively to the Schick test may be immunized with a toxin- 
antitoxin mixture. Each cubic centimeter of the mix- 
ture contains from 80 to 90 per cent, of the L+ dose 
of toxin, and one unit of antitoxin. One cubic centi- 
meter of this mixture is injected subcutaneously and 
repeated three times at intervals of six or eight days. 
The results as determined by the Schick reaction pro- 
duce an immunity in about 25 to 30 per cent, of in- 
jected individuals within four weeks; the remainder 
react slowly, in four months to two years. In addition 
to the above-mentioned measures care must be taken 
that the infection is not spread by the use of cups, 
spoons, dishes, toys, towels, handkerchiefs, and other 
articles used in common. The infected discharges 
should be rendered harmless at the bedside, and all 
objects that come in contact with the discharges from 
patients or carriers should be disinfected. A general 
fumigation with formaldehyde may be practised, but 
in a well-ordered institution special cleanliness of floors, 
walls, and other surfaces, will suffice. — (From Rose- 
nau's Preventive Medicine and Hygiene.) 

5. To prevent rabies in a person bitten by a mad dog: 
The bite should be cauterized with the actual cautery, 
with fumic nitric acid, or pure carbolic acid followed 
by alcohol. "Preventive i7ioculatio7i, which was origi- 
nated by Pasteur, consists of intensifying the action of 
the virus by passing it through successive rabbits, until 
the period of incubation is reduced to seven days. The 
spinal cords of these rabbits are preserved in dry air 
for twelve to fifteen days, and a small quantity of the 
emulsion prepared by triturating the cord with physio- 
logical salt solution is iniected into the person to be 
immunized. This is followed by injections on the 
following days of emulsions made from cords which 
have been preserved for fewer and fewer days, the 
contained virus being stronger and stronger. This 
method has given the most gratifying results, and 
where it is undertaken promptly is rarely unsuccessful." 
— (Gardner and Simond's Practical Sanitation.) 

6. "A complete sanitary analysis of water includes: 
(1) A physical cramination to determine odor, tur- 
bidity, color, and taste; (2) a microscopic exatnination 



to determine the number and character of ; 
in suspension, especially algse; (3) a chemical 

to determine the nature and amount of chen :- 

purities; (4) a bacteriological examination to eatimate 
the number and kind of bacteria; (5) a sanitary survey 
of the watershed, including the methods of collecting, 
storing, handling and distributing the water; and (6) 
clinical experience, which, after all, is the final test, 
for water may contain impurities that are not recog- 
nizable by any other method." — (Rosenau's Preventive 
Medicine and Hygiene.) 

7. Three sanitary methods for the disposal of gar- 
bage on a farm: The garbage may be (1) burnt, (2) 
buried, or (3) fed to the hogs. 

8. Parasitic condition which may be produced by the 
ingestion of raw beef: Tapeworm infection (Tsenia 
saginata). 

9. Reportable diseases of the New York State San- 
itary Code: Anthrax; chickenpox; Asiatic cholera; 
diphtheria (membranous croup); dysentery, amebic and 
bacillary; epidemic cerebrospinal meningitis; epidemic 
or streptococcus (septic) sore throat; German measles; 
glanders; measles; mumps; ophthalmia neonatorum; 
paratyphoid fever; plague; poliomyelitis, acute an- 
terior (infantile paralysis) ; puerperal septicemia; 
rabies; scarlet fever; smallpox; trachoma; tuberculosis; 
typhoid fever; typhus fever; whooping cough. 

10. Five metallic substances that may become faetort 
in occupational diseases: Lead, mercury, arsenic, brass, 
and copper. 

11. A disease that may be transmitted by the rat 
flea : Plague. 

12. The presence of a typhoid carrier may be de- 
tected: (1) by making a Widal test on all suspected 
persons; this reaction is almost constantly present in 
the blood of typhoid carriers. (2) The bacilli should 
then be souo-ht in the urine and feces of those giving a 
positive Widal reaction. 



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Medical Record 



■ n 



A Weekly Journal of Medicine and Surgery 



Vol. 94, No. 2. 
Whole No. 2488. 



New York, July 13, 1918. 



$5.00 Per Annum. 
Single Copies, 1 5c. 



(ingtnal Arttrlra. 

THE SOLDIER AND TUBERCULOSIS.* 

Kv El>\V.\r;i> O, OTIS, M D.. 

BOSTON. 

We are all familiar with the efforts that have been 
and are being made to eliminate tuberculosis from 
the Army before the soldiers are sent overseas. The 
startling statements with regard to the extent of 
tuberculosis in the French Army, since showii to be 
greatly exaggerated, were an additional incentive 
to such efforts. Both phthisiologists of long ex- 
perience and those recently trained by short in- 
tensive courses in the diagnosis of tuberculosis have 
been engaged in the work. The plan was as com- 
prehensive as the army itself, namely, to examine 
every soldier in camp. Two classes of cases came 
under consideration : One, the open active case.s 
which were to be rejected without question; and the 
other, the closed, latent, or arrested cases which 
were either rejected or referred for some service 
in the non-combatant force at home or abroad. 

Excellent rules and formulae have been given the 
examiners as to methods and procedure in the ex- 
aminations, but it must be confessed that the judg- 
ment and experience of the .seasoned diagnostician 
transcends any fixed rules, and he will make the 
diagnosis, when it can be made, in his own accus- 
tomed way better than when he is restricted or ham- 
pered by the methods of other men or by rules pre- 
pared by anybody else who may be his equal in skill 
and experience but who also arrives at his results 
in his own personal way. 

Obviously but few of the evident open progres.-iive 
cases will be, or in my experience were found, for 
such are generally detected either by the exemption 
board if drafted men or by the examining surgeon 
if volunteers. Some slip by, however, through 
either the carelessness or the inadvertence of the 
examiner, as the following cases illustrate. 

Quite recently a young man came to me whom I 
had seen eleven years previously and who then had 
unmistakable signs of tuberculosis. He now had 
active advanced disease, the left lung entirely in- 
TOlved and likewise the upper lobe or more of the 
right lung. He had so little free lung that any 
exertion caused dyspnea. Moreover, he had a tem- 
lerature of 10L2°. A short time previously, upon 
A.pril 5 of this year, he was examined by the ex- 
Jmption board of his city and placed in Class A. 
'qualified for .special and limited service." It is 
iifficult to imagine what kind of "special service" 

*Read at the Annual Meeting of the American Clima- 
ological and Clinical Association, Boston, June 6, 1018. 



a man with far advanced active tuberculosis could 
perform. 

A young man twenty-five years old came to me in 
the uniform of one of the services, in which the 
physical examination is supposed to be particularly 
rigid. Five years previously I had been called into 
the country to see him and found him in the third 
stage of active pulmonary tuberculosis, with ex- 
tensive infiltration and softening throughout the 
right lung and inactive disea.se in the left and with 
the usual symptoms of active tuberculous infection. 
The examiner had evidently neglected to make him 
cough on auscultation; if he had done so, I am sure 
he would have detected rales in the left lung. On 
ordinary respiration, however, it was easy for one 
not especially experienced to overlook the condition, 
for the man in appearance was perfectly healthy 
and well developed. 

On the other hand, a young man from Vermont 
came to me who had been anxious to enlist and 
who had been rejected by the examining surgeon 
of the Army on account of alleged tuberculosis. I 
was unable to find any physical evidence of the dis- 
ease; the .r-ray plate was negative, and he had a 
lung capacity of 250 cubic inches. I gave him a 
statement to tnis effect, and with this and his 
Roentgen-ray plate he appeared again for examina- 
tion, and was again rejected with the statement that 
the lungs were suggestive of a pretuberculous stage. 
The man was somewhat under weight and rather 
poorly developed, it is true, but, in my opinion, there 
was no good evidence of tuberculosis. While we 
are taking every means of eliminating tuberculosis 
from the Army it would seem to be the part of wis- 
dom to employ equally efficient means to prevent 
men from being rejected on account of tuberculosis 
without the clearest evidence of its existence. 

As in civil life the border line cases or suspects 
present many difliculties and the decision for re- 
jection or detention in the service must mainly be 
made upon the physical findings from the lack of 
time for observation and the rapidity with which 
the cases have to be determined. With the most 
experienced diagnosticians differences of opinion 
will occur as they always have occurred. It is in- 
evitable that some non-tuberculous men will be re- 
jected and some tuberculous ones passed. 

The question is how to reduce so far as may be 
the possibilities in the case to probabilities or cer- 
tainties. Careful re-examinations by several experts 
and a comparison of observations and opinions and 
the aid of the Roentgen ray may result in a definite 
decision. There is, and probably always will be, a 
difference of opinion as to the decisive value of 
Roentgen-ray revelations or lack of them. Many 
phthisiologLsts will, I think, agree with me that it is 



48 



MEDICAL RECORD. 



[July 13, 1918 



unsafe to base one's decision upon this evidence 
alone, and many will differ as to which set of obser- 
vations should be given the preponderance when they 
differ — those derived from the physical examination 
or those from the .r-ray examination. For exam- 
ple, Capt. A. of the Medical Reserve Corps came to 
me for examination with the history that while on 
duty at one of the southern camps he began to show 
signs of failing health, and on being examined by 
a physician of experience in tuberculosis he was 
declared to be tuberculous and sent home on a 
furlough. I examined him several times at inter- 
vals and always found persistent fine rales at the 
left supraspinous fos.sa. In consequence of this 
and from the previous history I advised his resig- 
nation from the service, and accordingly he went to 
Washington to accomplish it with a statement from 
me as to my diagnosis. This, however, was not re- 
garded as authoritative, and he was sent to the 
Walter Reed hospital for examination by an army 
surgeon of sanatorium experience. He was told 
that he had extensive disease in the left lung as 
well as some in the right one. Upon two separate 
occasions I had an .r-ray taken by one of our most 
accomplished Roentgenologists, now a major in the 
service and the head of one of the Roentgenological 
army schools, who told me that in both instances 
the plates were negative and showed no evidence 
of tuberculosis. Which set of evidences shall we 
take, the physical findings, which, in my opinion 
and that of the two other examiners, indicated 
tuberculosis, or the evidence of the .r-ray which 
showed no disease? In the one case the officer 
would be discharged, as he was, and in the other 
retained in the service. 

Again a lieutenant in the M. R. C. came to me, 
somewhat perturbed, because, while in the Roent- 
genological School for Officers, he had an .r-ray 
plate of his own chest taken which indicated some 
tuberculous infiltrations. I could detect no evi- 
dence of disease from the physical examination and. 
evidently the examiner for entrance into the Army 
"did not, and so far as the man knew he was in 
robust health. If the decision of his acceptance or 
rejection from the Army had depended solely upon 
the a;-ray revelations he would have been rejected. 
I strongly favor, however. Dr. Brown's suggestion 
that roentgenograms be taken of at least 10,000 men 
of the National Army "for the benefit," as he says, 
"of future drafts and for the benefit of the whole 
civil population." A comparison of the physical 
signs, or lack of them, and the roentgenological 
findings of this large body of men would be most 
interesting and instructive. So far I am inclined 
to agree with Hawes' that "in adults the a--ray may 
give a certain amount of confirmatory evidence but 
never enough on which alone to base a diagnosis." 

When one comes to the inactive, latent, or ar- 
rested cases, the "old tops," with no symptoms and 
only physical signs — and those perhaps indefinite — 
to indicate that a tuberculosis infiltration or fibrosis 
exists, the difficulties in both diagnosis and decision 
are often as great as in the border line cases. In 
the first place it is not always easy to determine 
the fact that "a very limited amount of tubercu- 
losis" is present, "that is latent or arrested," as 
Biggs states it, from any evidence we can obtain 
from the physical examination. Equally skilled 



diagnosticians may differ as to the existence of 
modified respiration or deficient resonance. In the 
second place it is a debatable question whether all 
cases of "a very limited amount of tuberculosis 
that is latent or arrested is almost certain to break 
down under the physical strain of militarj- training 
and army life," — to quote Biggs again. Some will 
and some will not, in my opinion, just as some will 
and some will not of those whose amount of tuber- 
culosis is not much more than that of their child- 
hood infection and which no human skill can detect. 
Herein come the judgment and experience of the 
examiner to determine, so far as may be, which of 
the two contingencies is most likely to happen and 
to act accordingly. The family and previous his- 
tory, the length of time the disease has been ar- 
rested, if it has ever been active, the present physi- 
cal condition as to weight, strength, muscular de- 
velopment and nutrition, the way the soldier has 
performed his military duties up to the time of his 
examination, — are all more vital points in making 
the decision, it seems to me, than the physical find- 
ings alone. An old "very limited " fibroid condition 
of many years' standing which has never shown any 
symptoms of breaking down under the ordinary 
conditions of civil life, or has in no way affected 
the general health, has a more than equal chance. 
I believe, of remaining firm under the extraordinary 
conditions of militarj^ life, and would appear to be 
a justifiable risk. It is a significant fact which I 
learned from Dr. Miller, who has been studying the 
tuberculosis problem in France, that the French 
think that mild cases of tuberculosis, whatever they 
mean by "mild cases," are improved in the trenches 
and in war activitie.s — an opinion supposedly based 
on observation and quite contrarj' to that of Dr. 
Biggs quoted above. 

On the other hand, a dubious family and personal 
history with a tendency to lowered resistance under 
slight or moderate provocation, indifferent assimila- 
tion, unsatisfactory development, and failure to de- 
velop vigorous health under training, with the same 
amount of latent trouble, will indubitably break 
down under the continued strain of army life and 
would be an unjustifiable risk. To treat both cases 
alike because they both show the same physical 
signs or the same J-ray picture, and to reject both, 
would seem to be poor judgment on the part of 
the examiner and defraud the Army of some good 
men who would in all probabilitj" go through the 
ordeal without developing active disease. Of course 
it is obvious that the consequences of a wrong de- 
cision in these latent, arrested no-symptom cases 
both to the Army and to the individual are more 
serious than in civil life. With the soldier it is 
the question of the continuance or abandonment of 
his occupation, — that is, of his militarj- life — while 
with the civilian no such decision ordinarily has to 
be made, or, if it does, such serious possibilities 
are not involved as in the former case. 

It is generally believed, and the evidence at hand 
seems to confirm this belief, that almost every adult 
has acquired some time during his childhood a tu- 
berculous infection, which has caused more or less 
deposition of tubercle in his glands or lungs. When 
such latent tuberculous infiltration is extensive 
enough to give definite physical signs, but with no 
symptoms, we are told that such latent disease 



July 13, 1918] 



MEDICAL RECORD. 



49 



should disqualify a man from active service. On the 
assumption, to quote Biggs once more, that this in- 
active process "will almost certainly become active" 
— how do we know that the lesser infiltration or the 
deeply buried focus which we do not or cannot dis- 
cover will not break down as well as the discover- 
able amount? Or that the discoverable amount will 
not remain latent and inactive under military life 
and conditions as well as the undiscoverable amount? 
We all know that a certain unknown number of men 
who are passed as without discernible signs of tu- 
berculosis will later develop the disease in the Army ; 
in this case it is the undiscoverable or undiscovered 
amount which has become active. It would be an 
interesting and instructive observation if some of 
these latent symptomless cases which could be dis- 
covered by physical signs or the .r-ray should be 
permitted to enter the Army, and compare the re- 
sults with those in whom no discoverable signs of 
latent tuberculosis were present. In other words 
how many greater infiltrations would break down 
and how many lesser ones. 

After all, the "conclusion of the whole matter" 
in our present state of knowledge in regard to 
eliminating tuberculosis from the Army is to reject 
all obviously active progressive cases, and, secondly, 
to reject or refer to the non-combatant force all la- 
tent, inactive, arrested cases which one's experience 
and judgment decide would probably break down un- 
der active military life. When all this is done it is a 
fairly debatable question just how much it will 
lessen the incidence and development of tuberculosis 
in the Army, for the real test of the soldier's ability 
to go through the strain of military service without 
developing the tuberculous infection or latent focus 
he has, or may have, into activity is not whether or 
not he has some discoverable lesion, the "very lim- 
ited amount" of Biggs, but it is dependent upon that 
illusive and unknown cellular response to infection 
and to his hidden lesion under varying conditions 
of life which we call resistance and whether or not 
the barriers which shut in the tubercle will with- 
stand the drive. It is Hindenburg versus the Al- 
lies. 

Do what we will to exclude tuberculosis from the 
Army, it is, of course, inevitable, as I have said, 
that a certain percentage of the men while in France 
will develop the disease and in consequence will have 
to be removed from the active force and placed under 
treatment. Already government sanatoria have 
been planned, or existing ones taken over, for the 
care and treatment of such invalided soldiers. Why 
not treat the curable cases in Europe where they 
are? In some favorable climatic regions of 
France? Such a plan would enable the men 
to be placed under treatment almost at once, 
and would avoid the long and weary journey over- 
seas with its incident ri.sks. We all recognize the 
capital importance of beginning treatment at the 
earliest possible moment after active disease is dis- 
covered. Moreover, the expense of the long trans- 
portation would be saved and accommodations and 
treatment abroad would probably be not more ex- 
pensive than in this country, if as such. Further- 
more, it is the desire of the Surgeon General's de- 
partment, as reported by Dr. Pattison', that the re- 
turned tuberculous soldiers should give themselves 
entirely to the business of getting well, and conse- 



quently they should not be placed in sanatoria close 
to their homes on account of the distractions of 
visiting friends and relatives. This objection would, 
of course, be obviated if the treatment was con- 
ducted abroad. Of course, some men would pre- 
fer to return to America for treatment on account 
of personal considerations, but others, I believe, 
would be glad to embrace the exceptional oppor- 
tunities that could be offered abroad. In France 
there are good climatic conditions for the curative 
treatment of pulmonary tuberculosis, and accommo- 
dations could be found in existing sanatoria and the 
various health resorts — now empty of guests — in the 
French Alps and Pyrenees, in the Riviera, at Pau, 
Cauterets, and many other places. They are but a 
comparatively few hours distant from the Western 
front, and the American soldier unfortunate enough 
to develop tuberculosis could be under treatment in a 
favorable climate almost at once after the discovery 
of his disease. I am unaware that such a plan has 
been proposed, but it seems to me a reasonable one 
to be considered. 

REFERENCES. 

1. Hawes: "Early Pulmonary Tuberculosis," New 
York, 1913. 

2. Pattison, H. A. : "Following up Tuberculous Sol- 
diers," Natioiial Assoemtion Bulletin of the National 
Association, March, 1918. 

381 Beacon Street. 



AN ANALYSIS OF THE WEAK FOOT WITH 

REFERENCE TO PRECISION IN THE 

USE OF DESCRIPTIVE TERMS 

IN TEACHING. 

By royal whitman, M D., 

NEW YORK. 

In 1917, 2,736 new patients applied for the treat- 
ment of weak feet at the Hospital for Ruptured 
and Crippled and it has been estimated that from 
30 to 40 per cent, of those examined by the exemp- 
tion boards during that year presented either po- 
tential or actual disability of this character. Nu- 
merically, therefore, and particularly from the mili- 
tary standpoint, the weak foot is the most important 
of the orthopedic aflfections. 

Many years ago I presented the proposition which 
I have since upheld, that the most direct of the pre- 
disposing causes of the so-called flat foot is a pos- 
ture that simulates the deformity, which may 
be defined as a persistent attitude of abduction. 
In this attitude, the mechanism is functionally out 
of gear and is subjected to abnormal strain when 
in active use. Treatment, therefore, whether pre- 
ventive, curative or palliative, depends for its ef- 
fectiveness on the restoration as far as may be of 
the normal mechanical relations. 

This proposition, once novel, is now, I think, gen- 
erally accepted by orthopedic surgeons, but it is 
not understood by the profession at large as rep- 
resented by the men sent to me for instruction in 
military orthopedics, nor is it clearly presented in 
the literature of the subject. 

The first essential of effective demonstration is 
precision in the use of descriptive terms and since 
there is an evident confusion on this point as it re- 
lates to the weak foot, one may with advantage 



50 



MEDICAL RECORD. 



[July 13, 1918 



analyze the attitude, that when persistent becomes 
deformity, before deciding on the term that best 
describes it. 

When normal feet are placed side by side with 
the heels and toes apposed, an interval persists be- 
tween them, caused by the slight outward curve of 
their inner border.s. In this position the line of 
strain transmitted from the muscles of the calf 
passes through the center of the leg to the neigh- 
borhood of the second and third toes, and the weight 
is properly balanced on the foot. 

The most important indication of the potential 
or actual weak foot is a bulging inward, so that the 
two feet when placed side by side are in contact 
throughout their entire extent or, if the bulging is 
more pronounced, it is impossible to appose the heels 
and toes simultaneously. If the heels are in con- 
tact, the toes diverge or vice versa. 

The bulging is caused by the inward and down- 
ward rotation of the astragalus upon the os calcis, 
rolling the foot over toward the inner side, de- 
pressing relatively the arch, and, since the leg, rest- 
ing on the astragalus must rotate inward with it, 
the line of strain is deflected from the center of the 
fore foot and falls over its inner border. Thus the 
most noticeable of the physical signs of the weak 
foot on inspection is the inward bulging; the most 
significant is the change in the relation of the power 
to the fulcrum; the least important, the incidental 
depression of the arch. 

This attitude, characteristic of the weak foot, 
may be described by any one of three synonymous 
terms : 

1. E version. 

2. Abduction. 

3. Pronation. 

Eversion, to tuin over, refers primarily to the 
relation of the sole to the base in which its inner 
border is depressed and the outer elevated. 

Abduction refers primarily to the divergence out- 
ward of the foot in its relation to the leg. 

Pronation, analagous to the movement of the fore 
arm that turns the hand over, refers primarily to 
the inward rotation of the leg and the effect upon 
the foot. 

If the foot is well arched and compact, the out- 
ward deviation from the middle line of the leg will 
be more apparent than the inward bulging. If its 
structure is relaxed, the bulging and depression of 
the arch will be more noticeable. They are, however, 
component parts of a tilting of the foot as a whole 
beneath the astragalus and the terms are for all 
practical purposes synonymous because the move- 
ments are circumscribed by the same joints. One 
cannot abduct without everting, nor pronate without 
abducting. If authority is desired for a statement 
that can be so easily demonstrated, Rudolph Fick* 
may be quoted. Many, he says, in describing the 
outward and inward tilting of the foot, use abduc- 
tion and adduction. The surgeons use pronation and 
supination, and the English, eversion and inversion. 

Of these terms, eversion has the disadvantage 
that its meaning is sometimes confused with out- 
ward rotation of the limb, and since it refers pri- 
marily to the sole it is difficult to demonstrate when 
the foot bears weight. 

Pronation is a German term, never used by Eng- 

*Anatomie dev Gelrnkc: Spozielle Mechanik. 



lish anatomists, and is from the standpoint of 
analogy, very difficult to demonstrate because the 
arrangement of the arm and leg bones is entirely 
different. Furthermore pronation signifies activity 
while the characteristic of the weak foot is passiv- 
ity. 

Abduction is, it seems to me, preferable to either 
because the change in the line of strain is most 
noticeable when the foot bears weight and the me- 
chanical disadvantage of such an attitude for active 
use is very apparent. 

I have found this preliminary exposition the more 
necessary because the meaning of the de.scriptive 
terms is usually confused by the student and often 
by writers on the subject. For example, in 
one of the authoritative Manuals of Orthopedics, 
eversion is used to indicate divergence of the feet 
caused by outward rotation of the limbs, whereas 
in true eversion of the foot the limb is relatively 
rotated inward and even the everted foot may be 
habitually turned inward, as is illustrated by the 
symptomatic pigeon-toed gait which is a common 
symptom of the weak foot in childhood. 

Abduction is described as a free lateral movement 
in the medio-tarsal joint, where its range is so lim- 
ited as to be negligible, as may be demonstrated 
by fixing the heel or by noting the contour of the 
external border of the foot in the contrasting atti- 
tudes of abduction and aduction. 

Finally the weak foot is said to be a combination 
of pronation and abduction which, however accu- 
rate, is hardly intelligible from the foregoing de- 
scriptions. 

The consideration of the weak foot from the 
standpoint of functional mechanics clears away 
much of the ob.scurity about what is in reality a sim- 
ple subject. For example, a foot habitually used at a 
mechanical disadvantage is predisposed to injury 
and since the primary symptoms of all weak feet 
are those of strain, the immediate disability has no 
proportionate relation to the degree of deformity. 
In fact, the well-formed foot subjected to persistent 
strain provides the most favorable opportunity for 
progressive and irremediable disability, since sta- 
bility (flatness) cannot be acquired without great 
lateral distortion and consequent disorganization of 
its structure. Whereas, the actual flat foot, an in- 
dividual or racial pccularity, or one that is acquired 
in early life, may be perfectly competent because 
stability does not require excessive lateral distor- 
tion of its component joints. 

From this standpoint one may estimate fairly the 
prospective ability of the weak footed recruit. 

The most favorable type is the well-formed foot 
in which the normal relations can be voluntarily re- 
stored. 

The next is the actual flat foot with but 
little lateral distortion. 

The last is that, in which the changes of struc- 
ture in accommodation to habitual deformity have 
advanced so far that the normal relations cannot be 
restored either voluntarily or by manipulation. 

The treatment of the weak foot follows the same 
principle. The first indication is to relieve the 
symptoms of strain and injury, but the final pur- 
pose is to assure the normal relation between the 
power and the fulcrum, as the essential preliminary 
for the restoration of muscular prwer and balance 



July 13, 1918] 



MEDICAL RECORD. 



31 



upon which permanent cure depends. It is this pur- 
pose and the means employed to accomplish it that 
distinguish reconstructive treatment from the com- 
mon routine, which is practically limited to the re- 
lief of the immediate symptoms. 

2S3 Lexington Avenue. 



FEEDING IN MARASMUS. 

By mark S. REUBEX, M.D.. 

NEW YORK. 



For centuries, men wasted useful lives in a futile 
attempt to find the elixir of perpetual youth and 
life. For many decades physicians have vainly 
tried to discover a feeding formula on which all 
infants would thrive. From time immemorial men 
have had visions which built bridges from dream- 
land to truth. Sir Launfal, in his search of the 
Holy Grail, traveled over land and sea without avail ; 
he finally returned, an old man, and found it in 
the domain of his own castle. The essence of truth 
which this parable contains is applicable to every 
sphere of life; and so it has been in the feeding 
of infants. A page could easily be filled with the 
names of men who have devised formulas and milk 
mixtures for the feeding of healthy and atrophic 
infants; these new mixtures have had their en- 
trances and their exits; they always attract at- 
tention, but seldom survive the test of time. The 
realization of the fact that in the proper modifica- 
tion of Grade A bottled milk, with the addition 
of suitable carbohydrates, we have found the ob- 
ject of our search, may sound prosaic, but it is 
true. 

Infants need not die of marasmus. With the 
means we possess to combat it, infantile marasmus 
.should be a disease of the past. The means and 
the armamentaria which we possess are the broader 
and the more rational application of knowledge we 
already have; no new mixtures, no new facts are 
necessary. 

From an e.xperience with over 1,000 atrophic in- 
fants we are thoroughly convinced that if an atro- 
phic infant can be saved it can be saved by the 
use of properly modified, clean, bottled milk, with 
the addition of suitable carbohydrates; and if it 
cannot be so saved, then no manufactured food 
will save it. If the general practitioner would only 
realize how quickly atrophic infants respond to sim- 
ple mixtures, and that the same principles laid 
down for healthy infants are applicable to mara.s- 
mic infants, it is certain that the rate of mortality 
from this cause would be lowered tremendously. 

In two previous papers we have discussed the 
fundamental principles of the art and the science 
of breast and artificial feeding of healthy infants. 
In this paper it is our aim to discuss the funda- 
mental differences between healthy and atrophic 
infants, in the chemical composition of their bodies, 
and in their nutritional requirements. 

Marasmus is not a disease entity; it is a condi- 
tion. It simply implies that the infant is in a 
wasted state, without suggesting the cause of this 
wasting. It may be due to various causes, such 
as congenital debility, constitutional disease, insti- 
tutional life, neglect, unhygienic surroundings, and, 



most frequently, it is a result of chronic nutritional 
disturbances. 

In undertaking the treatment of a case of maras- 
mus due to a nutritional disturbance we must al- 
ways be sure that the other causative factors are 
excluded; we must be sure that the case is a feed- 
ing case only; it is evident how fruitless our efforts 
will be if we do not recognize and do not treat 
an underlying luetic infection, which may be the 
cause of the malnutrition, or if other causative 
factors are not corrected. Very often, multiple 
causes are operative in the same case, all of which 
must be corrected if success be desired. 

When we are satisfied that the malnutrition is 
due to a nutritional disturbance we must go a step 
farther and determine the exact nature of the nu- 
tritional disturbance. The term nutritional dis- 
turbance also is a generic one, which does not 
specify the exact nature of the disturbance; it is 
only within the last 10 years that we have learned 
to differentiate the various factors which may be 
responsible for the marasmus. The various causes 
of malnutrition are given below. In every case 
we must determine all the causes which are re- 
sponsible. In no two cases shall we find the same 
exciting causes, and therefore in no two cases will 
the treatment be the same. 

Etiology op Ndtritionai. DisTURBAKfES. 

1A. Hereditary causes; congenital debility; ly.^; tuberculo'ns 
B. Congenital causes: congenital heart; pyloric stmoiis; Hirsch- 
sprung's disease; atelectasis; myatonia; harelip; cleft palate; 
adenoids. 
C. Acquired causes; lues; tuberculosis. 
D. Due to presence of diathesis: exudative; neuropathic; spasmo- 
philic; anemic; hemophilic; etc. 

(a) Quantity of food improper f overfeeding 
lunderfeeding. 
IToo much or too little at a feeding. 
Food given too fast or too slowly. 
Formula [Food given too frequently or too i 

proper. |(6) Improper i frequently. 

technique. [Too many or too few feedings. 
Food improperly administered. 
[Food improperly prepared, 
(c) Poor milk— fat or solids too low. 

B. Formula improper: Fats too high or too low; sugars too high or too 
low; too much flour; proteins too high or too low; salts too high or 
too low; water too much or too little; improper relation--? of ele- 
ments to one another: insufficient vitaminc content. 

C. Improper and unsuitable breast milk. 
f fFat too high in formula. 

of motility[ .i. Delayed motility. \ Pyloric stenoMs. 
tns of gas-^ i Hirschsprung's disease. 

B. Increased motility. 

[C. Deficient secretion of HCI; of lipase. 

i [Boric acid. 

fa) In milk. ^Salicylic acid. 
[Benzoic acid, etc. 
ib) In breast milk, Hg. morphine. I, etc. 
(c) Preformed in milk by bacteria. 
id) From nipples, pacifiers, toys. 
By bacteria and intestinal juices from 
milk, the juices, and from bacterial 
bodies. 
U. Toxins excreted in the intestinal tract — elaborated elsewhere. 

(A. Enteral— typhoid; dysentery; cholera, etc. 
B. Parenteral — pneumonia; influenza; diphtheria, etc. 
C. Due to abnormal virulence of normal flora (BadUut coli, entero- 
coccus). 

[A. Neglect. 

B. Insufficient or improper bathing, clothing, exercise. 
Improper hygiene. |C. Overheating, chilling. 
D. Overcrowding. 
[E. Lack of motherin.^, etc. 

The most common cause of marasmus is improper 
alimentation. Intolerance for milk as a whole, or 
for any of its elements, is the least common cause; 
for every case of malnutrition due to intolerance 
there are nine due to over or underfeeding, irregu- 
lar feeding, improper technique or method of prep- 
aration. Of the intolerances, that for fat is most 
frequent (70 per cent.), for sugar less frequent 
(20 per cent.), and for protein least frequent (10 



Disturbani 
and secretions 
troiDtestinal tract. 



52 



MKDICAL RECORD. 



[July 13, 1918 



per cent.). In this paper only those cases of ma- 
rasmus due to improper alimentation will be con- 
sidered. 

Chemical Composition of Atrophic Infants. — 
From the earliest fetal development to the birth 
of the full-term infant, the human embryo becomes 
poorer in water and richer in ash; thus a fetus at 
6 weeks is composed of 97.54 per cent, water and 
0.001 per cent, ash; at 6 months, 89.20 per cent, 
water and 1.94 per cent, ash; at birth, 71.8 per cent, 
water and 2.7 per cent. ash. The same process of 
dehydration and enrichment in salts continues to 
adole.scence and old age. The differences in the 
chemical composition of the adult and the infant 
are shown in the following table: 





Water, 
per Cent. 


Fat, 
per Cent. 


Carbohydrate, 
per Cent. 


Protein, 
percent. 


Ash. 
per Cent. 


Adult 

Newborn infant 


60.8 
71.8 


15.0 
12.3 


10 


18.0 
11.7 


6.0 

2.7 



Numerous chemical analyses of infants who had 
died of marasmus have shown that atrophic infants 
do not differ from normal infants in chemical com- 
position to any appreciable extent; the only notice- 
able difference is the reduction of fat in the atrophic 
infants. The percentage composition in regard to 
protein, salts, and water is nearly the same as in 
normal infants {see table). It seems that the 
chemical composition of the body does not become 
altered in chronic malnutrition, and that it is im- 
possible to effect such changes through the alimen- 
tary tract. In marasmus the infant's loss of weight 
is at first due to loss of stored fat, and then all 
elements seem to be equally involved. An atrophic 
infant weighs less than a normal infant of the 
same age, but the chemical composition of the nor- 
mal infant is maintained. The impulse for growth 
in infants is so great that they continue to grow 
(not to the same extent as normal infants) even 
when they do not gain or lose in weight. 







100 Cm. Ash Cost 


l.\s 








m Water 


Fat 


Nitro- 
Rcn 


Ash KsO Na«0 


CaO MgOFejOj 


PjOs 


CI 


Newborn 

infant... 71.8 
Atrophic 

irifant... 79.9 


12.3 
1.45 


2.26 
2.32 


2.7 7.06 
2.73 7.2 


7.67 

7.7 


38 08 1.43 
38.1 12 


0.83 
1.2 


37.66 
38.7 


6.61 
6.1 



Fat Indigestion. — The symptoms which must be 
considered in the different types of indigestion are 
the appetite, the vomiting, and the stools. In fat 
indigestion the appetite is poor; the infant does 
not finish its bottle, and is not hungry at the 
next regular feeding time; this is due to the fact 
that there is some residual food in the stomach 
from the previous feeding. The fats are the last 
element of milk to leave the stomach. When milk 
is introduced into an infant's empty stomach part 
of the milk enters the duodenum in the same form 
in which it was introduced (without any digestion). 
This explains why infants often take greater quan- 
tities at a feeding than their anatomic capacity 
would indicate. Then the whey of milk — salts and 
sugar — pass into the duodenum; the next to pass 
are the proteins; the last to leave the stomach are 
the fats. It is evident why the appetite in cases 
which receive too much fat is bad, and why the 



vomiting in fat indigestion takes place some time 
after the feeding has been administered. The 
vomitus usually consists of creamy, rancid-smelling, 
curdled milk. The stools are gray or white, and are 
greasy or shiny ; the stools smell strongly of butyric 
acid; they usually contain soft curds. When the 
soaps predominate they are dry and hard and are 
clay-colored and oily; the reaction of these stools 
is acid, and the odor is rancid. The gray stool is 
usually due to an excess of neutral fat; the white 
or soap stool is due to an excess of fat in the form 
of soaps. There are three requisites for the for- 
mation of soap stools: (1) A moderate amount 
of fat; (2) considerable amounts of casein and cal- 
cium salts; (.3) an absence of large amounts of 
carbohydrates in the food. 

Sugar Indigestion. — In sugar indigestion, the 
vomiting usually takes place soon after feeding, 
and is often repeated a number of times between 
feedings. The vomitus consists of sour-smelling 
watery fluid; flatulence and colic are usually due to 
indigestion of the carbohydrates, but may also be 
due to indigestion of protein or fat. The most 
marked symptoms in carbohydrate indigestion are 
intestinal, whereas those of fat indigestion are usu- 
ally gastric. The stools are loose, green, and scald 
the buttocks ; the odor is that of acetic acid or 
lactic acid. In severe cases, fever, glycosuria, and 
signs of intoxication are present; both sugar and 
starch may be present in the stool. 

Protein Indigestion. — The vomiting in protein in- 
digestion usually takes place some time after feed- 
ing, and the vomitus is cheesy, and consists of 
large, tough curds. The stools are loose, brownish, 
alkaline, and of putrefactive or fecal odor; very 
often they contain considerable amounts of mucus' 
and hard or protein curds. It is the least common 
form of indigestion. The reaction of the artificially 
fed infant's stool is alkaline; that of the breast-fed 
infant is acid; the reaction depends on whether the 
nitrogen free elements (carbohydrates) or the pro- 
tein predominate in the mi.xture; if the former is 
found in excess the reaction is acid; if the latter, 
it is alkaline. Thus an acid stool which scalds 
the buttocks may be changed into an alkaline stool 
by increasing the proteins and fats and by dimin- 
ishing the carbohydrates; an alkaline stool may be 
changed into an acid stool by increasing the carbo- 
hydrates. Stools which scald the buttocks are usu- 
ally acid. The carbohydrates are the laxative ele- 
ment of milk; regardless of which sugar is used, 
if a sufliicient amount is administered, looseness of 
the bowels will be produced. The proteins are the 
constipating element of milk; this is brought about 
by the alkaline intestinal secretion which they call 
forth and on account of the putrefaction they un- 
dergo; the fats per se have no effect on the bowels; 
their effect depends on the amount administered; 
small amounts are constipating, large amounts are 
laxative. Their effect on the bowel movements is 
also dependent on the presence or absence of other 
elements of milk in the mixture. Thus, a high fat 
in the presence of a high protein content and a 
low carbohydrate and low salt content has a con- 
stipating effect; but in the presence of low protein 
and high carbohydrate content it has a laxative 
effect. 

Curds: make their appearance in the stool both 



tl 



July 13, 1918] 



MEDICAL RECORD. 



53 



in fat and protein indigestion. The protein or 
casein curds are bigger, bean-sliaped, hard, tough, 
and are white or yellow in color; the fat curds are 
smaller, softer, more easily broken down, and are 
of yellow-green color. The total loss of food in 
fuel value in the curds is, in the great majority of 
cases, very slight. The hard curds are derived 
from the casein, and usually disappear when the 
milk is boiled; the soft curds are derived from the 
fat of the food. 

Mode of Onset. — The onset of the symptoms in 
fat indigestion is usually slow or subacute ; only 
when the amount of fat in the milk mixture is 
very high is the onset sudden. In the mild cases 
there may be no symptoms present for a number 
of weeks, and they only make their appearance 
when the fat in the milk mi.xture is increased. 
Of all the different types of indigestion, that of 
fat is most apt to run a latent course at the begin 
ning. In sugar indigestion the onset is subacute 
or sudden ; in severe cases it may be fulminating. 
The .symptoms are always manifest, even at the on- 
set. This type of indigestion never runs a latent 
course. The symptoms of protein indigestion are 
the mildest of all the forms of indigestion, and are 
usually slow in development. 

The appetite is always poor in fat indigestion ; 
even when there are no other symptoms present ; 
it is the premonitory sign of this type of indiges- 
tion, and unless heeded it means "trouble ahead." 
In sugar indigestion the appetite is good, except 
in severe cases with high fever; it is but slightly 
affected in protein indigestion. 

The weight, in fat indigestion, may not be af- 
fected at the onset; in fact, for a time such infants 
may even be gaining slowly in weight. Stationary 
weight, in cases which receive sufficient calories in 
the food, should always lead one to suspect the 
presence of a mild type of fat indigestion. Big 
losses in weight in this type of case are only noted 
when the limit of tolerance for fat is overreached, 
and is usually associated with "fat diarrhea." In 
sugar indigestion, the weight depends on the num- 
ber of stools which the infant passes and on the 
amount of water the stools contain. Very often, 
infants continue to gain in weight in spite of the 
presence of four to five loose, watery stools a day ; 
however, in severe cases, with many watery stools, 
the loss in weight may amount to two to three 
pounds in one week; this is usually due to the 
fact that infants overfed with carbohydrates have 
their water in loose combination, which, in the 
presence of the slightest digestive disturbance is 
quickly lost. One should always look for edema 
in cases which receive a high percentage of carbo- 
hydrates and show marked gain in weight. In 
protein indigestion the weight is but slightly af- 
fected. The temperature, in cases with fat indi- 
gestion, shows at first more than normal oscilla- 
tions; later the temperature has a. tendency to 
become subnormal; in cases in which there is fat 
diarrhea it is apt to be elevated one or two degrees. 
In sugar indigestion the temperature is slightly 
elevated at first, and in severe cases may be as high 
as 105° F. In protein indigestion the temperature 
is not elevated except in cases which receive more 
than 6 per cent, protein in their food. 

Metabolism. — Even in severe cases of atrophy, 



due to fat indigestion, the metabolism of the pro- 
teins is normal. In mild cases the absorption of 
fat is but slightly decreased — 85 per cent, (normal, 
95 to 98 per cent, absorbed) ; in normal stool, the 
calcium and the magnesium soaps constitute about 
18 per cent, of the fat excreted in the stool; in 
mild cases of fat indigestion they may constitute 
50 per cent, of the fat in the stool; the binding 
power of the calcium is so great, however, that this 
does not necessarily mean that there will be a 
negative balance of safts, but suggests that some 
of the calcium which would be excreted as calcium 
phosphate is now excreted in combination with 
fatty acids. In severe cases there is a loss of so- 
dium and potassium salts in the stools, and this 
leads to increased e.xcretion of ammonia in the 
urine, 15 to 20 per cent, (normally, ammonia forms 
8 to 10 per cent, of the nitrogen in the urine). 
This is due to the fact that ammonia is called upon 
to neutralize the acids liberated by the withdrawal 
of the sodium and potassium bases. 

In severe cases of mara.smus due to fat indiges- 
tion the nitrogen retention is diminished, and there 
may be a negative balance; this is not due to defi- 
cient absorption, but to a loss of nitrogen from the 
disintegration of cellular tissue, as these infants 
excrete more nitrogen than they take in. When 
fat diarrhea is present the absorption of fat is 
very poor (25 to 50 per cent.), and the insoluble 
soaps of calcium and magnesium diminish in 
amount. Hess has shown a deficiency of lipase in 
these cases, and it is possible that part of the loss, 
of fat is due to this cause. The tolerance for' 
sugars in many of these cases is also diminished. 
The salt metabolism suffers most in these cases; 
there may be a negative balance. The loss of alkali 
bases leads to increased acidity of body fluids, and 
this in turn leads to increased ammonia excretion 
in the urine (15 to 20 per cent.). 

In sugar indigestion the disturbances in the me- 
tabolism are due to the increased peristalsis and 
the abnormal secretion of the intestinal juices. In 
very loose stools there is a great loss of fat; the 
loss of fat runs parallel with that of the water; 
the greater the water loss the greater the loss of 
fat. In very loose stools there are hardly any 
soaps found at all (about 8 per cent.) ; most of 
the fat is in the form of neutral fat (65 per cent.) 
and fatty acids (27 per cent.). The amount of 
protein lost is about twice as great as in normal 
stools, but the relation of the nitrogen to the total 
residue is normal; most of the nitrogen excreted 
is derived from the intestinal secretions and not 
from the food. The actual amount of calcium in 
the loose stool is nearly the same as in the normal 
stool ; the quantity of Na and K is very much in- 
creased. The residue (cellulose of bacterial origin) 
is very much increased in very loose stools. 

The urine of infants overfed with flour shows 
no trace of chlorine ; there is also a deficient salt 
content in the blood serum; the blood is hydremic; 
in the liver there is a deposition of salts and water; 
on the whole, the findings show an impoverishment 
of salts and an accumulation of water in the sys- 
tem. As the salts are not present, the water must 
be retained in a colloidal state. 

In severe forms of sugar indigestion associated 
with acidosis due to retention of acid products, the 



54 



MIDICAL RECORD. 



[July 13, 1918 



disturbances in metabolism are very marked. The 
nitrogen in the feces is much increased, due to the 
larger amounts of feces passed; the relative per 
cent, of nitrogen in the feces is not changed ; the 
nitrogen in the urine is also increased, due to disin- 
tegration of cellular tissue. These infants seem to 
have lost the power to reduce the amino acids to 
urea, which is probably due to an insufficiency of 
the liver. The ammonia excretion is very much 
increased — 40 to 50 per cent, of the nitrogen in 
the urine. 

The fat resorption is diminished to 50 per cent. 
This is mostly due to increased peristalsis. Melli- 
turia in these cases is due to disturbed carbohydrate 
metabolism, and is usually associated with hyper- 
glycemia; the sugar is of alimentary origin, and 
the sugar which is introduced into the food is the 
one which is excreted into the urine. Glycosuria 
in these cases takes place long before the limit of 
tolerance for the sugar is reached. There is a 
great loss of water from the body in these cases, 
with severe diarrhea, and this leads to dehydration 
of the blood; and there is a corresponding increase 
in its viscosity. During the severe stages there is 
a great loss of salts, which can only be explained 
by the disintegration of cellular tissue. Sodium, 
potassium, and chlorine are lost in great amounts; 
only calcium and phosphoric acid are retained; the 
negative balance is due to increased excretion of 
sodium, potassium and chlorine in the feces; the 
bases are found in greater quantity than needed 
for the binding of the fatty acids, so that their 
increased excretion is probably due to increased 
peristalsis. 

Clinical Findings. — In the early stages of fat 
indigestion the infant may appear well nourished, 
but in spite of sufficient calories in the food the 
infant does not gain in weight. For a time, ano- 
rexia is the only .symptom; when the food is in- 
creased, gastric and intestinal symptoms make their 
appearance; general symptoms (pallor, diminished 
muscular tone, restlessness, disturbed sleep) soon 
make their appearance. If the fat in the food is 
not reduced, or if it is increased, acute symptoms 
supervene, and the infant may lose a pound in a 
few days; gradually they lose more and more in 
weight, until the complete picture of marasmus be- 
comes manifest. The emaciation becomes extreme, 
the face looks senile and pale, the respiration is 
irregular and the expiration is prolonged, the pulse 
is small and slow, the temperature is subnormal, 
the tolerance for food and the resistance to infec- 
tion are very much diminished; any erroneous 
change in diet may lead to a "weight crisis." These 
infants respond with very severe symptoms when 
subjected to starvation, and may suffer from col- 
lapse. On account of their lowered resistance to 
infection they are subject to influenza, bronchitis, 
etc., and very often a slight infection is the imme- 
diate cause of death. On account of their low 
resistance many of these infants are afflicted with 
various skin diseases (intertrigo, eczema, furuncu- 
losis). 

The symptoms of sugar indigestion may appear 
in a previously healthy infant or in one suffering 
from fat indigestion; the weight is stationary, or 
there is slight loss of weight; when the stools are 
not too numerous there may be gain in weight 



for a time; slight fever is usually present; vomiting 
and diarrhea soon make their appearance; tympa- 
nites, increased peristalsis, and gas formation are 
prominent symptoms. In mild cases, if the symp- 
toms are allowed to persist for any length of time, 
and the exciting cause is not corrected, the clinical 
picture of marasmus slowly but surely develops. 

Infants who receive an almost exclusively flour 
diet are prone to develop a chronic nutritional dis- 
turbance which differs from overfeeding with sug- 
ars, and which usually leads to marasmus; this is 
particularly apt to happen in very young infants. 
The symptoms which these infants present may be 
of two different varieties: (1) The atrophic, which 
do not differ from other types of marasmus; (2) 
the hydremic. In this type, the emaciation is 
partly obscured by the retention and the accumu- 
lation of water in the subcutaneous tissues and in 
the tissues. Thus, in later stages edema is a prom- 
inent symptom. The face is pale and swollen; the 
eyes are puffy; less marked edema is present in 
the extremities; the urine is negative. The resist- 
ance to infection is very much diminished; any 
slight infection may prove fatal; the slightest dis- 
turbance causes great loss in weight. In both these 
forms there is often found marked hypertonicity 
of the musculature; often opisthotonus is also pres- 
ent. These infants are apt to develop tetany, and 
usually show other signs of .spasmophilia. The 
stools in these cases may be of normal appearance; 
at times they have diarrhea; undigested starch is 
usually found in the stools. 

When the diarrhea of carbohydrate indigestion 
becomes very severe, and when there is superim- 
posed upon it an intoxication due to retention of 
acid inorganic salts, due to insufficiency of the 
kidneys, the whole clinical picture changes very 
quickly, and the symptoms of acidosis make their 
appearance. Hyperpnea is the chief symptom. 
The mental symptoms become marked ; coma and 
unconsciousness are frequently present; the face is 
pinched; the eyes and cheeks sunken; the color is 
ashy gray, but no cyanosis is present; great loss 
in weight takes place; the fontanelle is depressed; 
the temperature is elevated, and there may be hy- 
perexia (105° to 107° F.) ; vomiting, and especially 
diarrhea, are very marked; the breathing is toxic 
and deep; the pulse is flickering; the urine is di- 
minished ; and there may be complete anuria ; albu- 
minuria, and glycosuria of alimentary origin, are 
usually present; acetone breath is at times marked; 
at times only mere traces of acetone are found in 
the blood (in excess of normal amounts') ; no ab- 
normal organic acids are found in the urine; but 
there is an increase of acid phosphates in the blood, 
due to insufficient excretion by the kidneys. 

Differential Diagnosis. — The differential diagno- 
sis is not always a simple matter. Extreme cases of 
acidosis, atrophy, or simple cases of fat indiges- 
tion, are easily diagnosed; the etiology is at times 
obscure; thus, acidosis and intoxication may be due 
to excessive fermentation and intoxication with bac- 
terial products; it may also be due to excessive fat 
feeding (with diarrhea), or to severe intestinal 
infection, insufiiciency of the kidneys, with diar- 
rhea, and other causes. Atrophy, or marasmus, 
may be due to inanition, overfeeding, chronic fat 
indigestion, chronic sugar indigestion, secondary to 



July 13, 1918] 



MEDICAL RECORD. 



55 



some constitutional disease or to some systemic or 
intestinal infection; it may also be due to improper 
hygiene and neglect. A careful history is there- 
fore important. Of two infants, with soap stools, 
emaciation and stationary weight, one may improve 
on a fat-poor and carbohydrate-rich diet and an- 
other may develop diarrhea and lose weight; of 
two infants with marasmus, one may improve on 
large amounts of whole milk, and the other may lose 
in weight and die. Of two cases with loose stools, 
one may improve on starvation and reduced diet, 
the other may go into collapse, lose weight, and the 
diarrhea become aggravated. 

One must be very careful not to misinterpret the 
findings in the stools. The examination of the 
stool may give valuable information, but undue 
importance should not be attached to them; slightly 
dyspeptic stools may accompany very severe as well 
as very mild cases, and, on the contrary, frequent 
diarrheal stools, with much mucus, may be present 
in mild cases as well as in fatal cases. When judg- 
ing the nature or the severity of a nutritional 
disturbance, the findings of the stools must always 
be considered in conjunction with other symptoms. 
One must especially be careful not to misinterpret 
the findings in loose stools ; in cases with increased 
peristalsis the food residue depends on the com- 
position of the food introduced. 

The history may clear up the etiology. A com- 
plete history of all the foods the infant had received 
from birth, and how he reacted to each, should be 
ascertained ; every food formula should be reduced 
to calories and percentages, for it is only in this 
way that an accurate idea can be obtained whether 
the infant receives too much or too little food. It 
is only by carrying out this procedure, and by 
considering the findings in conjunction with the 
weight and age of the infant, that definite informa- 
tion can be obtained. A knowledge of all the dis- 
eases which the infant had suffered from birth is 
also important, because the nutritional disturbance 
may be secondary to some constitutional disease. 
Very often, in cases of fat indigestion, we obtain 
a previous history of overfeeding with carbohy- 
drates; and on the contrary, in a small number 
of cases of sugar indigestion we obtain a history 
of overfeeding with fat. Tolerance and intolerance 
are relative terms, and the above statement mav 
only mean that in those cases even small amounts 
of fat or sugar may produce symptoms of indiges- 
tion in susceptible infants. In severe cases of 
sugar indigestion, with numerous loose stools, one 
must always expect considerable fat indigestion, 
because the fat loss runs parallel with the water 
loss. 

"General Principles." — The feeding of atrophic 
infants is simple, and can be made successful in 
the great majority of cases if one keeps in mind 
the underlying fundamental principles. These prin- 
ciples are few, clear-cut. definite, of almost mathe- 
matical exactness; disobedience of these rules leads 
invariably to ultimate failure. One can attain a 
successful result in the great majority of these 
cases by adhering to these principles. Attention 
to the smallest details is the key to success. The 
principles, which should guide us in the feeding of 
atrophic infants are: 

1. A complete history and a complete physical 



examination of the infant to determine the cause 
of the malnutrition are essential. 

2. Our fir.st aim should be to prescribe a food 
which will preserve life and correct existing gastro- 
intestinal symptoms. The first step must be a 
period of reparation. When the symptoms have 
subsided we must prescribe a food which will pro- 
duce a regular gain in weight and proper physical 
development. 

3. We must not keep an infant for too long a 
period on a food which is not well balanced, but 
which must be given at the outset to correct exist- 
ing conditions. If we do, we may save the infant 
from the Scylla of marasmus and strand it on the 
Charybdis of scurvy and rickets. 

4. When the gastrointestinal symptoms have sub- 
sided we must prescribe a formula in which the ele- 
ment for which there is an intolerance is reduced 
to a minimum, and in which the other elements 
are correspondingly increased to supply the de- 
sired number of calories. As radical as the first 
change in formula should be, so conservative must 
all furtlier changes be (e. g. an infant who had been 
receiving 6 per cent, fat in its milk mixture, and 
developed an intolerance for fat, should be put on 
a mixture containing only ^2 to 1 per cent, fat; 
and when it has adapted itself to this amount of 
fat the next formula should contain only from ■''4 
to I'i; per cent, of fat). 

5. The more an infant is underweight the greater 
is the caloric requirement. Whereas healthy in- 
fants require from 40 to 50 calories to the pound, 
very few marasmic infants will thrive unless they 
receive 50 to 65 calories to the pound. No atrophic 
infant should receive its full caloric requirement 
at the beginning of treatment. No more than 35 
calories to the pound should be supplied in the 
first formula. 

6. The more an infant is underweight the greater 
is the water need. The quantity to be given at a 
feeding to an atrophic infant should be less than 
the age but more than the weight would indicate. 
A healthy infant requires about 2 to 2y2 ounces 
of water per pound in the second six months, 
whereas an atrophic infant would require 3 to 4 
ounces per pound under similar circumstances. 

7. No infant, whether healthy or atrophic, should 
receive more than seven feedings in the 24 hours; 
the intervals between feedings should never be 
less than three hours; in cases where vomiting 
is a prominent symptom the intervals should be 
3 to 4 hours. 

8. Never change the formula without a definite 
reason; never change the formula before the in- 
fant has had an opportunity to adapt itself to it; 
too many premature changes are the cause of many 
failures in the management of atrophic infants. 
All increases in the strength of the food must be 
more cautious and more gradual than in healthy 
infants. 

9. As atrophic infants have a tendency to have 
subnormal temperature, normal bodily heat must be 
maintained by the use of cotton jackets and exter- 
nal heat. 

10. A normal condition of the skin must be main- 
tained. Proper airing and bathing are indispens- 
able adjuvants of ultimate success. 

11. One must always remember that in the feed- 



56 



MEDICAL RECORD. 



[July 13, 1918 



ing of atrophic as well as healthy infants tempo- 
rary success may mean ultimate failure and tem- 
porary (apparent) failure may mean ultimate suc- 
cess. In healthy infants, an improperly balanced 
diet may cause temporary gain in weight, espe- 
cially if the carbohydrates are high, and may ulti- 
mately lead to scurvy or rickets ; and on the con- 
trary, in atrophic infants, a temporary but proper 
food may not produce immediate gain in weight, 
but leads to a correction of gastrointestinal symp- 
toms. In healthy infants our aim is to procure 
regular gain in weight and proper physical devel- 
opment; in atrophic infants, however, our fir.st aim 
is to relieve symptoms, even if the weight remains 
stationary, or if there be temporary loss of weight. 

12. Frequent and regular observation of the in- 
fants (three times a week) is essential. 

Treatment. — It is only after we have determined 
the exact cause of the marasmus that we are in 
a position to feed the infant rationally and scien- 
tifically; the treatment varies with the cause. We 
must have definite knowledge whether the maras- 
mus is due to improper technique, to over or under- 
feeding, or to an intolerance for one or more ele- 
ments of milk. The treatment also varies with the 
presence or absence of gastrointestinal .symptoms. 

We deem it advisable to wash the stomach of 
every atrophic infant when it comes to us for the 
first time. It is surprising how much mucus and 
products of fermentation are at times removed 
through this procedure. We then order a tenth 
of a grain of calomel (for every month of the 
infant's age) and allow only plain boiled water 
until the next morning. Great caution must be 
exercised in the starving of atrophic infants; these 
infants cannot withstand starvation for more than 
from 12 to 24 hours, and not infrequently show 
marked signs and symptoms of collapse as the result 
of it. 

Our next endeavor is to correct existing symp- 
toms. In cases where vomiting is a prominent 
symptom the infant's stomach should be washed 
daily, the intervals between feedings should not 
be less than SV^ to 4 hours, and the mother 
should be told to put the infant in an upright posi- 
tion immediately after feeding and gently to pat it 
on the back to assist it in the expulsion of any swal- 
lowed air. The formula should not contain a high 
percentage of fat, because of all the elements of 
milk this is most apt to delay the emptying of 
the stomach. 

Infants in whom there is a tendency to loose- 
ness of the bowels, and who have from 4 to 6 loose 
green stools, with curds and mucus, should be put 
on a mixture which is low in sugar and which has 
a moderate amount of fat and a high percentage 
of protein. Such a mixture is conducive to the 
formation of soap stools which are solid and formed. 
Soap stools per se are not to be sought, nor are they 
desirable, except as a means to an end — from loose 
to normal stools. 

This mixture controls the diarrhea by checking 
fermentation and by favoring putrefaction: the pro- 
teins produce an alkaline reaction in the intes- 
tines, and thus check the process of fermentation. 
For the formation of soap stools there are three 
requisites: A moderate amount of fat, a consid- 
erable amount of casein and calcium salts, and an 



absence of large amounts of carbohydrate in the 
food. We have only recently learned of the pro- 
tective influence of fat on the intestines in cases 
with loose stools ; it becomes evident why skim milk 
is contraindicated in cases with diarrhea, for un- 
der the circumstances there are no fatty acids pres- 
ent to unite with the alkaline bases to form soaps 
(the fatty acids are derived from the decomposi- 
tion of fat). An excessive amount of fat in the 
mixture, on the contrary, may not only fail to con- 
trol the diarrhea, but may aggravate it by produc- 
ing an excess of fatty acids over bases. As no 
infant will gain in weight on a mixture which is 
low in carbohydrates, the infant should not be kept 
on such a mixture any longer than is necessarv 
to control the intestinal symptoms; as soon as the 
intestinal symptoms have been controlled, carbohy- 
drates in the form of dextrin-maltose, or flour, 
should be gradually added. When the infant is 
able to take 5 or 6 per cent, carbohydrates it should 
be put on a whole-milk mixture or on a skim-milk 
mixture with a high percentage of carbohydrates 
(if the infant is very much underweight). 

A mixture which is low in carbohydrates, and 
contains moderate amounts of fat and a high per- 
centage of protein, can be made from a bottle of 
whole milk, as follows: 

L. S. Milk — Low Sugar Milk. — Take a bottle of 
Grade A whole milk and shake it so that the cream 
and the remainder are thoroughly admixed. To 
half a quart of this milk add two junket tablets: 
allow it to stand for half an hour; then strain, 
and discard the whey ( which contains the sugar, 
the salts, and the lactalbumin) ; the curd is rubbed 
through a fine sieve into the other half quart of 
milk; enough plain boiled water is added to make 
one quart. The whole mixture is now brought 
to a boil ( to destroy any further action of the 
junket tablet), under constant stirring, and is ready 
for use. Add no sugar to this mixture. No infant 
should receive more than one quart of this mixture 
in the 24 hours. 

Atrophic infants who present no gastrointestinal 
symptoms (there are very few such cases) should 
be put on mi.xtures made from properly diluted 
whole milk, or if they are very much underweight 
on skim milk with a high percentage of carbohy- 
drates. 

Atrophic infants who have an intolerance for one 
or more elements of milk must be put on mixtures 
which contain the element for which there is an 
intolerance reduced to a minimum, and which con- 
tain a high percentage of the other elements which 
are necessary to make up the caloric requirement. 
Thus, in cases of fat intolerance, we use skim milk, 
with a high percentage of carbohydrates; in sugar 
intolerance we may use top milk dilutions (with 
no addition of carbohydrates) or we may use the 
mixture described above, made from whole milk, 
in which part of the sugar of milk is removed; in 
protein intolerance the casein may he removed by 
the use of whey and the amount of casein in the 
milk formula may be gradually increased by add- 
ing more of the curd to the milk mixture; protein 
digestion may be facilitated by the use of alkalies 
(no protein digestion takes place in the stomach 
in an alkaline medium, we must add 25 to 50 per 
cent, lime water"), by the use of cereal diluents 



July 13, 1918] 



MEDICAL RECORD. 



57 



(.casein is precipitated in much finer flocculi), by 
the use of sodium citrate (,1^2 grain of sodium 
citrate to every ounce of milk used — the milk does 
not curdle under these conditions), by boiling, pep- 
tonizing, or homogenizing of the milk. In most 
cases all that is necessary is to bring the milk to 
a boil and all the symptoms of protein indigestion 
usually disappear. 

Uses of Skim Milk. — In 1909 a study was un- 
dertaken to determine the value of different kinds 
of milk (skim, whole, or top milk) as proper sub- 
stitutes for breast milk, in cases in which the latter 
was not available. A large number of infants 
were fed on each kind of food and they were ob- 
served for from one to two years, the effects of 
each kind of milk on the development, the mor- 
bidity, and the mortality of the infants being care- 
fully noted. The results of our studies have con- 
clusively proved to us that in the use of proper 
dilutions of whole milk we have the best substitute 
for breast milk; we were equally convinced that 
skim miUc, although not suitable as a permanent 
food for healthy infants, was of great value as a 
temporary food in all chronic cases of malnutri- 
tion, in which the infants presented no gastroin- 
testinal sj-mptoms and were very much under- 
weight. Skim milk with a high percentage of car- 
bohydrates produces a more rapid gain in weight 
than any other mixture known. 

The advantages of this method of feeding are: 

1. It eliminates or reduces to a minimum the fat 
of the milk, an element which is the most difficult to 
digest, one which most frequently causes indiges- 
tion, and one which requires for its proper diges- 
tion a greater expenditure of energy than any other 
element of milk. 

2. It makes it possible to furnish a high per- 
centage of carbohydrate in the mixture; the car- 
bohydrates are the most easily assimilable elements 
of milk; they require a lesser expenditure of en- 
ergy for their digestion than any other element of 
milk. 'WTien the fats in a mixture are low, a much 
higher percentage of carbohydrates can be given 
to advantage than when they are high; to a cer- 
tain extent the fats and the carbohydrates are in- 
terchangeable; when the fat in a mixture is not 
above 1 per cent, as high as 10 to 15 per cent, of 
carbohydrates will often be tolerated for a number 
of weeks without the slightest sign of indigestion. 
The carbohydrates have the greatest influence on 
the weight; they also have the greatest laxative 
effect; and when given in excess they are apt to 
cause a retention of abnormal amounts of water 
with resultant edema, and glycosuria may be pres- 
ent. The appearance of vomiting and loose stools 
in an infant who receives a high percentage of 
carViohydrates should always lead to an immediate 
reduction of this element. If the early symptoms 
of vomiting and diarrhea are not heeded the com- 
plete picture of acidosis with hyperpnea, anuria, 
glycosuria, and coma may develop within 12 to 24 
hours. 

3. The protein, an element which but seldom 
causes any indigestion and an element which is 
essential for growth, is found in a high percentage 
in skim milk; as infants suffering with chronic 
malnutrition are undersized, the presence of a high 
percentage of protein offers material for tissue 



building. The presence of a high percentage of 
protein makes it also possible to prescribe such 
high percentages of carbohydrates, without the pro- 
duction of loose stools. When the proteins in a 
milk mixture are abundant they call forth an alka- 
line intestinal secretion and in this way counteract 
the tendency of the carbohydrates to produce fer- 
mentation. The proteins seem to exert a bene- 
ficial influence in other ways also; when an infant 
who receives a skim milk mixture with a high per- 
centage of carbohydrates is put on a mixture con- 
taining the same number of calories, but the pro- 
teins are made lower, and either the fats or the 
carbohydrates are made correspondingly higher, 
there is no gain in weight for a number of weeks 
(under the circumstances the salts are also made 
lower and it is possible that the deficient gain in 
weight is due to decrease in salts). 

4. The salts in this mixture are high, and are, 
therefore, helpful in the retention of water; the 
infants for whom this kind of mixture is indicated 
are usually atrophic and dehydrated; the retention 
of large amounts of water is therefore helpful and 
desirable and becomes deleterious when it is re- 
tained only extracellularly (i.e when it gives rise 
to edema). 

5. A greater number of calories can be supplied 
to an infant in the form of skim milk with a high 
percentage of carbohydrates than in the form of 
whole or top milk. Any one who has fed a large 
number of infants can recall cases which for a time 
were gaining in weight, then stopped gaining, and 
when the food was strengthened they immediately 
began to lose in weight and developed gastrointes- 
tinal symptoms. 

At times marantic infants die of starvation be- 
cause not enough food can be supplied to them 
without producing a gastroenteritis. In these 
cases moi-e calories per kilo can be supplied in the 
form of skimmed milk with a high percentage of 
carbohydrates than any other milk mixture with- 
out producing a gastroenteritis, and with resultant 
gain in weight. In a number of cases we have 
been able to prescribe from 75 to 85 calories to the 
pound, with resultant gain in weight and with con- 
tinued benefit to the infant, and without the de- 
velopment of any digestive disturbances. The pre- 
scribing of the same number of calories in the form 
of whole or top milk invariably led to severe diges- 
tive disturbances. 

Skim milk mixtures with a high percentage of 
carbohydrates are especially indicated in cases of 
(1) fat intolerance; (2) malnutrition due to under- 
feeding; (3) malnutrition following acute infec- 
tious diseases; (4) all cases of malnutrition with- 
out gastrointestinal symptoms; (5) weaning. 
(They are contraindicated in all cases of sugar and 
protein intolerance.) (6) They are also indicated 
in infants born prematurely and congenitally debile. 
The fat-splittig ferment is the only ferment which 
is found in deficient quantities in prematurely born 
infants, in marasmus, and in febrile conditions. All 
the other ferments are present at birth (including 
starch-splitting ferment) and their concentration 
in the intestinal tract is not affected in marasmus. 

Technique. — 1. We must first determine the kind 
of milk which is indicated in the particular case 
("whole, top, skim, or "curdled low sugar" milk). 



58 



MFDICAI. RECORD. 



[July 13, 1918 



2. The next step is to determine the quantity to 
be given at a feeding, the number of feedings in the 
24 hours, and the total quantity in the 24 hours. 

3. Calculate the caloric requirement of the in- 
fant; in the first food it is seldom advisable to fur- 
nish more than 30 to 35 calories to the pound. 
Slowly but steadily increase the strength of the 
formula until the full caloric requirement is cov- 
ered and the infant begins to gain in weight. 

4. Never change the formula without definite 
reason. In the first few days after the infant had 
been put on a new formula our policy must be one 
of watchful waiting; our first aim must always be 
to abate symptoms and to improve the general con- 
dition; when this is accomplished we must aim to 
produce regular and sufficient gain in weight and 
proper physical development. 

5. The quantity at a feeding should be increased 
by half an ounce every two or three weeks; no in- 
fant under one year should receive more than 42 
ounces in the 24 hours. 

6. As atrophic infants are apt to be anemic they 
should receive other articles of food ' fruit juices, 
cereals, vegetables, beef juice, yolk of egg) before 
they reach the normal weight for their age. 

7. As the flours are less fermentable than the 
sugars they have a greater field of usefulness in 
infants in whom there is a tendency to looseness 
of the bowels than in healthy infants. Of the 
sugars the dextrin maltose preparations are the 
most useful in cases of atrophy, because they are 
least apt to produce looseness of the bowel and be- 
cause they produce the greatest gain in weight. 
Lactose seems to be the most laxative of the sugars 
and should therefore not be used in cases where 
there is a tendency to looseness of the bowels. In 
healthy infants it is never advisable to raise the 
sugar above 7 per cent in the mixture; when the 
food must be strengthened it is always better to 
increase the milk (not above one quart) than to 
raise the carbohydrates above 7 per cent. In cases 
of fat intolerance it is sometimes necessary to raise 
the sugar to from 10 to 13 per cent.; in these cases 
part of the carbohydrate must be given in the form 
of flour, and more than one kind of sugar must be 
used in the same mixture. In this way we can pre- 
scribe a high percentage without developing an in- 
tolerance. No infant should be kept on a mixture 
containing over 10 per cent, of carbohydrates for 
any length of time, because such infants usually 
have a diminished resistance to infection, even 
though they may be above normal in weight. 



8. In cases in which skim milk is ordered the first 
formula should not contain more than 1 i>er cent, 
fat; to obtain a 1 per cent, milk we must remove 
the upper 8 ounces; as all the fat that rises as 
cream does so in the top 8 ounces, the percentage of 
fat in the remainder of the milk is of uniform com- 
position I 1 per cent, fat ) ; it is thus not possible 
to obtain a skimmed milk of less than 1 per cent, 
fat by the gravity method. When a fat-free milk 
is desired the fat must be removed by a centrifuge 
or separator. When the infant is adapted to take 
1 per cent, fat we should then order IVg per cent, 
fat in the mixture (a skim milk containing 1.5 per 
cent, fat is obtained by removing the upper 6 
ounces ; the lower 26 ounces contain about 1 ^ ^ per 
cent, fat) ; and then we gradually skim less and 
less (one ounce at a timej until the infant takes 
whole milk. As the fat in the mixture is raised 
the sugar is proportionately lowered. 

9. In cases in which top milk is indicated, we 
begin with a 10 per cent. milk. A 10 per cent, 
milk means that the fat in the milk is 10 per cent. 
The proteins, the sugars, and the salts, in top 
milk, whole milk, and .skim milk are approximately 
the same (proteins 3.5 per cent., sugars 4.5 per 
cent., salts 0.75 per cent.) ; slightly less in top milk, 
except very rich cream, where they are reduced to 
two-thirds of the original quantities. To obtain a 
10 per cent, milk we must use only the upper 16 
ounces of the bottle. As the infant develops greater 
tolerance for carbohydrates, we decrease the fat in 
the mixture by using a 9 per cent, milk (obtained 
by using the upper 12 ounces) and correspondingly 
increasing the carbohydrates. As the infant's tol- 
erance for sugars increases we decrease the fat in 
the mixture by successively using 8, 7, 6, 5, and 4 
per cent. milk. 

10. In cases in which the low sugar milk mixture 
above de.scribed (L. S. milk) is used we must keep 
the infants on this mixture until soap stools are 
obtained. As infants but seldom gain in weight on 
this mixture, on account of the low carbohydrate 
content, we must begin to add carbohydrates to the 
mixture (preferably flour or dextrin maltose 
sugar) very gradually; when the infant is able to 
take 5 to 6 per cent, of carbohydrates in this mix- 
ture to advantage it should then be put on a whole 
milk mixture or on a skim milk mixture with a high 
percentage of carbohydrates ( if the infant is very 
much underweightl. 

"ILLVSTR.ATIVE CASES." 
Case I. — Marasno'x D>ie to Inanition. — M. R., birth 



Afie in weeks 

Weipht in poands and i 

Kinti of milk, per cent. 

Milk in ounces 

Boiled water in ounees. 

Granulated sugar, in level table- 
spoonfuls 

Dextrin-maltose, in level table- 
spoonfuls 

Wheat flour, in level tableapoon- 
tuls 

Quantity at a feeding. 

Intervals in hours. . . . 

Additional food 



46 
10:6 
4 
14 
18 

1 


47 
9:9 
4 
16 
IG 

1 


48 
10:7 
4 
18 
17 

1 


40 
9:1.5 

4 
30 
IS 

1 


r.o .-.1 
10 10:13 


52 
11:8 


53 
11:13 
4 
22 
16 

2 


S4 

12:8 


55 
13:3 

... 


56 
13:6 

2*5 
2 


14:9 


S<i ,W 60 
14:12114:1515:15 

^^4 ... 1 ... 


61 
16:6 


65 
17« 

4 
.10 
10 

1 


69 

1S:8 I 
4 1 

32 1 
S 

1 1 


2 


2 


3 


3 






3 






3 




:i 




-> 




*^ 


^^ 


S 
3 


3 


i:;j:.. 




3 

* 






1 
6 
3 
t 


'.". 


1 

7 1., 
3 ...'., . 
... t 1- 


;:: 


4 


.<! 



*Oran(EC juice, 2-^1 ounces; between the first and second bottles. 
tBcef jiiirc, 2-3 ounrrs; in the afternoon. 

jOno tablcapoonful rcrt-ftl: farina, rice, oatmeal, barley; boiled in a double boiler, for at \vjk»X tli 
§Three tahlospoonfuls cerral. 

**VpRetabIe soup; pea*), beanit. spinaeh, earrots. potato: to be boiled for three li 
with a spoon; a'^out one tablespimnfxil at a feedinK. 



> be siraineii; to be fc*I with a spoon. 



n a littlr watrr; strnincvl ibronph a fine i 



and to be frd 



July 13, 1918] 



MEDICAL RECORD. 



59 



weight 7 pounds 2 ounces, breast fed for seven weeks, 
was then put on a mixture containing mixed milk 
1 ounce, barley water 3 ounces, and granulated sugar 
one-half teaspoonful; this quantity was given every two 
hours, eight feedings in the twenty-four hours. The 
infant vomited from three to four times in the twenty- 
four hours, almost immediately after feeding, prob- 
ably due to agitation and hunger contractions; the 
bowels were constipated. The infant came to our clinic 
at the age of forty-six weeks, weighing 10 pounds 6 
ounces. In the first few weeks under treatment the 
infant did not gain in weight, because the full caloric 
requirement was not supplied. The general symptoms, 
however, almost entirely disappeared. As soon as the 
full caloric requirement was supplied the infant began 
to gain from 6 to 8 ounces every week. The vomiting 
subsided in the course of three weeks, and the bowels 
became regular and moved spontaneously. 



weaned the infant entirely and prescribed the follow- 
ing formula: 10 ounces of mixed milk, 11 ounces of 
boiled water, and 1 ounce of cane sugar. The vomiting 
and the loose stools continued. There was no gain in 
weight. Then the infant was brought to our notice, 
weighing 7 pounds 15 ounces at fifteen weeks. From 
the symptoms it was evident that this was a case of 
sugar intolerance, and the infant did very well on top 
milk mixtures without the addition of carbohydrates. 

As soon as the infant was put on top milk the stools 
decreased in number and the infant began to gain in 
weight. The fat in the formula was gradually de- 
creased and the sugar slowly but gradually was in- 
creased. At six months the infant was able to take 6 
per cent, carbohydrates. (Ten per cent, milk is obtained 
by using only the upper 10 ounces of a quart; 9 per 
cent, milk, the upper 12 ounces; 8 per cent, milk, 
the upper 14 ounces; 7 per cent, milk, the upper 16 



Age in weeks 

Weight in pounds and ounces 

Kind of milk 

Milk, in ounces 

Boiled water, in ounces 

Granulated sugar, in level tablespoonfuls . 
Dextrin-maltose, in level tablespoonfuls. 

Wheat -Hour, in level tablespoonfuls 

Quantity at a feeding 

Intervals in hours 

.\dditionaI food 



•Orange juice. fBeef juice. tCereal. one tablespoonful. ICereal, three tablespoonfuls. ••Vegetable. 



Case II. — Marasmus Due to Fat Intolerance. — L. M., 
birth weight 7 pounds 12 ounces, breast fed for four 
weeks; as the breast milk diminished the mother put 
the infant on condensed milk (two teaspoonfuls to 4 
ounces of water) ; this was gradually increased in 
strength, so that at nineteen weeks the infant was tak- 
ing four teaspoonfuls of condensed milk to 6 ounces of 
water every two hours. The infant vomited almost 
immediately after every feeding and the bowels were 
constipated. The mother consulted a physician, who 
put the baby on the following formula : Top milk, 12 
ounces (the upper 6 ounces of two bottles), 24 ounces 
of barley water, 2 ounces of lime water, and 1 ounce 
of milk sugar. There was marked aggravation of all 
the symptoms. The infant now began to vomit also 
between feedings and the bowels were very loose (seven 
to eight times a day). On this mixture the infant lost 
from 4 to 6 ounces every week. The infant came to 
our notice at the age of thirty weeks, weighing 8 pounds 
4 ounces. In the first few weeks there was no gain in 
weight, because L. S. milk is low in sugar. As soon as 
the stools were controlled dextrin-maltose was added. 
Later the infant was put on a 1 per cent, milk, and one- 
half tablespoonful of granulated sugar and 1 ounce of 
dextrin-maltose were added. From this time there was 
regular gain in weight. The milk was skimmed less 
and less and the sugars were correspondingly lowered. 
At sixty-two weeks the infant was of normal weight 
and development. 



ounces; 6 per cent, milk, the upper 18 ounces; 5 per 
cent, milk, the upper 24 ounces, and 4 per cent, milk, the 
whole 32 ounces.) 

316 West Xinett-fourth Street. 



THE RESULTS AND INTERPRETATION OF 
THE WASSERMANN TEST.* 

Br CLARENCE A. JOHNSON, A.B., M.D., 

LOS ANGELES, CAL. 



In this paper I shall give a preliminary report of 
the present status of the Wassermann test in diag- 
nosis, and as a control in the treatment of syphilis, 
together with some of the things which I have 
found to be of practical value from my experience 
with over six thousand Wassermann tests which 
I performed personally at the Los Angeles County 
Hospital. 

The Wassermann test has been given a thorough 
trial in all parts of the world with the result that 
the consensus of opinion is that, all in all, it is the 



Age in weeks 

Weight in pounds and ounces 

Kind of milk, per cent 

Milk in ounces 

Boiled w ater in ounces 

Cane sugar, in level tablespoonfuls . . . 
Deitrin-maltose, in level tablespoon- 
fuls 

Quantity at a feeding 

Intcr\ als in hours 



11 


12 


13 


14 


1.5 


16 


17 


18 


19 


20 


21 


?.■>. 


23 


24 


30 


38 


42 1 


7:11 


7:11 


7:14 


7:10 


7:15 


S:7 


8:12 


9:1 


H:S 


9:8 


9:14 


10:4 


11 


11:1 


13:6 


1,t:2 


16:4 


4 


4 


4 


10 


9 


9 


9 


8 


8 


7 


6 


5 


5 


4 


4 


4 


4 


10 


11 


14 


11 


10 


12 


12 


14 


14 


16 


18 


18 


19 


23 


28 


30 


32 


11 


10 


14 


17 


18 


20 


20 


18 


18 


16 


14 


14 


16 


12 


14 


12 


10 


2 


2 


2 





^2 


H 


1 


1 


1^ 


IH 


I'A 


2 


2 


2 


2 


2 


2 











n 




















1 


1 


1 


1 


2 


2 


2 


3 


3 


4 


4 


4 


4i4 


Hi 


4H 


4H 


m 


4H 


4^ 


S 


5 


6 


7 


7 


3 


3 


3 


3 


3 


3 


3 


3 


3 


3 


3 

* 


3 


3 


3 


3 

** t 


3 

t 


3 



•Orange juice. fBeef juice. JCereal, one tablespoonful. SCereal, three tablespoonfuls. ••Vegetable 



Case III. — Marasmus Due to Sugar Intolerance. — 
Grace Mc, birth weight 7 pounds 6 ounces, breast fed 
for four weeks; best weight while on the breast was 7 
pounds 4 ounces. There was considerable vomiting 
about fifteen minutes after nursing and the infant had 
from six to eight loose green stools every day. It \yas 
then put by a physician on mixed feeding: mixed milk, 
6 ounces; boiled water, 15 ounces; milk sugar, 1 ounce. 
Three ounces of this mixture were given every three 
hours immediately after nursing. The child continued 
to vomit and to have six to eight green stools with 
mucous and hard curds; the buttocks were excoriated. 
At eleven v/eeks she consulted another physician, who 



most valuable aid that we possess in the diagnosis 
of syphilis. This test is the most delicate and per- 
sistent of all the symptoms of syphilis and one 
should not consider a patient cured of syphilis so 
long as the blood or spinal fluid reacts positively. 
If this reaction is persistently positive we are sure 
that there is present somewhere in the body, the 
living spirochete. This is further proved by the 

*Presented before the Innominate Medical Club of 
Los Angeles, Cal., Aug. 30, 1917. 



60 



MEDICAL RECORD. 



[July 13, 1918 



provocative Wassermann test, which will be posi- 
tive after the administration of salvarsan or neo- 
salvarsan, if the test has been negative after a 
course of treatment. 

The technique which I have employed has been 
that of a sheep hemolytic system with an antigen 
which was an alcoholic extract of the human heart 
reinforced with cholesterine. 

The Specificity of the Wassermann Test. — In my 
experience I have found that only a very few of the 
known diseases besides syphilis will give a positive 
reaction — leprosy and malarial fever in the febrile 
stage and carcinoma of the gastrointestinal tract. 
I did not find any of these diseases mentioned that 
would give more than a positive one plus unless 
there was a positive history of an initial lesion, and 
I am of the opinion that the Wassermann test, 
when properly performed and giving more than a 
positive one plus, is indicative of syphilis. 

The Percentage of Positive Rewtions in the Vari- 
ous Stages of Syphilis. — An important question is 
the percentage of positive results that may be ex- 
pected in the various stages of syphilis. Practically 
all observers agree as to the percentage of positives 
in the various stages and I will only give the per- 
centages obtained in my laboratory in a series of 
6,000 cases : Primary, 89 ; secondary, 96.1 ; tertiarj', 
87.4; and congenital, 82.2. 

How Soon May a Positive Wassermann Reaction 
Be Expected After the Appearance of the Chancre? 
— As would be expected, a certain degree of tissue 
change must occur before syphilis begins to appear 
in the blood. Even with the best technique there is 
a limit to the sensitiveness of the Wassermann re- 
action, so that, while the antibody may be produced 
at the very onset of an infection, time and further 
tissue changes are required before sufficient anti- 
bodies are produced to yield a positive complement 
fixation reaction. 

A positive reaction may be secured as early as 
from three to five weeks after infection has oc- 
curred. In such cases, however, it is oftentimes 
probable that the time of infection really antedates 
the time given by the patient. Craig has reported 
a positive reaction occurring five days after the 
appearance of the initial lesion. 

It is generally agreed that a diagnosis should be 
made as early as possible and vigorous treatment in- 
stituted. A Wassermann test may be performed 
and if it shows a positive result, this indicates the 
presence of syphilis even if the lesion under sus- 
picion is not specific, the reaction being due to a 
previous infection. A negative reaction, however, 
does not exclude syphilis, and, if it is at all possible, 
a micro.scopic examination, using the dark ground 
illuminator, should be made for the treponema. In 
primary syphilis a microscopic examination of the 
secretions of the lesions by a competent person is 
usually more valuable than the serum test. As a 
general rule, both examinations should be made, es- 
pecially in patients in whom the chancre is almost 
healed or atypical. 

The cerebrospinal fluid of persons in the primary 
stage of syphilis will always react negatively. The 
following table of 100 cases gives the blood findings 
in the primary stage. 

Factors Influcnci7ig the Result of the Test. — 
There are several known factors that markedly in- 



fluence the result of the Wassermann test, the three 
most important being — (1) the variation in the 
amount of complement-inhibiting substances in the 
patient's blood serum; (.2; the ingestion of alcohol; 
(3) and the growth of various bacteria in the blood 
serum. These factors will be considered separately. 



Week of 


No. of 










Difiease. 


Cases. 


Positive. 


Negative. 


Doubtful. 




I 'A 


1 


1 










3 


4 


2 


1 


1 




4 


10 


7 


3* 







5 


S 


6 





2 




6 


6 


6 





n 




8 


71 


67 


2t 


2 




Total number of 












cases 


100 


89'.£ 


6% 


5'( 





*One alcoholic, positive a few days later. 
tTwo having liad treatment. 

The Variatioti in the Amount of Complement-Iiv- 
hibiting Substance. — Until quite recently it has been 
considered that the strength of the Wassermann 
reaction varied but little, in the same serum from 
day to day, but I have shown that the blood serum 
of undoubted syphilitics may, in the absence of spe- 
cific treatment, give a negative reaction during cer- 
tain intervals, although previous and subsequent 
tests are positive. Craig's observations regarding 
the fact were published in 1914 and were stimu- 
lated by the fact that in practice he had noted cases 
in which the blood serum had given contradictory 
results within a short period of time. Thus he had 
observed cases in which the reaction varied from a 
positive one plus to a negative within intenals of 
a few days, the patients in the meantime having 
received no treatment. While such observations are 
not numerous in practice, their undoubted occur- 
rence caused an investigation of the phenomenon, 
and for this purpose he selected ten prisoners in 
the United States Prison at Fort Leavenworth, two 
in the primary stage, four in the secondary stage, 
and four in the latent stage of the disease. Th^se 
men were under the strictest discipline, upon rou- 
tine diet, and the question of the possible influence 
of alcohol upon the result of the test could be abstv 
lutely excluded. The ordinary technique was used 
in the performance of the test and samples of b'ood 
were collected and tested each day from each of the 
prisoners. The results demonstrated that the titra 
tion of daily specimens of blood serum during each 
stage of the disease showed great variations in the 
strength of the reactions, and that these variati'^n-; 
occurred without reference to treatment. The ex- 
periment demonstrated that this normal variation 
in the strength of the Wassermann reaction must 
be carefully considered in using the test in the di- 
agnosis or as a control in the treatment of syphilis. 

Craig demonstrated that in one case of primary 
syphilis a doubtful reaction was obtained on three 
of seven days, the reaction being positive on five 
days. In one case of secondary syphilis a negative 
reaction was obtained on one day, a doubtful on 
four days, and a positive or double-plus reaction on 
only two days. In another secondary case a doubt- 
ful reaction was obtained on two of seven days. In 
two secondary cases a positive result was obtained 
upon every day of the week during which the serum 
was tested. It would seem that this phenomenon 



July 13, 1918] 



MEDICAL RECORD. 



61 



was more likely to be present in the primary stage, 
due likely to the few sj-philitic antibodies which 
may be developed daily in the early stage. 

Influence of the Ingestion of Alcohol. — Nichols 
and Craig first called attention to the influence of 
this drug upon the Wassermann test. They found 
that the ingestion of alcohol in the form of beer or 
whiskey, as well as alone, and in amounts varying 
from 180 to 240 c.c. of whiskey, 90 c.c. or 95 per 
cent, alcohol, and 700 c.c. of Munich beer, was 
capable of rendering a positive Wassermann re- 
action negative, and that the reaction remained 
negative for several hours after the last dose of 
alcoholic liquors, and in one case as long as three 
days. In all these cases the Wassermann reaction 
was double plus before the administration of alco- 
hol and all became negative within a few hours af- 
ter the administration of this drug. If this drug 
influences a double plus to this degree, one can 
readily see that a one plus or doubtful serum would 
necessarily give a negative and, therefore, make an 
accurate serum diagnosis impossible. The follow- 
ing is a report of my personal e.xpierience of patients 
who had taken this drug within twenty-four hours 
from the time the specimen was taken. 

Two cases with secondary rash gave positive one 
plus on entrance, and two days later gave positive 
three plus. 

Two cases with diagnosis of cerebral hemorrhage, 
both drunk, gave positive one plus, and two days 
later gave positive two plus and positive three plus. 

Gastric crisis one case doubtful, two days later 
gave a positive two plus. 

Corneal ulcer, one doubtful, three days later gave 
positive one plus. 

Psychosis, six cases, ranging from a negative to 
a one plus, three days later gave a positive in all 
six cases. 

Syphilitic iritis, two cases, one negative, the 
other positive one plus, after two days in hospital 
both gave positive two plus. 

Arteriosclerosis, two cases, one negative, one 
positive one plus, after two days both positive two 
plus. 

The Growth of Various Bacteria in the Ser>nn. — 
This phenomenon was an experiment which I did 
with a number of negative sera after taking them 
to the wards and infecting them with stitch ab- 
cesses, appendicial drainage, boils, and infections 
of various tjpes. All gave positive three plus after 
twelve hours incubation. 

If this agent influences the test, we must be 
aseptic in obtaining the blood. I have been asked 
by many physicians how to sterilize their syringes 
for doing venous section and my instruction has 
been as follows: The syringe should be washed 
thoroughly with tap water and then with alcohol. 
This renders it chemically free from antibodies and 
then it should be boiled to render it bacteriologically 
clean. If one is to use a syringe soon after boiling, 
it is good technique to wash it with sterile salt solu- 
tion or allow it to drain thoroughly. This also 
applies to tubes in which the blood is to be sent 
to the serologist. It is also well to keep the blood 
in a cool place after withdrawal, in order that bac- 
teria, in case any should be present, may not multi- 
ply, and thus give a false reaction. 

The Provocative Wc.ssermann Test. — This meth- 



od of applying the Wassermann test is of the ut- 
most value in the diagnosis and control of the treat- 
ment of syphilis, and while it has been most in- 
tensively used in deciding whether a patient is or 
is not cured of the disease, it is also a most val- 
uable diagnostic test, and should be applied in every 
case where the Wassermann test is negative but 
there is good reason to suspect syphilis is present. 

In 1910 Gennerich called attention to the fact 
that patients previously treated with salvarsan or 
other drugs and who gave a negative or very weak 
positive reaction in the blood, became strongly 
positive after a dose of salvarsan, the blood being 
tested daily for at least a week after the adminis- 
tration of the drug. His obser\'ation3 were soon 
confirmed by Milian, and have since been confirmed 
by every investigator of the provocative Wasser- 
mann test, as it is called, and is now the accepted 
method of diagnosing and controlling the syphilitic 
infection. 

After the administration of a small dose of sal- 
varsan the positive reaction may occur within twen- 
ty-four hours or may be delayed for from three tf) 
seven days, and even longer, in rare instances. As 
the positive reaction may occur within twenty-four 
hours after the administration of the drug, and as 
it may be evanescent in character, in properly ap- 
plying this test it is necessary to make a Wasser- 
mann test every day for at least a week, as other- 
wise the positive reaction may be missed. For this 
reason the test is not always practicable, but its 
value is without que.stion, both in diagnosis and as 
an indicator of the efficiency of treatment. 

The following statement appears to be authorized" 
by the evidence that has accumulated regarding 
this test : In patients who have presented a nega- 
tive Wassermann reaction for a period of over a 
year, and in whom symptoms have been absent, the 
provocative Wassermann test sometimes results 
positively, thus proving that spirochetes are still 
present and that the disease has not been cured. 

Although this test has been but little used in 
diagnosis, it is true that a small dose of salvarsan 
or neosalvarsan, administered to individuals sus- 
pected of being syphilitic but in whom the ordinary 
Wassermann test is negative, will often produce A 
positive result and thus establish the diagnosis. 
For this reason I would urge the more general em- 
ployment of the test in diagnosis, firmly believing 
that if it were used generally in early primary cases 
the diagnosis could be made within a week of the 
appearance of the initial lesion, and that our per- 
centages of positive results in tertiary and latent 
cases would be greatly decreased. Of course if the 
dark field microscope is at hand the ideal method 
cf diagnosis in the primarj' stage is the demonstra- 
tion of the Spirochxta pallida, but in many in- 
stances this cannot be done and then the provoca- 
tive test will prove most useful. In applying the 
test a great advantage is that only a small dose of 
this drug is necessary, from 0.3 to 0.4 gms. of sal- 
varsan intravenously being suflScient, and we are 
not only applying a valuable diagnostic test, but a 
therapeutic agent at the same time. If we have 
this valuable aid in diagnosis, physicians who neg- 
lect the use of the Wassermann test in the diagnosis 
and control of treatment of .syphilis are doing their 
patients a great inju.stice. This test has conclu- 



62 



MEDICAL RECORD. 



[July 13, 1918 



sively demonstrated that many of our clinical con- 
ceptions of syphilis are erroneous, that the disease 
n%ay be present for years without producing symp- 
toms sufficient to attract the attention of the indi- 
vidual affected. If this be so, the supposed cure by 
mercury and other drugs, even including the best 
of all specifics, salvarsan, is a dangerous fallacy 
and sj^philis must be regarded as one of the most 
insidious and persistent of all the infections oc- 
curring in man. 



Since we have a method in the provocative test 
for bringing out such latent antibodies as may be 
present, this therapeutic agent should be used both 
from a diagnostic and treatment standpoint. 

600 Merritt Buildino. 



Nation 


No. 

of 

Cases. 


Posi- 
tive 
Historj'. 
per 
Cent. 


No His- 
tory As- 
certained 
or Denied, 
per Cent. 


Positive 
Reaction, 
per Cent. 


Negative 
R eaction, 
per Cent. 




979 

131 

4 

51 

49 
182 

45 

11 
4 
1 

13 
7 

59 
1 
6 

69 
4 

31 
3 
2 
1 
2 
4 
2 
4 
1 
3 


10 
15 

13 
24 
15 
17 

25 

7 
14 
20 


10 
25 

I 


100 







90 
85 
100 
87 
76 
85 
83 
100 
75 
100 
93 
86 
80 
100 
100 
90 
75 
98 
100 
100 
100 

100 
100 
100 
100 
100 


30 
27 

26 
40 
29 
29 
18 
25 

44 
2S 
37 
10 
17 
36 
50 
28 
67 



25 






70 


English aod Scotch . 


73 
100 


rrioh 


74 


Scandinavian 


60 

71 




71 




82 




75 




100 
56 




72 




63 




83 


Greek 


S3 


Colored 


64 




50 




72 


Turks 


33 




100 


Polish 


100 




100 






Hungarian 

Belgian 


100 

100 


Danish 


100 



The above table is incomplete as I have not been 
able to go over all the records of the 6,000 cases, 
but felt that this line of investigation might be 
of interest, as I have been unable to find anything 
similar to it in the medical literature. 

Conclusions. — If the things which I have men- 
tioned affect the Wasserniann to this extent the fol- 
lowing factors should be taken into account when 
one wishes to use the serum test for diagnosis and 
as a check to treatment : 

The time of the appearance of the syphilitic anti- 
body in the serum after the infection varying 
from five days to several weeks, it must be borne 
in mind that a negative result may mislead the 
physician as to diagnosis and that a microscopic 
examination should be made if available. 

The second factor which influences the test is 
the amount of complement-inhibiting substance in 
the serum and, as I have mentioned above, the lesion 
may be fairly characteristic and give a negative 
reaction when it may be of a specific nature, there- 
fore, to give the patient the benefit of this reac- 
tion another test should be made in the days fol- 
lowing. 

If alcohol influences this test as has been demon- 
strated, the history of having taken alcohol twenty- 
four hours before the test should be ascertained and 
if taken within this time advise the patient to re- 
turn twelve hours later, in order to prevent the in- 
fluence of this drug upon the reaction. 

If the growth of bacteria influences the negative 
to positive, then it is absolutely essential to have 
all needles and glassware bacteriologically clean. 



STAMMERING. 

Bv ERNEST TOMPKINS. 

PASADENA. CAUF. 

The article on stammering by Dr. Pacini in the 
Medical Record of May 11, 1918, brings up a 
wonderful opportunity for the United States in 
win-the-war work. Up to 1914 Germany led us in 
the investigation of stammering, but we have a 
clear field to win all the practical benefits from her 
work and ours because the old mistakes have be- 
come cemented in the German schools as State in- 
stitutions, whereas we are comparatively free to 
follow the light. If we fail to seize this oppor- 
tunity to take the laurels from the German we have 
light regard for American science and American 
efficiency. 

Let us outline the new view of stammering and 
then test it by supplementing Dr. Pacini's article 
by means of it. Contrast with the old view will 
help us to grasp the new one. The old one was that 
stammering was caused by a lack; the new one is 
that stammering is caused by an excess, an extra 
thing — and that is a mistaken, but not illogical, 
idea of disability. The complete description is as 
follows : 

(1) By an accident or Incident, a child is induced 
to interfere with his normal speech by a conscious 
effort. (2) The spasm resulting from the inter- 
ference attracts ridicule. (3) The child makes fur- 
ther interfering efforts to avoid the ridicule, and 
the failure of these efforts engenders more, and so 
on until the idea of speech disability is thoroughly 
confirmed. 

The reader may prove this view in five minutes. 
Let him do anything which the stammerer does — 
hold his breath, exhaust his breath, press his tongue 
against his upper teeth or his palate, press his lips 
together — and try to talk, and he will find that he 
is impeding his speech, and anyone looking at him 
would think that he was stammering. Indeed, if he 
made the test when his speech was newly acquired, 
he would soon develop into a stammerer. 

In order to avoid unscientific procedure, which 
has been the universal pitfall in the field of stam- 
mering, let us consider what scientific procedure 
is. Haeckel expresses it well in the following lan- 
guage: "The value which every scientific theory 
possesses is measured by the number and importance 
of the objects which can be explained by it, as well 
as by the simplicity and universality of the causes 
which are employed in it as grounds of explanation. 
On the one hand the greater the number and the 
more important the meaning of the phenomena ex- 
plained in the theory, and the simpler on the other 
hand, and the more general the causes which the 
theory assigns as explanations, the greater is its 
scientific value, the more safely we are guided by 
it, and the more strongly we are bound to adopt it." 

Let us put the speech interference theory to the 
test, beginning with the etiology of stammering, 
which is unexplained. The etiology is a temporary 



July 13, 1918] 



MEDICAL RECORD. 



63 



interruption to speech. In voluntary imitation, the 
interruption is intentional and unquestionable. In 
association, the imitation may be unintentional, or 
may be prompted by the desire to avoid the disorder, 
a case of which is described by Sidis in the Journal 
of Abnormal Psychology, June, 1917. In stuttering, 
the interruption is the repetition, which, when 
visited with ridicule, brings out the stammering. 
In sickness, fright, injury, hysterics, fainting, and 
so on, the temporary interruption is the broken 
speech which follows them. It is significant that 
Freudeanism, dextrosinistrality, and innumerable 
other alleged causes do not harmonize with the 
etiology ; but as these causes may be shown to be 
fallacious regardless of the theory, the theory jus- 
tifies itself by e.xclusion of them. 

The sex ratio of stammering is readily accounted 
for by well verified facts, namely (1), the diver- 
gence of the ratio from unity in infancy to 1:9 in 
adulthood owing to [2} the "spontaneous recovery" 
of the girls. The statistics do not go back to in- 
fancy, but stop at school age. However, the trend is 
unmistakable, and we know that conditions prior to 
school age are much more favorable to recovery 
than subsequent conditions, for the school treat- 
ment confirms stammering. Conradi says, "Gutz- 
mann gives 2:1 for children, but 9:1 for adults, and 
says with girls it is more apt to disappear than 
with boys." The ratio in American schools is, girl 
stammerers to boy stammerers, 1 :3, and the adult- 
hood ratio is 1 :9 ; so, for 9 stammering boys there 
are 3 stammering girls, whereas in adulthood for 
9 stammering men there is only 1 stammering 
woman. Two girls out of three recover between 
school age and adulthood. In short, recovery of the 
girls accounts for the sex ratio, and from that we 
see that there is no sex determinant of stammering. 

Whether the stammerer's nervousness is ante- 
cedent or resultant is a much discussed phase of the 
disorder. Temporary nervousness following shock 
or illness is a great inducing cause, and that has 
been considered permanent without due warrant. 
That the extended nervousness is resultant ought to 
be evident; for the disorder is a constant mental 
torture and any animal can be made nervous by 
constant torture. 

Heredity seems to be a view which we shall have 
to abandon. It rested mainly on the idea of a lack, 
which idea, and consequently its superstructure, i.'^ 
no longer tenable. The observations which seemed 
to warrant heredity have long been suspected to 
warrant other conclusions. This common opinion 
is expressed by a writer in the "Encyclopedia 
Medica" as follows: "It is said by many writers 
to be hereditary, and to occur in families with a 
neuropathic diathesis. Such an explanation does 
not cover the whole field. . . It is highly prob- 
able that cases of so-called heredity are really to be 
explained by imitation." There are very many rea- 
sons why heredity can not be accepted in the case 
of stammering: no satisfactory evidence of it has 
ever been presented; some of the alleged proofs of 
it turn out to be positive disproofs when they are 
examined; and no theory of the disorder involving 
heredity has ever been sustained. (See Scientific 
American Supplement, March 23, 1918, p. 186.) 

Health and stigmata of maldevelopment may be 
considered together. Since they come in the "lack" 



class they are immediately under suspicion, and 
investigation justifies the suspicion. Let us take a 
whimsical demonstration. Suppose that these ail- 
ments are connected with the stammering. Com- 
bine them. Since almost every investigator has 
given a list of his own — a recent list contains at 
least nineteen ailments — the total of all the lists 
would make the subject a corpse; but this is con- 
trary to the hypothesis that he is a stammerer, so 
the ailments must be rejected. The claim that 
preference should be given to some ailments cannot 
stand, for the evidence in support of one is no better 
than that in support of another. There is another 
way of deciding the question. Let us bring a stam- 
merer to a doctor who has established a connection 
between certain stigmata and stammering. If the 
connection is valid the stammering should be de- 
terminable from the stigmata. Say to the doctor, 
"We will talk for this man and give you any health 
information desired; tell us from his stigmata 
whether he is a stammerer." No wise doctor will 
meet that test, and whoever does meet it is sure 
to be discredited. It is unquestionable that stam- 
merers have ailments just as other people do; but 
no connection between those ailments and the stam- 
mering has ever been shown. In illuminating dis- 
tinction to the labored efforts to establish a con- 
nection is Fletcher's conclusion, beautiful alike for 
its truth and its simplicity, "The subjects are 
not to be distinguished physically from other 
people; . . ." 

Immoralitj\ A child acquires the unfortunate 
habit (Scripture) of interfering with his speech. 
His parents are to blame, for he is too young to be 
blamed. Immediately he is outlawed; for conven- 
tions are unwritten laws, and the speech conven- 
tions are made for the other 99 people — not for him. 
Society is against him on every side. His parents 
make him talk to callers, run errands, answer the 
doorbell or telephone; his teachers force him to 
stand up before a class and exhibit his humiliating 
affliction, so that the other children are infected and 
he is confirmed in it, and regardless of clear laws 
which should protect them even if good sense and 
mercy do not; his employers -equire him to tele- 
phone, dictate, quote prices, do what any other em- 
ployee does, or "Out you go"; even those who take 
his money to cure him teach him exercises which 
inculcate intensified stammering (Liebmann). 
Then, when he sees his family in want in spite of 
strenuous efforts to provide for them, when he is 
sick with loneliness for someone who understands 
him; when he wishes to die and has to fight off the 
inclination to gratify the wish — then someone calls 
him "immoral." If this is not adding insult to 
injury, what is it? 

Transient amnesia. This theory is notable for 
two things — the elaborateness with which it was 
advanced and the ease with which it is exploded. 
Fletcher has already considered it and its first 
cousin "Visual Center Asthenia" (see Journal of 
Abnormal Psychology, April-May, 1917). But an 
elaborate consideration is superfluous. Imitation 
and association account for much of the stammer- 
ing — Fletcher and some others think for most of it. 
But Bluemel, the very inventor of the amnesia 
theory, says, "The two causes of stammering that 
do not produce aphasia are association and imita- 



64 



MEDICAL RECORD. 



[July 13, 1918 



tion. " What good is a theory that is applicable to 
only half of the field to which it pertains? His 
attempt to save his theory by an effort to show that 
there are at least two kinds of stammering does not 
help his case, for it indicates that the same sort of 
logic was used in the original demonstration. It 
is well known that the stammerer is an adept in the 
substitution of synonyms. But amnesia, as Dr. 
Pacini says, is "Incapacity to form an antecedent 
verbal image." How can one substitute a synonym 
for a word which he does not know? Bluemel en- 
deavors to show that the "color" of the vowel is the 
only unknown portion, and that confusion of vowels 
is common to the stammerer ; but the first propo- 
sition is built up on dogma, and the stammerer's 
slips of the tongue are no more than anyone would 
experience who was strenuou.sly dodging difficult 
words. It is unnecessary to give the many fallacies 
of this theory. Dr. Makuen, who took it up with 
great aviditj', dropped it with almost as much. He 
had to drop it; for it makes the stammerer's trouble 
auditory, and Dr. Makuen was on record to the 
effect that examination of 1000 cases of stammering 
revealed no auditory trouble connected with the 
affection. 

Breathing and articulatory exercises. These are 
intensifiers of the disorder, as Liebmann showed 
twenty years ago. Why does the medical profession 
at large suffer the discredit which accrues to it from 
persistence in mistaken practice by a very small 
group of specialists? Putting aside ethics and 
science and coming down to commerce, the physi- 
cians as a whole are losing manifold more dollars 
by it than a few of them are making. An important 
field of work — medical inspection in the public 
.schools — may not be closed, but it will certainly be 
hedged, by the forcing of these injurious treat- 
ments into the schools. 

Treatment. "Re-educate the stammerer in a new 
mental imagery." Yes. But it cannot be done in 
the manner proposed. Rather, the manner proposed 
does not reduce the stammering. The idea of dis- 
ability which is the continuing cause of stammer- 
ing was instilled by thousands of speech failures, 
and the only way to remove it is by thousands of 
speech successes. The victim must decline to in- 
dulge in the convulsive effort, and then what spon- 
taneous speaking he does contributes to his recovery. 
The more he increa-ses that spontaneous speech the 
less slowly he recovers; we cannot say the more 
rapidly, for the recovery of confirmed cases is never 
rapid. We are talking now of the real recovery 
and not of the temporary relief which is so readily 
produced, which is the support of 99 per cent, of the 
alleged remedies on the market, and which is so 
generally misrepresented as cure. The spontaneous 
speech may be stimulated by environment which 
reduces the embarrassment. Indeed, efficiency in 
overcoming the difficulty opens a big field for in- 
genuity; for the stammerer must live during the 
greater part of his recovery in a world antagonistic 
to his speech interest. Just to live in that world, 
let alone making a living in it, without being forced 
back into the disorder, requires more sagacity and 
intelligence than one would imagine. 

Dr. Pacini should be commended for using Eng- 
lish nomenclature. The German invasion of the 
field of stammering with the word "stutter" to 



mean stammer has caused much confusion there, 
and the quicker we throw it out the better. To com- 
plicate further a confused field by a confusion of 
tongues is anything but scientific. 

Just a word, in closing, about the speech-interfer- 
ence theory. It gives us the etiology, the common 
causal factor, the causes of origin by imitation, sex 
discrepancy, and many other features which are 
every day pronounced unknown. Indeed, it satisfies 
every requirement; .so, in the words of Haeckel, 
" .- . . we are bound to adopt it,' that is, tho.se 
of us who are scientific. 

610 XORTH El. MoLiNO Avenue. 



A NOTE ON THE TRANSFUSION OF BLOOD 
BY THE CITRATE METHOD. 

Bv .ABRAHAM ZIXGHER. M.D . 

NEW YORK. 



The transfusion of blood by the citrate method is 
probably the simplest way of transferring blood 
from donor to recipient. It is, therefore, impor- 
tant that all the technical details of this method 
of transfusion should be as nearly perfect as 
possible. 

The citrate method of transfusion, as recom- 
mended by Lewisohn, seems to the writer to have 
three radical faults: 

1. The use of 0.2 per cent, citrate of sodium for 
preventing coagulation of the blood. With this 
concentration the blood often clots in the con- 
tainers or in the needle while it is being injected 
into the recipient. 

2. The collection of blood in one large con- 
tainer, like a graduate, necessitating the stirring 
with a glass rod to mix the blood with the citrate 
solution. This stirring has a tendency to defibri- 
nate the blood. 

3. The use of a 2 per cent, solution of citrate 
of sodium for purposes of citration, instead of a 
more concentrated one, causing an unnecessary 
dilution of the blood. 

The objection features will occasionally cause 
the failure of a transfusion and could be remedied 
by using the following procedure, recommended 
by the writer in a previous communication on 
the transfusion of young children by the citrate 
method. (Medical Record, March 15, 191.5.) 

1. The blood is citrated with 0.3 per cent, in- 
stead of 0.2 per cent, citrate of sodium. The addi- 
tional amount of citrate of soda is not sufficient 
to make the blood to be injected more toxic and 
avoids any possibility of troublesome and danger- 
ous clotting. 

2. The blood is collected in a series of 100-c.c. 
bottles, 60 c.c. being drawn into each bottle. A 
number of small grape juice bottles will serve the 
purpose very well. To each of these bottles the 
necessary amount of citrate of sodium solution is 
previously added. 

3. Tiie use of a 10 per cent, solution of citrate 
of sodium instead of a 2 per cent, solution to avoid 
any unnecessary dilution of the blood: 2 c.c. of 
this citrate solution are added to each of the 
bottles. 

The bottles should be prepared by sterilization. 



July 13, 1918] 



MEDICAL RECORD. 



65 



each bottle being stoppered with a gauze plug. For 
collecting and injecting the blood a salvarsan can- 
nula or an ordinary needle, gage 15, will be found 
convenient. 

While the blood is flowing in the bottle it is 
gently stirred from time to time and also after the 
entire quantity is obtained, so as to insure a 
thorough incorporation of the citrate with the 
blood. After all the bottles are filled the blood is 
passed through a few layers of gauze, moistened 
with a 0.3 per cent, solution of citrate of sodium, 
into a single container and is injected by means of 
a salvarsan apparatus. In an emergency the barrel 
of a large syringe and a piece of rubber tubing 
with a suitable needle or cannula will serve the pur- 
pose very well. 



DEATH FROM VOLVULUS CAUSED BY ROUND 
WORMS. 

Bt victor G. HEISER. il.D., 

NEW YORK. 

Dr. John F. Kendrick reports the following case 
from the Seychelles Islands : 

A child four years of age was given six minims of 
oil of chenopodium. Two days after the adminis- 
tration of the chenopodium the child was reported 
very ill. There was marked distention of the abdo- 
m.en, with severe pains, frequent vomiting, and the 
bowels had not moved since the day treatment was 
given. On post mortem a mass of round worms 
the size of a man's fist was found blocking the 
bowel ; the intestines below the mass were so twisted 
as to cause complete obstruction ; there was local 
peritonitis in the vicinity of the obstruction, and 
more than 300 round wonns were found in the 
intestinal canal. 

SI Broadway. 



Malpractice — Insufficient Evidence of Negligence. — 

In an action for damages alleged to have been sus- 
tained because of the unskillful and negligent manner 
in which the defendant, a practising physician, reduced 
and treated a fracture of the radius of the plaintiff's 
left arm, the allegations of negligence were: First, 
that the defendant was negligent in not reducing the 
fracture properly; second, that the defendant was negli- 
gent in using only pasteboard splints at first, and after- 
wards inadequate and improper splints, and in not ap- 
plying proper bandages and appliances to keep the 
broken bone in alignment or proper apposition. There 
was no direct evidence showing that the fracture was 
not properly reduced. There was no direct evidence that 
the broken parts were not put in proper apposition. 
There was no direct evidence that the splints and ban- 
dages used were not the appliances ordinarily used by 
physicians and surgeons in the treatment of such frac- 
tures. 

A physician is held to the exercise of the skill 
and learning of the profession generally in the com- 
munity in which he practises. The case" was purely a 
fact case, with the burden resting on the plaintitf. At 
the conclusion of the testimony, the court directed a 
verdict for the defendant. The "plaintiff appealed. The 
Iowa Supreme Court reviewed the eWdence in detail 
and summed up as follows: "There are authorities say- 
ing that where the condition found upon an examina- 
tion is of such a character, so out of harmony with con- 
ditions that ought to exist under proper treatment that 
a physician, seeing the result, may as an expert testify 
that the proper treatment was not administered or such 
a result would not be found. Now, it is true, as a gen- 



eral proposition, that the result furnishes no evidence 
of negligent treatment, but some cases may arise where 
evidence of the poor result alone might convince an 
expert that the treatment must have been improper. 
An opinion based upon such a showing would be com- 
petent evidence to establish the ultimate fact charged 
in the complaint. 

"But such a case is not before us here. The only e.x- 
pert called by the plaintiff who is shown to have been in 
a position to know just what the condition of the bone 
was after it had healed and the manner in which the 
fracture was reduced is Dr. Crenin, and he tells us that 
he found the bone in proper apposition and properly 
healed; that the alignment was as good as you could 
expect under the conditions which he found there. 
The only condition which he found that required treat- 
ment was the callus which nature throws out and over 
which the attending physician has no control. It seems 
that an excessive amount of callus had been thrown out 
around the wounded part. The excessive callus, as this 
record shows, may be due to many causes, none of 
which are under the control of the attending physician, 
and a careful examination of the x-ray pictures shows 
that the deformity appearing in the pictures is caused 
by the excessive callus and which, when removed, left 
the arm with all its functional properties normal. It is 
apparent that the plaintiff relies upon negligence — 
negligence of the attending physician in the treatment 
of the arm. It rests on the plaintiff, therefore, to show 
affirmatively that the condition of which he complains 
was due, at least in some measure, to the negligence of 
the physician in respect to the matters relied on as con- 
stituting negligence. A verdict to the effect that the 
doctor was negligent in reducing the fracture or negli- 
gent in the treatment of the fracture after it was re- 
duced would rest necessarily upon mere speculation. 
The evidence pointed to no act of negligence on the part 
of the defendant. Every doctor who testifies or as- 
sumes to say that the result was not perfect tells us 
in this record that, even with the best treatment, with 
the fracture perfectly reduced and proper bandages 
and appliances to keep it in position used, the condi- 
tion here found might fairly be expected." Judgment 
for the defendant was affirmed.^-O 'Grady vs. Cadwal- 
lader, Iowa Supreme Court, 166 N. W. Too. 

Hypothetical Questions. — Objections to a hypo- 
thetical question put to a physician concerning th« 
plaintiff's injuries that such question did not embrace 
all the facts shown by the e%-idence, but which failed 
to point out what facts were omitted, were held un- 
availing. In a street car passenger's action for injuries, 
testimony had been admitted but later stricken that she 
suffered three fractured ribs. It was held that a hypo- 
thetical question put to her physician whether the ac- 
cident alleged could have produced the conditions visible 
when he examined her was not erroneous as permitting 
an answer based upon the rib fracture; such not being 
visible.— Shafer vs. Kansas Cits* Rvs. Co., (Mo.), 201 
S.W. 611. " ■ 

Corporations for Pecuniary Benefit. — The Illinois Su- 
preme Court holds that a medical association organized 
for the advancement of medical science and to improve 
methods for the treatment and prevention of disease is 
not a corporation for pecuniary benefit under sections 
1-28 of the Illinois Corporation Act, and may elect its 
trustees through delegates without the limits of the 
state, in view of section .32 and the bv-laws of the asso- 
ciation.— People v. Grant, (111.) 119 N.E. 344. 

Certificates of Qualification.- — The Alabama Court of 
Appeals holds that requiring a certificate of qualifi- 
cation from persons proposing to engage in the prac- 
tice of treating diseases as a profession and for a live- 
lihood is a police regulation designed to protect the 
public from the ignorant and incompetent, and the Leg- 
islature may prescribe a test to determine qualification, 
and confer authority on a designated board, to conduct 
the proper examination through which the test may be 
applied, as is done by the Alabama statute denying the 
privilege to such persons without a certificate from the 
"state board of medical examiners," and a chiropractor 
not being excluded or discriminated against, and having 
equal right to apply for a certificate, is not exempt 
from the operation of the regulation. — Williamson v. 
State, (Ala.) 78 So. 308. 



66 



MEDICAL RECORD. 



[July 13, 1918 



Hilttary iflpiiriup. 

SYMPOSIUM ON MILITARY SURGERY. 

The meeting of the Section on Surgery of the Medical 
Society of the State of New York, held on Thursday, 
May ^3, was devoted to papers and discussions on Mili- 
tary Surgery. Dr. Thomas F. Laurie of Syracuse was 
in the chair. 

Treatment of Gunshot Wounds of the Humerus. — Cap- 
tain G. E. Wilson of Toronto, Ont., presented this sub- 
ject (by invitationj .■ He showed a wire splint devised 
for fractures of the humerus. This was supported by 
a plaster bandage around the chest and by a shoulder 
strap. If the plaster slipped the shoulder strap could 
be adjusted. This gave absolute tixation, movement 
being limited to that of the subcutaneous tissues on the 
deep fascia of the ribs. One point that always seemed 
to help the wounded soldier was to let him have a 
cigarette while the plaster was being applied. No mat- 
ter how wornout he was, this would generally help 
him to smile. When the splint was adjusted, the pa- 
tient could be treated as a walking patient and be 
transported in a lorry. This was an economic saving. 
The splint would carry the weight of the arm, by sup- 
port from the chest, and thus relax the shoulder girdle 
muscles. As there was no traction upon the axilla, the 
splint was applicable to compound fractures. With 
pressure on the axilla, there was not good extension. 
With a large wound posteriorly, the flannel supports 
across the splint were arranged so that the wound 
could be dressed. If the x-ray showed imperfect 
alignment, the arrangement of the armpiece on the 
chestpiece could be altered. A test as to the proper 
arrangement of the splint was, that if in proper posi- 
tion, one could shake the patient and the movement 
would cause no pain. To prevent slipping, the shoulder 
straps were embedded in the plaster. 

Treatment of War Wounds. — Major C. L. Gibson, 
M. R. C, made this presentation. He said that the 
surgery of civil life did not apply at all to the condi- 
tions of modern warfare. The deep trench fighting 
made of the soldier a filthy and contaminated person 
and the elements to be dealt with in treating the 
wounded had no counterpart in civil life. Fear, lack of 
food, shock, multiplicity of wounds, the tedious and 
dangerous journey from the trenches, all tended to 
complicate the patient's condition. Three elements had 
to be combatted — shock, hemorrhage and sepsis. Sep- 
sis was an active element in one hundred per cent, of 
cases. In order to overcome this, early treatment was 
of the first importance. Wounds had to be freely laid 
open and all foreign bodies removed. Surgeons were 
seeing the necessity of moving the line of relief nearer 
to the battlefront and good surgery could now be done 
near the line. The removal of foreign bodies and of 
damaged and necrotic tissue was effected as soon as 
possible. Until this was done the use of the Carrel 
Dakin method was of little avail. Combined with free 
excision it gave good results. Good surgery, at an early 
stage, was the sine qua non. The special technique 
necessary for the Carrel Dakin method made it unavail- 
able for a large number of wounded. The methods car- 
ried out at present were simple and avoided complica- 
tions. A radical excision of all bruised tissue and for- 
eign bodies was made at the clearing station, 10 miles 
back of the line, where a 200-bed hospital was estab- 
lished. The wounded wei-e first brought to dug-outs for 
first aid, then taken to a dressing station 3 miles behind 
the line. They were kept warm and comfortable in 
the waiting room and any treatment that could be done 
under local anesthesia or nitrous oxide was undertaken. 
A resuscitation ward had special resources for caring 
for the wounded. Plenty of fluid was usually given on 
account of the dehydration of the patient. The more 
serious cases were given surgical attention first. Badly 
shocked patients were taken care of at once. Surgical 
teams, accustomed to work in cooperation for many 
months, handled the operating, often several teams in 
one large theater. In the so-called "peace" times, x-ray 
studies were made. The French excelled in their 
fluoroscopic apparatus. They were accustomed to swab 
out wounds with some antiseptic, the most popular 
being ether. The British used 1 per cent, iodoform. 



The head wounds and abdominal cases were always 
treated first. They were kept in the hospital one week 
and then moved back to the base hospital. The results 
of this procedure were generally good. Primary suture 
of wounds was now usually practised, after thorough 
surgery. If the cultures showed streptococci or the 
Welch bacillus the wounds were left wide open. The 
French had their base hospitals nearer to the front 
than the British. The further one got away from the 
battle line, the more conditions resembled those in civil 
life. 

Development of a Military Roentgenological Seryice 
in New York City. — Dr. L. T. Le Wald of New York 
presented this report, ile said that the profession in 
America had the advantage of ihe experience of French 
and British medical men. A roentgenological service 
had been organized for the army, just as had been 
done with other branches — orthopedic, neurological, or 
pathological. Different forms of apparatus had been 
devised to meet the situation. An electric vibrator had 
been devised to supplement radiographic diagnosis, by 
the oscillations of which the presence of a foreign body 
could be detected. Another of these accessory methods 
was the telephonic localizer which would show by a 
clicking the neighborhood of a metallic foreign body. 
When working with the fluoroscope the surgeon wore 
an adjustable hood through which he could make the 
fluoroscopic examination, and which he could turn back 
over the head and continue the operation. The Sutton 
method was by a sort of fish-hook, which caught in the 
tissues and came in contact with the foreign body. 
Alfred Taylor had devised the use of a stiff wire, in- 
stead of using a cannula. The Hertz compass was also 
in use. This pointed to the projectile. A peculiar type 
of angular forceps was used, when removing the foreign 
body, under the fluoroscope. These did not interfere 
with the direction of the ray. A portable Coolidge tube 
was also in use, and a portable x-ray apparatus for 
bedside work. Major Paul had invented a stereofluoro- 
scope, in which two tubes worked exactly alike and by 
means of which the surgeon and the roentgenologist 
could both work together in locating foreign bodies. At 
Cornell Medical College, at the present time, Dr. Le 
Wald said he had just completed the training of 500 
roentgenologists to supply the government demand for 
that equipment, to go with a force of 1,000,000 men. 
This staff was now ready for work. He would like to 
know if Captain Wilson's splint could be made in 
aluminum. 

Dr. R. H. Sayre of New York said that in examining 
Captain Wilson's splint, he thought that the patient 
might buckle with the weight of the arm. Would not 
the support be increased by running it down so as to 
gain the support of the pehns. It seemed as if that 
might get better traction against the entire chest wall. 
Dr. G. D. Stewart said he thought most people had 
an idea that army surgery was a rough and ready busi- 
ness. The army, however, had the largest and best 
equipped surgical laboratory in the world. It was in- 
teresting to note that in the treatment of fractures 400 
years ago Ambrose Pare poured boiling oil into wounds 
caused by gun shots. John de Vigo at the siege of 
Milan wished to follow this treatment. The supply of 
oil running out, he poured in white of egg and turpen- 
tine instead, and, his conscience troubling him in the 
night (like many of his successors), he got up to see 
how the men were doing without the oil. To his sur- 
prise he found that they were doing much better than 
they did with it. This early treatment was along the 
line of antisepsis. They should feel indebted to Dr. 
Martin for grouping the treatments. First, use of 
sera, which had not gone very far; second, the use of 
antisepsis, which was about equivalent to Lister's work: 
third, use of free excision, which was a distinct ad- 
vance. Most of the profession had come to that con- 
clusion. 

Dr. Walton Martin of New York said that the value 
of the x-ray examination in modern surgery in regard 
to excision of the wound tract was to be emphasized. 
Men were injured in every possible position and it was 
difliicult to see the direction in which the bullet traveled. 
A man might be hit in a crouching position and the 
bullet would take a curious route. In regard to the his- 
torical points, a history written in the second century 



July 13, 1918] 



MEDICAL RECORD. 



67 



dealt with injuries by bullets of lead from a sling. A 
chapter mentioned the disadvantages of leaving them 
in the tissues. 

Capt. G. E. Wilson said that aluminum would not be 
strong enough for the arm splint unless a considerable 
bulk were attained. This would not be as easy to 
handle. The stereoscope could be used for getting good 
position of the frag^ments. Dr. Sayre suggester strap- 
ping the support lower down on the pelvis. The plaster 
was put on to stop the movement of the dorsolumbar 
vertebra. It was necessary to put the plaster on with 
the spine in correct position, and if this was done the 
patient did not buckle. 

The Medical Section of the Council on National De- 
fense. — Dr. George David Stewart of New York pre- 
sented this address. The Council of Defense for New 
York State, he said, had instructions to add to its mem- 
bership, the only limit being un^ieldiness. Each mem- 
ber had to be recommended by a sufficient number of 
good men, but not so many as were necessary to save 
Sodom. It was as important to get good men as it was 
to prevent undesirable men from getting in, and this 
side had also received attention. Women members were 
now to be added to the council. The Council of 
Defense was merely missionary in character and 
extraconstitutional in action. It controlled by impres- 
sion. Its function was to present to the doctor the med- 
ical necessities of the Grovernment and to present to the 
Government the medical help that it needed. The first 
effect that was produced was by starting men to think. 
In New York State a medical census was taken and an 
idea obtained of, for instance, how many one-legged, 
blue-eyed orthopedists could be commandeered in the 
Empire State. The personal touch was heeded in these 
inquiries. How much trouble a man had with his 
mother-in-law was taken into consideration. County 
committees were formed and now every county had two 
or three representatives who were part of the auxiliary 
Council on National Defense. Confidential information 
was furnished and spread of propaganda undertaken. 
The potential effect of a selective draft was considered 
and measures taken to preserve teachers, health officers, 
and men necessary to the community for work at home. 
The idea of conscription, allowed at one time to fall into 
innocuous desuetude, had lately again been discussed. 
It was considered likely, however, that the volunteer 
Medical Service Corps would be sufficient. New York 
State had given more than its quota of men to the Med- 
ical Reserve Corps, but still it had not the top place. 
When the war broke out there were 4.35 men in the 
medical service of the army. Now there were 22,000 
doctors in the service, and that without conscription. 
The Government needed 7,000 more by the first of July 
and of these New York State had to contribute one- 
tenth. With such a leap of numbers, from 4.35 to 22,000, 
it was only human that there should be some mistakes, 
some clogging of the machinery. Still, the profession 
had to face the problems of the future. Most of them 
were apt to look upon America as the land of promise, 
the land where one v.-ho was willing to work would 
achieve success. The Atlantic Ocean had made this 
possible, had made the Monroe Doctrine possible — in 
fact, the Atlantic Ocean was the Monroe Doctrine. This 
feeling was in the blood of every American. It was a 
good country to live in, but it was going to be better. 
If this was to be true, every American had got to take 
tEought how it was to be brought about. The tendency 
of all nations was to rise with strife, but to relax with 
comfort. Spring was the time of effort, but after the 
fullness of summer followed the winter and death. This 
was the inevitable law. None of them wanted the 
spring of this country's life to be too short. The les- 
sons of patriotism, taught by an enforced military train- 
ing, were tending to make America more of a nation. 
The war was living a new bill of health to ten million 
Americans. Those fit for class two would be trained 
and made fit for class one. This war was forming a 
new post-graduate class for most of the medical profes- 
sion in America. America had been spoken of as the 
"melting pot"; the war was starting new fires under 
the melting pot and it was bubbling up to a new 
nationalism. It had been a great country, it would now 
be a great nation. Those to go to the war should be 
the young men of good training and good health. The 
old should do the work at home. The young man with 



moderate practice did not make such a great sacrifice 
of his professional prospects; indeed, he often improved 
his standing. The question of love of wife and children 
had to be balanced with love of country. The American 
had to ask himself, "Do I care to live Lf my country is 
in bondage?"' If he did care to do so, he was not an 
American. In every mind there was a willingness to 
follow an ideal. This it was which distinguished man 
from the animals. It was a Canadian doctor, who had 
died in the early days of the war, who wrote : 

"Take up the torch and bear it high. 
If ye break faith with us who die 
We shall not sleep, though poppies grow 
In Flanders fields." 

They who had lived in the Land of Freedom could 
feel the truth of Kipling's message: 

"There's but one task for all; 
There's but one life to give." 

Now, as before, they would answer the battle cry of 
freedom and answer to Uncle Sam, "We are coming, 
fifty thousand strong." 

Needs of the Medical Reserve Corps. — Major S. S. 
Simpson, M.R.C, presented this address by invitation. 
The problem of the medical needs of the army was a 
very large one. There were four basic factors to be 
considered: (1) The impossibility of considering any 
\-ictory except upon the basis of enduring peace; (2) the 
need for equipment of a large army, such as was asked 
for by the President; (3) the medical corps of the army 
should be composed of volunteers and the task of pro- 
viding officers fell upon the medical profession; (4) the 
fact that the enemy was trying to undermine the con- 
fidence of this nation as had been done in Italy and 
Russia. Prussian autocracj', by repetition of words and 
phrases, was trying the same trick in America. This 
attempt to retard preparations here, by making believe 
that Germany was weak and ready for peace, should 
deceive no one. The President did not believe this and 
now, if any, was the time to strike. An army without 
limit was requested and needed. It now fell upon the 
medical profession to furnish advisors for the army 
force. The integrity of the nation was seriously threat- 
ened and all resources should be commandeered. If 
volunteers failed, the nation would have to resort to 
conscription. This probably would not be necessary as 
the profession were met to consider >vhat measures 
could be taken to meet the needs of the Government. 
Splendid work had been done in New fork State, but 
many other States were doing as well. The surgeon- 
general had issued a call for 8,000 medical officers. 
This did not mean in the future, it meant noxv. The 
Navy needed 1,000 medical men at once. A knowledge 
of the nation's resources and a wise use of them was 
therefore essential. A comprehensive classification had 
been compiled one year ago, and was revised from time 
to time, dealing with material needs as well as with 
personal. As new troops were called, new medical 
officers were wanted. An assurance was needed, and 
was given, that positions should be undisturbed during 
the war and that men should return to them again. In- 
dividuals would do well to put their affairs in order so 
that when called they would be able to respond. The 
peace needs of the army were for 7,000 doctors to 1,000,- 
000 men and the war needs of the army were 10,000 
doctors to 1,000,000 men. Twenty thousand medical 
men had been recommended for the Medical Reserve 
Corps, but of these many were not available for service, 
some being with the Allies, some not being physically 
fitted for service. It was as necessary for the Surgeon- 
General to have a surplus of doctors as for a bank to 
have a surplus of funds. The appeal was made to each 
man to take this matter as one of direct personal mo- 
ment to himself. Some could not go, but they could see 
that other men were sent. No man was absolved from 
duty to the nation. All must do their share to win, and 
have confidence in winning. He could not quite agree 
with Dr. Stewart that the Committee on National De- 
fense was unofficial. It was authorized by the Presi- 
dent, and each State and county committee constituted 
part of the Federal Government. It was not necessary, 
however, to have this made a federal thing. The med- 
ical profession was doing it, and would continue to do 
the work successfully to the conclusion of the war. 



68 



MEDICAL RECORD. 



[July 13, 1918 



Meningitis at Camp Greene. — Cerebrospinal 
meningitis has been unduly prevalent in many of 
the training camps of this country during the 
past winter, and therefore any data concerning 
the diseases which appear likely to elucidate its 
obscure and moot features, thereby rendering its 
control more easy, should be carefully collected 
and earnestly studied. Capt. Paul G. Wooley, 
M.R.C., writes in the Journal of Laboratory and 
Clinical Medicine regarding conditions at Camp 
Greene. He says that cerebrospinal meningitis 
was at no time truly epidemic in that camp, for 
during a period of something over two months 
only thirty cases occurred in a camp population 
varying between 30,000 and 40,000. Under the 
conditions of camp life such as prevailed during 
the past winter, with exceedingly cold weather, 
with sleet and rain alternating, with the men 
practically living in the mud, wet from one day's 
end to another, huddling together for warmth, 
in other words with all the inost favorable condi- 
tions for the transmission of infection, such an 
incidence cannot be called epidemic. As a matter 
of fact, it was surprising that the sick rate was 
as low as it was, and the comparatively slight 
amount of disease that occurred from all causes 
spoke well for the care exercised over the men. 
Cases of meningitis began to appear in December, 
1917, and after the appearance of the first case 
continued to come sporadically during January 
and February, 1918. 

The only available statistics at hand indicate 
that there were between 5 and 7 per cent of car- 
riers at Camp Greene. These figures came from 
the detention camp and are therefore too high, 
in all probability, for in this camp all meningitis 
carriers were isolated pending bacteriological ex- 
amination. It would appear, therefore, that the 
percentage of carriers was smaller than in other 
camps. However that may be, it represents after 
all merely a guess, because the only organizations 
which were cultured were those in which menin- 
gitis appeared and probably represented not more 
than half the personnel of the whole camp. 

More interesting is the fact that in the only 
organization which made use of systematic nasal 
sprays from the first of the year not a single case 
developed, and also that in those organizations 
in which the use of sprays were resorted to after 
the appearance of the disease no other cases ap- 
peared. This might be merely a coincidence, but 
when one discovered that also following the adop- 
tion of sprays the total sick rate fell, especially 
that due to respiratory diseases, and bore in mind 
the current conception that the menigococci in- 
habited the nasal passages, one came to have a 
very healthy respect for dichloramine-T as an 
aj;ent for the prevention of diseases originating 
from the upper respiratory tract. From his ex- 
perience in Camp Greene, Wooley recommends the 
routine use of dichloramine-T nasal spraying as a 
prophylactic measure for respiratory diseases, 
especially in military camps. 



Hospital Ship Torpedoed Without Warning. — 

The Canadian hospital ship, Llandovery Castle, 
wa? sunk without warning by a German submarine 
off the southern coast of Ireland on June 27. Of 



250 persons who sailed on the vessel only 24 are 
alive. This latest crime of the German sub- 
marine was even more wanton than those that 
have preceded it, for after sinking the ship the 
enemy fired on life boats filled with sur\'ivors and 
even pushed off the victims of their inhumanity 
from the wreckage to which they were clinging. 
Most of those aboard the vessel were Canadian 
Red Cross men and women. The attack on the 
survivors was evidently made with the object 
of wiping out all trace of the crime. 

Widening the Activities of the U. S. Public 
Health Service. — President Wilson has placed all 
sanitary and public health activities carried out as 
war measures under the Public Health Service. 

Veterinarj' Force SuflScient to Meet the Needs 
of the Army. — There is available a force of 
veterinarians sufficient to meet the needs of the 
army for some time to come. Examinations for 
commissions have been closed. In addition to the 
1,700 officers and 10,000 enlisted men on active 
duty there is a waiting list of men who have 
passed the examinations and who will receive com- 
missions when vacancies occur. A training school 
for commissioned veterinarj' officers on active 
duty has been established at Camp Greenleaf, 
Chickamauga Park, Ga., from which one hundred 
men are graduated every month, after having re- 
ceived a two months' special course. 

Lutherans OflFer New Hospital for Soldiers. — 
A resolution was passed by the Board of Direc- 
tors of the Lutheran Hospital of Manhattan, on 
July 2, offering their hospital building at Con- 
vent Avenue and 144th Street, as well as their 
nurses' home nearby, to the Government as a 
hospital for wounded soldiers returning from 
abroad. The building has accommodations for 
one hundred patients. 

Captain E. J. Presper of the Medical Reserve 
Corps, attached to the British Expeditionary 
Forces, is reported by the Adjutant General's 
office to be a prisoner in Germany. 

W. M. Wood Gives Convalescent Hospital. — A 
large Red Cross convalescent hospital has been 
established by William M. Wood on his estate at 
Cuttyhunk, near the mouth of Buzzards Bay. The 
hospital will accept as patients officers from all 
branches of the service, both of the L'nited States 
and her Allies, who need rest to put them in shape 
for further service. Dr. Norman E. Ditman is 
medical director of the hospital. 

Women Workers to Treat Gas Cases. — The 
Women's Overseas Hospital, which has now some 
thirty women physicians, nurses, and aids in 
France, has been asked by the French Government 
to send immediately fifty women to run a hospital 
of 300 beds about to be established for the treat- 
ment of gas cases. Dr. Alice Gregory who headed 
the civilian unit of the Overseas Hospital, has 
gone to establish a hospital at the front and will 
be succeeded by Dr. Marie Formad of Philadel- 
phia. Mrs. Raymond Brown, who has just re- 
turned from France to recruit the unit, states 
that there is a great field for women dentists 
among the civil population of France. 

Hospitals for Americans in I.<ondon. — The Brit- 
ish Army Council announces that the Red Cross 
will take over two London hospitals for the ex- 
clusive use of American wounded. , 



July 13, 1918J 



MEDICAL RECORD. 



69 



Medical Record. 

A Weekly Journal of Medicine and Surgery. 



THOMAS L. STEDMAN, A.M.. M.D., Editor. 



PUBLISHERS 
WM. WOOD &. CO., 51 FIFTH AVENUE. 



See fourth page following reading matter for Rates of Subscription 
and Information for Contributors and Subscribers. 



New York, Jaly J3, I9I8. 



ECONOMY IN MEDICAL MATERIAL. 

The time is surely coming, if the war continues as 
long- as it now promises, when the shortage in army 
medical officers will become acute, unless steps are 
taken in time to prevent it. We sometimes think 
we have done pretty well in furnishing the present 
army of two million men with the necessary doc- 
tors, but that is only two-fifths of the army that it 
is estimated we shall need in order to put an end 
to the crimes of Germany. That means that nearly 
thirty thousand more physicians must volunteer, 
and this without counting those needed for 
the constantly growing navy. Where are these men 
to come from? There are, roughly, about 140,000 
physicians in the United States, over 20,000 of 
whom are already in the services, leaving less than 
120,000 to be drawn from; therefore at least 25 
per cent, of the medical men now in civil practice 
must enter the army or navy. 

This will mean inconvenience and hardship for 
many, but it must be, and the only problem is to 
effect the necessary readjustment with as little dis- 
turbance as possible. That calls primarily for the 
greatest possible economy in medical material. There 
is a large number of physicians in the country who 
are an.xious to do their part but whose offers of 
military service are rejected because they are over 
.55 years old; yet hundreds if not thousands of 
these "superannuated" physicians have the physique 
and possess medical skill amply fitting them for 
service in base hospitals in this country, while 
others could do much of the clerical work which 
now keeps many younger men of superior attain- 
ments from doing that for which they have been 
specially trained. Other over-age men who are not 
fit for such work or who could not for one valid 
reason or another undertake it, are perfectly capa- 
ble of discharging the duties of attending physi- 
cians and surgeons in the civil hospitals of the 
country, thereby freeing a host of younger men 
constituting capital material for army or navy ser- 
vice. Then there are 5,000 women physicians in the 
country, many of whom could fill responsible posi- 
tions in base hospitals here and abroad and on the 
staffs of civil hospitals. 

A plan of economy in hospital service has been 



suggested by Dr. S. S. Goldwater, chairman of the 
war service committee of the American Hospital 
Association. In an appeal recently made to the hos- 
pitals of the country, he has urged that they put 
themselves on a war footing by abolishing the ro- 
tating service, substituting therefor a plan of con- 
tinuous service, thus releasing a large number of 
competent men for the country's need. The ro- 
tating service is one which is filled by a certain 
number of men each serving a certain number of 
months only in each year, and this plan Dr. Gold- 
water would do away with for the period of the 
war. "In this crisis," he writes, "no plan of or- 
ganization is admissible which does not release 
every competent physician who can be spared for 
military duty," and his slogan is, "One job, one 
man!" This would doubtless relea.se a number of 
men of army age, but there are objections to it. 
In the first place a large and active hospital service 
is too much for one man to care for twelve months 
in the year. The sole attending physician or sur- 
geon would have to be a young and physically strong 
man, just the kind of man the army needs. Then, 
again, should he die or be suddenly incapacitated, 
the hopsital would suffer until a capable successor 
or substitute could be obtained. Of course, he 
would have to have an assistant or understudy who 
could act in such an emergency, but there again 
would be a good man kept out of the army. A bet- 
ter plan, we venture to think, is the one above sug- 
gested, of raising the lower age limit of the attend- 
ing staff, keeping the rotating service as it is, but 
calling to it only men over the army age. Many such 
are even now in hospital service, and the places of 
the younger members of the staff could readily be 
filled temporarily by older men. many of whom have 
had a long hospital e.xperience and who had retired 
only to give the younger men a chance. Some men 
who have retired may not relish being drafted for 
service again, but every man must do his part in 
winning the war and that will be theirs. 



THE PSYCHIC DISTURBANCES OF LOCO- 
MOTOR ATAXIA. 

It is quite essential to make distinctions among the 
psj'chic disturbances which may be met with in 
cases of locomotor ataxia, not merely as to their 
nature and the place they may occupy in mental 
syndromes, but also and above all on account of 
the relation of causality uniting them to tabes. In 
the first category should figure those cases of 
mediocre interest in which psychosis of some type, 
present before or after the development of the 
tabes, is related to the latter process by no etiolog- 
ical circumstance whatsoever. In these cases of 
simple coincidence, the sensitivo-sensorial or motor 
disturbances of locomotor ataxia may, nevertheless, 
exercise an accessory or secondary influence on the 
delirium, either by imparting to it a particular 
shade or by being the starting point of an errone- 
ous diagnosis. 



70 



MEDICAL RECORD. 



[July 13, 1918 



Locomotor ataxia may be an occasional factor in 
the awakening or manifestation of psychoneuro- 
pathic manifestations, such as neuresthenia or psy- 
chasthenia, particularly a phobia of the equilibrium 
or the gait. But these instances being eliminated, 
it is at present a universally established fact that 
the vast majority of psychic disturbances encoun- 
tered in tabes belong to an associated general paraly- 
sis, anterior or contemporaneous with, but usually 
following upon the meningo-radiculo-medullary 
process. Amaurotic locomotor ataxia, in which 
mental disturbances are particularly common, 
would appear to confirm this opinion. 

In addition to the foregoing, however, many other 
psychopathic manifestations should be looked upon 
as having a direct etiological relation with locomotor 
ataxia. Such are changes in character or moral dis- 
turbances, psychoses of the depressive type with 
psychosensorial disturbances, paroxysms of excita- 
tion with a delirium of megalomania, and deficient 
states, commonly called tabetic dementia. It would 
appear that the first three of the above-mentioned 
disturbances have when first observed, or soon after- 
ward assume, the characters of psychopathic states 
developing on a more or less distinct basis of intel- 
lectual weakening, so that they finally enter the 
fourth category, namely, tabetic dementia. Thus, if 
associated general paralysis be eliminated, the entire 
question of the existence of the mental disturbances 
of locomotor ataxia is reduced to existence of a ta- 
betic dementia quite distinct from general paralysis. 
According to a number of writers tabetic dementia 
is differentiated from paralytic dementia by a num- 
ber of physical and psychic signs. There is no dis- 
turbance of speech, or if it does exist, it is very 
slight. The dementia is less profound and not so 
rapidly progressive, and often undergoes quite long 
remissions. But these clinical characters are en- 
countered in certain instances of general paralysis, 
so that they do not offer a sufficient ground for dif- 
ferentiating with certainty between tabetic and 
paralytic dementia. 

Pathological anatomy and histology are unable as 
yet to serve as a criterion for diagnostic differentia- 
tion. In certain cases of tabetic dementia clinically 
characterized lesions of chronic diffuse meningo- 
encephalitis, identical with those of general paraly- 
sis, will be found at necropsy. In still other cases 
the lesions, although retaining the same type, are 
less diffuse and recall those found in certain cases 
of luetic meningoencephalitis, intermediary between 
cerebral syphilis properly speaking and the diffuse 
meningoencephalitis of general paralysis. Finally, 
the common lesions of arterial atheroma, softening 
and senile degeneration are present. 

It would, therefore, seem logical to conclude that 
in the vast majority of cases the demential psycho- 
ses of tabetics are chargeable to general paralysis. 
Sometimes the condition is one of syphilitic men- 
ingoencephalitis, which is as yet ill-defined from the 
viewpoint of clinical symptomatology and to a cer- 
tain extent realizes the Guillain-Thoan syndrome. 



which is met with in conditions other than tabes. 
Finally, it may be an ordinary dementia resulting 
from arterial or senile lesions. 



FIBROID INDURATION OF THE CORPORA 
CAVERNOSA. 

Sclerosis of the corpora cavernosa affects various 
forms but it is usually found as small hard nodes, 
generally sunk in the midst of the erectile tissue, 
which are found only upon examination. These 
nodes may vary in size from a cherry-stone to an 
olive, but usually they are much smaller. They may 
occupy one or both corpora. When the penis is 
flaccid they are invisible but are readily palpated. 
In most cases they are separated from each other 
by apparently healthy tissue, but they may be 
united by fibrous bands, giving a hard, sclerous feel 
to the entire corpus cavernosum. These sclerous 
formations are embedded in the midst of the erec- 
tile tissue like a foreign body and have no connec- 
tion with the urethra, glans, nor albuginea of the 
corpus cavernosum. The process preferably occurs 
in the superficial portion of the erectile tissue but 
does not become adherent to the enveloping mem- 
brane in most cases. The nodules are absolutely 
indolent and never give rise to inflammatory reac- 
tion. 

The development of the sclerosis is insidious and 
it is only after a time that it is noticed by the 
patient during erection, because the penis becomes 
laterally curved, a condition that the immortal 
Ricord was pleased to call strabismus of the penis. 
Occasionally the normal curve of the member is 
accentuated but the lateral deviation is by far the 
most frequent. The deformity is all the more pro- 
nounced the nearer the sclerosis masses are to the 
base of the corpora cavernosa, and besides the de- 
formity occurring during turgescence of the penis 
there are also a decrease in the caliber of the organ 
at certain points, a weakening of the erectile rigid- 
ity, and a collapsus of the genesic sense. From all 
this, more or less serious disturbances accrue which 
hinder or prevent coitus from taking place and at 
the same time exercise an unfortunate reflex psychic ' 
action on the morale of the patient. 

The causes of this interesting process are still 
obscure. According to some writers the morbid pro- 
duction is due to gonorrhea, traumata, senility, or 
certain diatheses, such as gout, arthritism, or dia- 
betes, but it is also an unquestionable fact that 
sclerosis of the corpora cavernosa may be purely 
and simply a tertiary syphilitic process, as showTi 
by the cases reported by Arion in his recent thesis 
(Paris, 191G). Besides the ulcerating tertiary 
syphiloma or gumma syphilis produces other essen- 
tially sclerous lesions which are all the more prone 
to follow this evolution, the greater the vascular 
supply to the structures involved. The erectile tis- 
sue of the corpora cavernosa fulfills these conditions 
to a nicety, therefore it is only natural that the 
luetic virus should set up the usual sclerotic process 



July 13, 1918] 



MEDICAL RECORD. 



71 



in it by vascular irritation. As a matter of fact, 
ulcerating gummata are ne%'er met with in the erec- 
tile tissue. 

The evolution of cavernous sclerosis is exceed- 
ingly slow, but its progress is influenced by anti- 
syphilitic treatment, and although a complete and 
permanent cure of the process cannot be obtained, 
at least a marked improvement in the condition may 
be effected if the treatment is begun before the 
sclerotic process has gotten well under way. If the 
etiology of the sclerosis is uncertain it is well to 
make a Wassermann test and if even then the result 
is doubtful a test treatment should be essayed, which 
although it may not result in anything tangible 
will at least have a happy effect on the neuropathic 
state of the patient. 



THE VAGINAL DOUCHE. 

The antiseptic vaginal douche has become such a 
common and popular method of treating all pelvic 
Ills of the female, especially by the laity, that the 
indications and the dangers from its use have been 
quite overlooked. The indiscriminate use of the 
vaginal douche for general cleansing purposes re- 
gardless of the presence of pathological conditions, 
this being often advised much in the same way as the 
bath, is, unlike the latter, an uncalled-for interfer- 
ence with natural conditions. The vaginal secretions 
and the flora are protective rather than harmful. 
The saprophytic organisms contained therein are 
inimical to the development of pathogenic organ- 
isms, and the removal of these secretions by the 
douche leaves the vaginal mucosa unprotected and 
more easily subjected to trauma and infection. The 
chronic douching habit has probably as much to do 
with cases of idiopathic sterility as any other con- 
ditions. It is a fallacy to believe that the vaginal 
mucosa has little absorptive power, and that any 
antiseptic solution short of a caustic can be used 
with impunity. In the first place, any antiseptic 
that is physically destructive to the organisms con- 
tained therein is also physically destructive to the 
tissues. In the second place, disease is more likeiy 
to occur from introduced infection not successfully 
removed by the douche than if under the same cir- 
cumstances no douche had been employed. But even 
if all infection is removed by the douche, the injury 
of the mucous membrane and the removal of the pro- 
tective secretion make infection from outside 
sources very likely. The use of strong antiseptic 
solutions of bichloride, carbolic acid, etc., may 
harm the organism through absorption. Frank 
cases of poisoning are frequently reported. 

When the object is to destroy pathogenic infec- 
tions occurring in the genital tract, the methods of 
dry cleaning are far more effective and without the 
objections to the vaginal douche. Dry cleaning can- 
not so easily speed the infection to other parts of 
the tract as it must be obvious the douche so often 
does. Nevertheless, the hot vaginal douche has a 
use in pelvic inflammations through the production 
of pelvic hyperemia. But as a matter of fact, when- 



ever the hot vaginal douche is advised only a warm 
douche is given. The warm douche tends to en- 
courage congestion, the very thing to be avoided. 
On the other hand, even the warm douche has its 
place. It can act as a poultice or fomentation in 
cases of pelvic disease when the hjT)eremia produced 
aids in the absorption of the pelvic exudates. But 
both the warm and the hot douche must have a clear 
therapeutic indication if their use is to be productive 
of good. 



Colored Hearing. 



This most common of the synesthesias now has a 
large literature, but few truths can be uttered in 
respect to it, on account of its individual and im- 
pressionistic character. In the issue of the Journal 
de Medecine et de Chirurgie Pratiques for May 10 
is a brief account by Professor Blanchard of some 
old episodes of this character. About a dozen years 
ago he assisted at a concert at Eg.vptian Hall, Lon- 
don, in which while a piano was played in the dark 
each note was represented by flashing an incan- 
descent light in a specially colored bulb. The same 
note was always indicated by the same color. The 
experience was a novel one, and many of the audi- 
ence-spectators professed to be able to experience 
the same pleasure from the harmony of the colors 
that others feel from the harmony of sounds. The 
author does not know whether the "chromatic" 
scale of the lamps was arbitrarily chosen, or based 
on a quasi-musical notation. More recently (1913) 
a similar concert was held, also in London, which 
the author knows of only from the press. In this 
case there was a demonstration of an organ in 
which pressure on the keys caused colored lights 
to flash on a screen. The organist executed color 
symphonies which gave to some of the spectators 
pleasure analogous to that of musical symphonies. 



Nptns of the ffilffk. 

Disease in Germany. — A recent message from 
Berlin states that there are approximately 100,000 
cases of Spanish influenza in Germany and at 
least 25,000 in Berlin alone. All the hospitals 
are filled with cases of this malady and all the 
doctors and nurses are down with it. It is re- 
ported also that Austria-Hungary is suflfering from 
an epidemic of typhus, and that influenza has ap- 
peared in Budapest and in Danzig. 

Start Work on County Tuberculosis Hospitals. — 
County tuberculosis hospitals are in the process of 
construction in Broome, Rockland, and Nassau 
counties, New York. The contracts for the 
Broome County institution total ?117,233. The 
hospital is located several miles from Bingham- 
ton and is to have seventy-five beds. The Rock- 
land County Hospital will be located near New 
Citj' and is to cost approximately ?90,000. The 
Nassau County Hospital is being erected on a 97- 
acre site near Farmingdale and will cost about 
$108,259. 

School Kept Open During Measles Outbreak. — 
The June issue of the Bulletin of the New York 
State Health Department states that in controlling 
an outbreak of measles it is not always, advisable 
to close the schools. When measles appeared in 



72 



MEDICAL RECORD. 



[July 13, 1918 



Kingston the sanitary supervisor made a survey 
and found that there had been 355 cases of 
measles reported to the city health officer. A sur- 
vey of the schools showed that 83 per cent, of 
the children in the parochial schools and 79 per 
cent, of the children in the public schools were im- 
mune to measles. The sanitary supervisor ad- 
vised keeping the school in session as the chil- 
dren who were susceptible could be easily watched. 
Just as soon as a child exhibited signs of measles 
he was sent home. By daily visits to the schools 
the school physician was able to detect and con- 
trol the beginning cases. 

Commissioner Copeland Exonerates Dr. Brown. 
— At a hearing on July 5, Dr. Lucius P. Brown, 
director of the Bureau of Food and Drugs, de- 
fended himself against the charges brought 
against him by Mayor Hylan and ex-Civil Service 
Commissioner McBride. Dr. Brown produced evi- 
dence showing that the charges against him were 
false. At the end of the hearing Dr. Copeland 
commended Dr. Brown and admitted that the re- 
sults of his work were of value to the city and 
that the honesty and integrity of Dr. Brown were 
in no way in question. 

More Cities to Have Tuberculosis Dispensaries. 
— Through the cooperation of the State Charities 
Aid Association, which has been assisting local 
public and private tuberculosis organizations to 
establish dispensaries for medical oversight, as- 
sistance, and sanitary supervision of tuberculous 
soldiers rejected from military service, arrange- 
ments have been made which assure the opening 
of such dispensaries in Hudson, Newburgh, King- 
ston, Binghamton, Auburn, and Mount Vernon 
within a month. Plans have also been perfected 
for the reopening of dispensaries in Cohoes and 
Little Falls. Approximately |2,500 a year is re- 
quired to secure a medical and nursing staff and 
to equip and operate a dispensary in the smaller 
cities of the State. In a series of villages and 
towns in Westchester County arrangements are 
under way for occasional clinic service to be given 
by tuberculosis specialists of New York. 

A Child Welfare Station in Manufacturing In- 
dustr>'. — At the suggestion of the State Depart- 
ment of Health, through its Division of Child Hy- 
giene, the Endicott-Johnson Company of Endicott 
has established in its plant a Child Welfare Sta- 
tion, where the children of all persons employed 
by this company are cared for medically. Ample 
provision has also been made for the proper edu- 
cation of expectant mothers in matters pertain- 
ing to their personal health and hygiene and for 
the better care of the nursing mother and the 
new-born babe. 

Charitable Gifts and Bequests. — The will of 
Meyer H. Lehman bequeathes $25,000 to Mount 
Sinai Hospital, New York, and $10,000 to the 
United Hebrew Charities. 

The proceeds of a base ball game and a circus 
for the benefit of the Saranac Lake General Hos- 
pital have netted that institution over $1,000. 

By the will of the late Gustavus A. Miiller of 
Philadelphia bequests of $500 each are made to 
the Lankenau and the St. Agnes Hospital. 

By the will of the late I\lary Anspach Ashmead 
of Philadelphia trust funds are set aside yielding 



incomes as follows: Philadelphia Home for In- 
curables $10,000, Methodist Episcopal Hospital 
$5,000, Hospital of the University of Pennsylvania 
$3,000. 

By the will of the late Dr. Gwilym G. Davis of 
Philadelphia the sum of $3,000 is bequeathed to 
the Hospital of the University of Pennsylvania for 
the Children's Orthopedic Ward, and the sum of 
$500 to the College of Physicians of Philadelphia. 

Under the will of Dr. William Mecklenburg Polk, 
Cornell University receives $5,000 to continue the 
John Metcalf Polk scholarship in the Medical School. 

The Women's Hospital and the New York Dis- 
pensary, each receive $10,000 under the will of 
Miss Cornelius A. Beekman. 

Dr. Jay Frank Schamberg has been elected Pro- 
fessor of Dermatology and Syphilology at Jeffer- 
son Medical College in succession to Dr. Henrj' 
W. Stelwagon resigned. 

Dr. Martin E. Rehfuss has been elected Associ- 
ate in Medicine at the Jefferson Medical College, 
Philadelphia. 

Dr. William C. Woodward, health officer of the 
District of Columbia, has been appointed Health 
Commissioner of Boston. 

Dr. R. Morton Smith of Riverport, R. L, has been 
elected President of the State Board of Health of 
Rhode Island. 

Dr. Harry S. Bernton has resigned his position 
as Pathologist of the State of Rhode Island in 
order to accept the position of Chief of the Bureau 
of Preventable Diseases and Director of the Bio- 
logical Laboratories of the District of Columbia. 

Dr. Charles H. Weinsberg of St. Louis, who was 
tried on the charge of violation of the espionage 
act, has been acquitted by the Federal courts. 

Positions Open to Physicians. — The Civil Serv- 
ice Commission of the State of New York an- 
nounces that there is a vacancy in the position 
of Medical Officer and Inspector, Department of 
Health Officer, Port of New York. The salary is 
$1,200 a year. The position of Resident Physician, 
State Training School for Girls, Hudson, is open 
to women physicians and carries a salary of $1,800 
a year. No written examinations will be required, 
but applicants will be rated upon education, train- 
ing, experience, etc. Applications must be in the 
hands of the Civil Service Commissioners at Al- 
bany by July 24, 1918. 

New Hospital for the Bronx. — The Bronx Hos- 
pital Association has acquired a new hospital 
which is to have a children's ward and a dispen- 
sary. Property has been purchased at Fulton 
Avenue and 139th Street for a little more than 
$110,000, known as the Eichlen estate, and the 
Eichlen mansion will be remodeled to serve as a 
hospital building. A campaign to raise $35,000 
with which to alter and equip the building has 
been started. Dr. Alexander Goldman is presi- 
dent of the hospital association. 

Physicians Raise Fees. — A number of East Bal- 
timore physicians met recently and formed an or- 
ganization for social and professional advance- 
ment. One of the first things they did was to de- 
cide upon a new schedule of fees, namely, office 
calls $1, outside calls $2, and night calls $3, and 
the lowest fee for obstetrical cases $25. 



July 13, 1918] 



MEDICAL RECORD. 



73 



Italian Hospital Needs Funds. — A campaign to 
raise $100,000 is being carried on by those inter- 
ested in the Italian Hospital, New York. This 
amount of money is urgently needed to keep the 
hospital going until the end of the year. 

Medical Society Elections. — The Massachusetts 
Medical Society, at its 137th annual meeting, on 
June 18, elected the following officers for the ensu- 
ing year: President, Dr. Samuel B. Woodward of 
Worcester; Vice-President, Dr. George P. Twitchell 
of Greenfield; Secretary, Dr. Walter L. Burrage of 
Jamaica Plains; Treasurer, Dr. Arthur K. Stone of 
Framingham Center; Librarian, Dr. Edwin H. Brig- 
ham of Boston. 

The Medical Society of the State of New Jer- 
sey, at its 152d annual meeting, held at Spring Lake 
on June 25 and 26, elected the following officers: 
President, Dr. Thomas W. Harvey of Orange; First 
Vice-President, Dr. Gordon K. Dickinson of Jersey 
City; Second Vice-President, Dr. Philander A. Har- 
ris of Paterson; Third Vice-President, Dr. Henry B. 
Costill of Trenton; Secretary, Dr. Thomas N. Gray 
of East Orange; Corresponding Secretary, Dr. 
Harry A. Stout of Wenonah; Treasurer, Dr. Archi- 
bald Mercer of Newark; Editor of Journal, Dr. 
David E. English of New Brunswick. 

The American Climatological and Clinical 
Association, at its thirty-fifth annual meeting, held 
in Boston, June 5 and 6, elected the following offi 
cers: President, Dr. Guy Hinsdale of Hot Springs, 
Va. ; Vice-Presidents, Dr. Joseph H. Pratt of Boston 
and Dr. Hugh M. Kinghom of Saranac Lake, N. Y. ; 
Secretary-Treasurer, Dr. Arthur K. Stone of Boston ; 
Recording Secretary, Dr. William D. Robinson of 
Philadelphia. 

The Woonsocket District Medical Society, at 
its meeting in Providence, R. L, on June 22, elected 
the following officers: President, Dr. Edward L. 
Meyers; First Vice-President, Dr. James A. King; 
Second Vice-President, Dr. Robert G. Reed ; Sec- 
retary, Dr. E. F. Cameron of Slatersville ; Treas- 
urer, Dr. A. Constantineau. 

Obituary Notes. — Dr. Charles Alfred Tyrrell, 
a graduate of the New York Eclectic Medical Col- 
lege, in 1900, died at his home in New York on July 
2, aged 72 years. 

Dr. William Dillon died at his home in Brook- 
lyn on June 26, aged 61 years. He was a graduate 
of the Royal College of Surgeons, Dublin, in 1884, 
and of the Royal College of Pharmacy of Ireland 
in 1885, and practiced medicine in London before 
coming to this country. 

Dr. Simeon Leslie West died at Philadelphia on 
June 22 at the age of 73 years. He was graduated 
from Jefferson Medical College in the class of 1868. 
He was a member of the Medico-Legal Society of 
Philadelphia, the Philadelphia County Medical So- 
ciety, and the Medical Society of the State of Penn- 
sylvania and a Fellow of the American Medical 
Association. 

Dr. John Shri\'er Wentz died at Philadelphia on 
July 1 at the age of 81 years. He was graduated 
from the medical department of the University of 
Pennsylvania in the class of 1858. He served as 
a surgeon in the United States Army during the 
Civil War. 

Dr. Edwin C. Cowperthwaite, a graduate of the 
Hahnemann Hospital and Medical College, in 1895, 



died at his home in Philadelphia on June 11, aged 
45 years. 

Dr. Robert Simpson died at Philadelphia on June 
19 at the age of 74 years. He was graduated from 
the medical department of the University of Penn- 
sylvania in the class of 1874. 

Dr. Charles C. Hendrick, a graduate of the 
New York Homeopathic Medical College in 1894, and 
for many years a resident of New York City, died 
in Plainfield, N. J., on June 26. aged 55 years. 

Dr. William T. JIcAvoy. a graduate of the Ben- 
nett Medical College, Chicago, in 1913, and formerly 
a member of the Swedish Hospital, Brooklyn, died 
at his home in that city on June 21, aged 37 years. 



INTRATRACHEAL ANESTHESIA. 
To the Editor of the Medical Record: 

Sir: — In my address on "Thoracic Surgery" which 
appeared in the issue of the Medical Record for 
July 6, I discuss Dr. Bevan's statement with regard 
to intratracheal anesthesia. I sent this to Dr. 
Bevan on May 31 for an expression of opinion. Un- 
fortunately he did not receive my letter until June 
27, but in a letter dated June 28 Dr. Bevan writes: 
"I should be very glad to have you make the follow- 
ing statement from me in your article provided you 
quote in full in regard to intratracheal anesthesia." 
This letter came too late to permit the incorporation 
of Dr. Bevan's statement in my article. The state- 
ment is as follows: "I have not personally em- 
ployed the intratracheal method of Meltzer and 
Auer, nor have I had any personal experience with 
a number of other methods which I have discussed 
in this paper on the 'Choice and Technique of the 
Anesthetic' For instance, I have not produced com- 
plete anesthesia with scopolamine and morphine 
alone; I have never employed spinal anesthesia in 
my work; I have never blocked the Gasserian gang- 
lion; I have never employed the intravenous anes- 
thesia with ether, nor intrarectal anesthesia with 
ether, nor the so-called "anoci association.' The 
statements which I have made in regard to these 
various methods with which I have had no personal 
experience are made from a study of the literature, 
from observation of the work seen in the hands of 
other men, and from an attempt logically and judici- 
ously to estimate the relative values." 

One who read my address and now reads Dr. 
Bevan's statement will judge for himself whether 
the position I took requires any change. 

S. J. Meltzer, M.D. 

Xew York. 



MEDICAL WEEK IN CANADA. 

(From a Special Correspondent.) 

Hamilton', June In 

The thirty-eighth annual meeting of the Ontario 
Medical Association began its sessions in Hamilton 
on May 30. Among the papers read at the morning 
session was one by Dr. W. Gordon Lyle of New 
York, with reference to modern methods in the 
diagnosis of nephritis. Charts of cases of patients 
who had been studied for renal function were pre- 
sented, and the value and significance of blood analy- 
sis and functional tests in the diagnosis of early 



74 



MEDICAL RECORD. 



[July 13, 1918 



nephritis were discussed. The findings in several 
hundred cases with special reference to the nitrogen 
partition of the non-protein nitrogen residue of 
blood were presented, and the phenolsulphonephtha- 
lein test and nephritis test meal were described. 

Dr. J. Chandler Walker of Boston, Mass., read a 
paper in which he dealt with the clinical study and 
treatment of bronchial asthma. The importance of 
a careful history of bronchial asthma was empha- 
sized, and sensitization and the treatment of sensi- 
tive cases were discussed. Walker did not seem to 
think that a neurotic temperament bore any definite 
relation to the causation of bronchial asthma. He 
laid a considerable amount of these upon the influ- 
ence that the protein of food and the protein of pol- 
len exerted upon the production of the condition, 
and pointed out that judicious dieting was of great 
service both in the prevention and treatment of 
bronchial asthma. The treatment of non-sensitive 
cases was discussed and a clinical classification of 
bronchial asthma and a discussion of such classifi- 
cation was presented. 

A paper was given by Dr. Alan Brown and George 
Smith of Toronto, in which the autoserum treat- 
ment of chorea was dealt with. As for the causa- 
tion of chorea, attention was directed to the fact 
that a large number of observers believed that cho- 
rea was a manifestation of scarlet fever. Auto- 
serum treatment of this condition was first intro- 
duced by Dr. Goodman of New York. Brown and 
Smith had developed three modifications. A detailed 
report of technic, and results obtained, was pre- 
sented, and a description was given of the with- 
drawal of blood from the patient, separating the 
serum from the blood and its injection into the 
patient's spinal canal. 

In the section in surgery, on the morning of May 
30, Prof. Jasper Halpenny of Winnipeg discussed 
the methods pursued in the training of the surgeon 
at the present time. He was extremely critical of 
many of these methods, and quoted Rutherford 
Morison in support of his contention that the train- 
ing of the surgeon was not conducted on high lines. 
However, while Halpenny's criticisms were destruc- 
tive his suggestions in the way of reform were, 
in a high degree, constructive. He pointed out 
the best way of connecting the training-interneship, 
assistantship, post-graduate work, and the visiting 
of other clinics. In fact, he indicated the meas- 
ures which in his opinion would best tend to train 
the surgeon in the most thorough and effective man- 
ner. 

Radical operations for cancer of the breast were 
considered by Dr. D. Guthrie of Sayre, Pa. The 
history of the development of the operation for 
breast cancer was given, and the comparative mer- 
its and distinctive features of these were discussed 
at some length. The work of Von Volkmann-Hein- 
denhain with respect to cancer of the breast was 
gone over and the Meyer, the Halsted, the Warren, 
the Jackson and the Rodman operations were criti- 
cally dealt with, and the surgical principles involved 
therein discussed. Guthrie held that the methods 
of operating for cancer of the breast subsequent 
to the introduction by Meyer of his method were 
all modifications of the Meyer method. In the dis- 
cussion that followed the reading of this paper 
Dr. Coborn suggested that it would be in the best 



interests of all concerned if the operation for cancer 
of the breast could be standardized. Each great 
surgeon had his own way of operating, and this 
tended to confuse the student. If the best features 
of the best-known modes of operating for cancer of 
the breast could be standardized it would not only 
make the operation simpler but would facilitate 
matters for the student and would be better for the 
patient. The point was emphasized that especial 
attention must be paid to the lymphatics in cancer 
operations. The method of fulguration after oper- 
ation for cancer, introduced by Keating-Hart, was 
referred to favorably. The good results obtained 
from fulguration by Dr. William Seaman Bainbridge 
of New York were alluded to as conspicuous exam- 
ples of the value of the method in the treatment of 
cancer. Dr. Beal of London thought there was 
no need to attempt to standardize an operation for 
cancer of the breast. The essential methods of 
procedure were alike in all, and the slight modifica- 
tions introduced by different surgeons mattered but 
little. 

The toxemia of eclampsia was discussed by Dr. 
K. C. Mcllwraith of Toronto. There was a toxemia 
peculiar to pregnancy, usually of slow development, 
and in some degree controllable. The controllable 
factors were diet, eliminations, chill, neurotic fac- 
tors. The essence of treatment was the measure 
of toxicity which would show when delay was pos- 
sible and when action was imperative. 

At the general sessions on the afternoon of May 
30 the addresses, on obstetrics, on pediatrics, and 
on medicine were given. The address on obstetrics, 
which was entitled "Methods and Operations for 
Reducing Fetal Mortality, With Special reference 
to the Newer Methods of Csesarean Section," was 
delivered by Dr. Joseph De Lee of Chicago. He gave 
a history of the various methods by which women 
were delivered in ancient times, and a long and 
interesting account of the evolution and develop- 
ment of the operation for Csesarean section. The 
indications for the operation were given in full 
detail, and it was stated that there were two oper- 
ations in common use nowadays, the classical oper- 
ation and the cervical. De Lee advocated the cervi- 
cal operation for cesarean section rather than what 
is known as the classical, because convalescence waa 
much smoother. 

The address on pediatrics, the title of which was 
"Asthma in Infancy and Childhood," was given by 
Dr. Isaac A. Abt of Chicago, 111. Dr. Abt said in 
part that it must be borne in mind that infantile 
asthma differed in type from the form of the disease 
which occurred in the adult. Asthma in children 
was more prevalent among the rich than among 
those in less prosperous circumstances. Seasons had 
a good deal of effect on the incidence of infantile 
asthma. Locality had a curious effect on its inci- 
dence. Some young children got rid of it in a 
dry climate, others in a moist climate. The affec- 
tion was very capricious. It might occur in one 
room in a house while in the remaining rooms no 
symptoms of asthma presented themselves, so that 
really locality exercised no particular influence on 
its causation. The hypotheses as to its origin were 
many and various. It had been attributed to bacte- 
ria or toxins. Asthma might be the expression of 
an anaphylaxis, but there was a lack of proof with 



Julv 13, 191J 



MEDICAL RECORD. 



lb 



regard to this theory. It might be said, however, 
that anaphylaxis in infant.s and children was some- 
times produced by the ingestion of protein. Injec- 
tion of a small portion of albumen of egg would 
produce asthma in a certain child. Pollens and 
horsehair would produce asthma in some children. 
Asthma in infants and children has been ascribed 
to an exudative diathesis. It was said to have a 
connection with eczema, urticaria, adenoids, etc. 
Diet certainly played a part in the treatment. Abt 
thought that the hypothesis as to asthma in the 
young being due to an exudative diathesis was 
purely speculative. Bronchial tetany had a closer 
relationship to asthma than bronchopneumonia. 
Nasal lesions might bring on an asthmatic attack. 
Asthma occurred at almost any age in children, and 
began with marked bronchitis. So far as therapeu- 
tic treatment was concerned, calcium chloride had a 
good effect on asthma. Respiratory exercises might 
be recommended for older children who suffered 
from asthma. 

The address in medicine, "On the Significance of 
Heart Murmurs Found in Examination of Candi- 
dates for Military Service," was given by Dr. Lew- 
ellyn F. Barker of Baltimore, Md. Dr. Barker 
said, in part, that attention at the present time 
was focused upon the hearts of recruits. From 
1886 great progress had been made in knowledge re- 
garding the heart. The mechanical means for gaug- 
ing the heart's action had made possible this ad- 
vance. Dr. Barker pointed out that owing to im- 
proved methods of treatment a large proportion of 
men with heart murmurs, and at the present time 
not fit for active service, would be rendered wholly 
or partly fit. Reference was made to the fact that 
the Central Powers were sending out men with heart 
affections. The modes of differentiating between 
organic or functional heart murmurs were de- 
scribed, and it was shown that while some men with 
heart murmurs should be totally exempted others 
with murmurs were just as fit to carry on as if no 
murmurs were apparent. 

In the section in medicine of the Canadian Medi- 
cal Congress, on the morning of May 31, Dr. Bea- 
trice M. Hinkle read a paper discussing the psycho- 
analysis of the moral conflict in functional neurosis. 
The dictum of Jung that moral conflict is found to 
be the basis of every neurosis was referred to, and 
it was pointed out that Freud's psychoanalysis was 
the first attempt of medical science to find in the 
psyche the cause of neurotic conditions. Dr. Hinkle 
covered practically the entire ground alluded to in 
the title of her paper, paying particular attention 
to Freud's theories of repression and resistance, 
transference, infantile sexuality, dream interpreta- 
tion, and the technique of p-sychoanalysis. 

In the section on surgery, Capt. George Ewart 
Wilson, C. A. M. C, of Toronto, read a paper deal- 
ing with the treatment of compound fracture of the 
humerus. Attention was drawn to the unsatisfac- 
tory methods at present taught for treating com- 
pound fractures of the humerus. A full description 
was given of a splint invented by the author which 
allows of the suitable placing of fragments, proper 
extension and changing of dressings without re- 
moval of splint. 

Another paper was read by Dr. E. J. McGuire of 
Buffalo on surgerv of the colon. The author ani- 



madverted somewhat on Lane's theories and surgi- 
cal procedures with respect to intestinal stasis. He 
said, however, that his teaching should not be wholly 
discarded, as there was contained therein some real 
element of truth. Notwithstanding, surgery of the 
large intestine must be limited, with few excep- 
tions, to cases showing definite evidence of obstruc- 
tion. Ileosigmoidostomy should not be done as an 
operation of election, resection being the ideal pro- 
cedure. As a matter of fact, according to McGuire, 
Lane had discarded sigmoidostomy in favor of resec- 
tion. Moreover, side-to-side anastomoses were un- 
satisfactory, as demonstrated by the frequency with 
which diverticula developed in the blind end. End- 
to-end anastomosis gave the most satisfactory re- 
sults. 

Among the papers read in the section in obstet- 
rics, on the morning of May 31, was one by Dr. 
B. P. Watson of Toronto, entitled "The Technique 
of Operations for the Repair of the Perineum." 
In it were discussed the value of immediate repair 
after delivery, and especially the importance of 
closure of tear in vaginal mucosa and coaptation of 
musculofacial layers. The secondary operation 
was described and the need for the thorough ex- 
posure and union of separated levator ani muscles 
and of the torn triangular ligament was empha- 
sized. The paper was illustrated by lantern slides. 

Dr. Joseph C. Beck of Chicago gave a lecture on 
the teaching of plastic surgery of the head and 
neck. The importance of teaching plastic surgery 
was dwelt upon and the types of injuries in the 
present war were described, as well as the varieties 
of injuries of the internal ear and of the external 
ear and their plastic reconstruction. A description 
was also given of the plastic reconstruction indicated 
when a great part of the nose \Vas lost, with special 
reference to the use of the superior maxilla; also 
temporary and permanent resection for bullets in 
the retromaxillary fossa and the plastic reconstruc- 
tion of the larynx. The question of cartilage and 
bone transplantation was entered into, and nerve 
plastic procedures with special reference to the 
facial-hypoglossal and facial-spinal accessory ana- 
stomosis were considered. Laryngeal plastic oper- 
ations, and cosmetic means for restoring features 
to apparently normal conditions were discussed at 
considerable length. 

On the afternoon of May 31 the general session 
was devoted to a .symposium on Intracranial Pres- 
sure. Dr. J. J. R. Macleod of Cleveland, Ohio, gave 
an address on the physiology of the subject. He 
said there could be no expansion through intracra- 
nial pressure unless there were means for such ex- 
pansion. Venous pressure was more important than 
the work done by the arteries, but at the same time 
their action was interdependent. When the heart 
failed cerebral pressure was raised and arterial fell. 
As for the cerebrospinal fluid, it only acted as a 
lubricant, in the same way as the synoidal gland 
acted. The apparent absence of vasomotor nerve 
fibers was referred to and the consequent depend- 
ence of the blood supply upon changes occurring in 
other parts of the vascular system. He said that 
Leonard Hill of London was the greatest authority 
on intracranial pressure, and had devised the only 
instrument to measure correctly intracranial pres- 
sure. Macleod asked whv a tumor had caused intra- 



76 



MEDICAL RECORD. 



[July 13. 1918 



cranial pressure, and answered that it did not. It 
caused local cerebral anemia and increased intro- 
cranial pressure by producing anemia. 

Medicine and surgery in their relation to intra- 
cranial pressure were discussed by Drs. W. P. Ham- 
ilton and A. E. Garrow of Montreal respectively. 
Both speakers necessarily covered a good deal of the 
same ground as Dr. Macleod. Dr. Garrow described 
the various surgical methods for removing the ef- 
fects of intracranial pressure caused either by in- 
jury or disease. 

Dr. H. Beaumont Small of Ottawa was elected 
President of the association. The Vice-Presidents 
are the presidents of affiliated societies and the 
presidents of provincial societies ex-officio. Secre- 
tary-Treasurer, Dr. W. W. Francis, on active ser- 
vice. Acting Secretary, Dr. J. W. Scane of Montreal. 

The Canadian Medical Protective Association 
elected the following officers: Dr. R. W. Powell of 
Ottawa, President; Dr. J. A. Camarand of Sher- 
brooke, Quebec, Vice-President; and Dr. J. Fen ton 
Angus of Ottawa, Secretary-Treasurer. 

The Ontario Medical Association elected the fol- 
lowing officers: President, Dr. J. S. Cameron, To- 
ronto; First Vice-President, Dr. J. H. Mullen, Ham- 
ilton; Second Vice-President, Dr. J. F. Argue, Ot- 
tawa; Honorary Treasurer, Dr. Gordon Bates, 
Toronto; Honorary Secretary, Dr. T. C. Rontley, 
Hamilton; Assistant Secretary, Dr. F. C. Harri- 
son. Toronto. 



OUR LONDON LETTER. 

(From Our Own Corresponilent ) 
CONCERTED ACTION UPON FOOD QUESTIONS — FEES FOR 
MEDICAL ATTENDANCE ON MEDICAL MEN — THE 
COMING MINISTRY OF HEALTH — EXEMPTION OF 

MEDICAL MEN FROM MILITARY SERVICE CARE OF 

THE TUBERCULOUS SOLDIER — THE LATE DR. ROBERT 
KARQUHARSON. Londox, June 13. 191S. 

It is as important that the Allied nations should 
come to some complete mutual understanding upon 
food questions as upon questions of munitions, 
transport, medical care, and even military strategy. 
Concerted action in every department of life .should 
he the motto of the Allies, and medical men in each 
of the Allied nations have been prompt to point out 
that as regards food such action would have enor- 
mous value in conserving the strength and man- 
supply of the belligerents for the right. It may be 
remembered that an Inter-Allied Conference was 
held in Paris late last year at which an Inter- 
national Scientific Commission was instituted, 
whose function should be to meet at stated inter- 
vals for the consideration of any food problems 
that were presenting themselves. The periodical 
sessions were to be of a strictly scientific character, 
and it was understood that their outcome would be 
communicated in the form of expert advice to the 
various governments. The International Scientific 
Commission has a strong membership, as the fol- 
lowing name.s show: France. Professors M. Gley 
and J. P. Langlois; United States. Professors R. H. 
Chittenden and Graham Lusk — these four men by 
themselves constitute a powerful and learned com- 
mittee on all food questions; United Kintidoyn, Pro- 
fessor E. H. Starling, our most learned practical 
physiologist, and Professor T. B. Wood, Professor 



of Agriculture in the University of Cambridge; 
Italy, Professors Pagliani and Botazzi; and Bel- 
gium, the Home Secretary, Professor Hulot. Two 
sessions of the Commission have now been held. 
The first in Paris last March cleared the ground by 
coming to certain conclusions in respect of mini- 
mum food requirements ; the second, held in Rome 
in April and May, considered questions of general 
interest to the Allied i)opulations, the conclusions 
thereon being now in the press. 

A recent action in the High Courts of Justice 
has given a sort of legal standing to what hitherto 
has been merely a convention, though a universal 
one, among British medical men. In the case in 
question, a physician, who was in attendance on 
the wife of another physician, sued his patient for 
medical services rendered, the action, primarily 
again.st the wife, taking effect against the husband, 
who was the legal defendant. The case of the 
plaintiff was that his fees were to be paid, not by 
the husband, but by the patient's stepfather, the 
motive of the action being to speed up the step- 
father, rather than to mulct the husband. As the 
action, however, occurred in the courts, it was 
brought by a plaintiff doctor against a defendant 
doctor, for money owing in respect of medical ser- 
vices, and, as such, was a novelty in the courts, be- 
cause among doctors such matters when in dis- 
pute are settled outside the law. The universal 
convention in this country is that doctors render 
gratuitous medical services to other doctors and to 
their immediate family and dependents. Excep- 
tions occur where an arrangement to the contrary 
is made on the ground either that the medical ser- 
vice required would be unusually onerous, or that 
the medical man who is being benefited is mani- 
festly a richer man than he whose services are de- 
manded. No such mutual understanding had been 
reached in the case in question. Certain pecuniary 
help was received from the stepfather, whereby 
certain fees were paid to the plaintiff, but the other 
money was paid by the defendant out of his own 
pocket, believing himself to be making a complete 
settlement in so paying. The action was for a bal- 
ance alleged to be still due and unpaid. Judgment 
was given for the defendant, the position being 
recognized that the account should not ha%'e been 
rendered by the plaintiff; but on the suggestion of 
the .iudge, the amount of payment still due. if 
any. to the plaintiff, further than that which he had 
already received, wa.* referred to Sir Henry Morri.^ 
as arbitrator. No better arbitrator could have been 
found. Sir Henry Morris, lately President of the 
Royal College of Surgeons of England, which body 
he represented for years on the General Medical 
Council, is also Treasurer of Epsom College, a 
medical foundation, and has all his life been in the 
closest possible touch with questions affecting medi- 
cal procedure and standards of conduct. Sir Henry 
Morris interviewed both the plaintiff and the de- 
fendant, and came to the decision, which has now 
been published, that the plaintiff had no grounds 
for thinking that he had not been fairly treated by 
his patient or by her husband. The statements 
made to him by the two parties showed that the 
plaintiff had been remunerated for several years at 
a rate varying from £100 to £180 per annum, in 



July 13. 1918] 



MEDICAL RECORD. 



view of which Sir Henry Morris considered that 
the plaintiff had not any moral claim to further 
payment. 

The discussion at the Royal Society of Medicine 
on the professional problems arising out of the im- 
pending establishment of a Ministry of Health 
was continued this week and last week, the im- 
portant speakers being Sir William Osier, Sir Wat- 
son Cheyne, Dr. G. E. Haslip ( Treasurer of the 
British Medical Association), Dr. Smith Whitaker 
( Deputy Chairman of the National Insurance Com- 
mission), Dr. C. E. Buttar (Chairman of the Ex- 
ecutive of the Central Medical War Committee), 
Professor Benjamin Moore, and Surgen General 
Sir Bertrand Dawson. As the result of a free in- 
terchange of views the meeting decided unani- 
mously that a committee of the Society should be 
appointed to hold a watching brief for medical in- 
terests. This resolution has been transmitted to 
the governing body of the Society, and is sure to 
receive effect. Such a committee may prove of real 
value to the medical profession when the bill con- 
stituting a Ministry of Health comes before Par- 
liament. 

The Central Medical War Committee has issued 
this week to the medical profession, through its 
local bodies, the Local Medical War Committees, a 
memorandum dealing with the duties of those 
bodies, especially in making the new calls on the 
medical profession as little onerous as possible. The 
position of the medical man who makes no claim for 
exemption is set out in some detail. He is given 
an exemption which holds good so long as he is not 
offered a commission, with the proviso that he will 
undertake such professional work as the Director 
General of National Service may offer him — -"stand- 
ard exemption." The position works out as fol- 
lows and displays considerable ingenuity on the part 
both of military and civil officialdom: The Local 
Arrangements Sub-Committees of the Central 
Jledical War Committee will consider from what 
areas, having regard to their population, medical 
men can be spared, either for the army or for dis- 
tricts less fortunately provided with medical ser- 
vice ; in those areas where a tall is made the doctors 
will be examined physically by boards appointed by 
the Ministrv- of National Service; they may be 
granted a "standard exemption," but those who 
wish for a different form, i.e. a more complete 
form of exemption, will be given a hearing. It is 
understood that men will not be moved capriciously 
from one district to another by the Ministry of 
National Service, and that the desire is to disturb 
as few practitioners as possible, it being felt that 
their best work can probably be done in the familiar 
environment. The choice of the authorities in al- 
lotting work to a man, military or civil, will be de- 
termined mainly by his age and his health. These 
are the promises, and they will be kept if only be- 
cause to break them would be too silly. 

The tuberculous soldier is already proving one 
of the most difficult problems of this country, a 
problem whose solution will not be arrived at un- 
til many years after the nations have laid down 
their arms. By the end of 1917 20,000 men at 
least had been invalided from the British Army 
through tuberculosis, and it is felt that on all 



grounds careful watch should be kept, first in the 
recruiting stations to see that infected subjects 
are not admitted to the army, and, secondly, in the 
ranks to see that the cases which occur are taken 
in hand early. Both in Italy and France tubercu- 
losis as a cause of invaliding from the army has 
become a serious matter, while Italy has recently 
received large batches of interned prisoners from 
Austria among whom tuberculosis is very preva- 
lent. In fact it seems quite undoubted that the in- 
cidence of tuberculosis on the central empires is 
much heavier than it is on the Allies. In France 
the situation is being dealt with by local comm.it- 
tees in each department, who inquire into all cases 
of tuberculosis among service men, and, while ob- 
taining medical treatment for them, take steps also 
to insure their civil employment when they are re- 
stored to health. We have today greatly increased 
provision for the treatment of tuberculosis, both 
medical and surgical, in existing institutions, w-hile 
new ones are being built especially for the purpose : 
also five Farm Training Colonies have been started 
for tuberculosis patients, one near Bournemouth, 
one near Liverpool, one near Hull, one near Cam- 
bridge, and one near Edinburgh. 

The ominous position of tuberculosis in Ire- 
land, where the stress of war has not yet been 
felt, leads directly to the observation that the con- 
nection between a certain increase in tuberculosis 
rates which have occurred locally and the returned 
soldier is not so direct as has been supposed. The 
death rate for tuberculosis has risen for example 
in Belfast, where the civilian population at the 
present moment probably enjoys higher wages and 
better food than it has ever enjoyed; and simul- 
taneously with this we find that in some crowded 
British areas the incidence of tuberculosis is lower 
than usual and its mortality correspondingly abated. 
In Dublin, where the artisan class is not so pros- 
perous as in Belfast and where there is always a 
great deal of poverty, the City Corporation should 
have ample funds to deal with tuberculous cases, 
and there is no reason why the tuberculosis rates 
should be connected directly with the war. There 
is something about the public health aspects of 
tuberculosis which everlastingly seems to invite con- 
fusion of mind, and it would almost seem as if some 
public health authorities are prepared to attribute 
any rise in tuberculosis to the war instead of in- 
vestigating other circumstances, any of which 
might equally well or ill be the determining one in 
a particular locality. One point here, however, 
must be remembered — the public health departments 
of some localities have been depleted with the only 
result that organized tuberculosis work has suf- 
fered. As a rule, however, the local Government 
Board has exercised its power to obtain exemption 
from military service of all medical officers the 
cessation of whose work might be attended with 
widespread mischief to the population. 

The death is announced this week at the age of 
82 of the Laird of Finzean, the Right Honorable 
Robert Farquharson, who was for many years 
Member of Parliament for an Aberdeen constitu- 
ency, and also while in the House of Commons was 
the untiring advocate of medical reform. He en- 
joyed the rare distinction for a medical man of 



78 



MEDICAL RECORD. 



[July 13, 1918 



being a Privy Councillor, and before succeeding to 
the family estate was one of the surgeons to the 
Coldstream Guards. 



OUR LETTER FROM PARIS. 

(From Our Own Correspondent ) 
CHILDRENS' DISPENSARY AT MARSEILLES — LOSSES IN 
THE ARMY MEDICAL CORPS — THE RED CROSS AND 
THE FRENCH SCHOOLS — NEW FACES FOR THE DIS- 
FIGURED NEW MEMBERSHIP IN THE ACADEMY. 

Paris, June 4. 1918. 

More than 200 mothers brought their children to 
the opening session of the Red Cross children's dis- 
pensary at Marseilles this week. Aided by five 
nurses, Dr. Oscar H. Sellenings, of the Children's 
Bureau, examined child after child and gave advice 
on medical care to their mothers, but more children 
came than he could possibly attend to in a single 
afternoon. The dispensary is the first Red Cross 
institution to open in Marseilles, where Dr. William 
Palmer Lucas, chief of the Children's Bureau, has 
arranged for a hospital and a child-welfare exhibit 
as well. The Red Cross work at Marseilles is done 
in close cooperation with a large group of French 
societies which have united to form a "section of 
defense against infant mortality of the central office 
of the ceuvres of Marseilles." Among the ceuvres 
which are co-operating with the Red Cross are the 
"Abri Maternal," with which Dr. d' Astros is asso- 
ciated ; the "Protection Maternelle d'entr'aide Femi- 
nine," the "Pouponniere du Prado," the "Charite 
Saint-Joseph," and so on. 

Before the war some 80,000 babies died annually 
in France; investigation has shown the condition 
is even more serious now. Women's work in the 
munition factories, although a national necessity, 
has been in fact jeopardizing the future to save the 
present. It has tended to lower the national birth 
rate which was already too low. In conjunction with 
the Ligue contre la Mortalite Infantile and the 
Federal Government, the Children's Bureau of the 
American Red Cross has worked out a definite pro- 
gram of preventive measures. Whatever clinics 
for nursing mothers exist, or have existed, the 
Red Cross aids them or aids them to reopen them. 
Since most of the women available for health vis- 
itors or nurses have been drawn into the military 
hospitals, the Red Cross is aiding to create short, 
intensive courses for women who have had some 
hospital training to make them effective health 
visitors. Such courses have already been estab- 
lished at Paris, Lyons, Marseilles, and Bordeaux. 
The opening of the dispensary at Marseilles and 
the establishment of the training courses for health 
nur.ses there, in intimate cooperation with French 
societies which have long been at work, are the 
first steps in the preventive campaign in the com- 
mercial capital of Southern France. 

We of the French Medical Corps have known that 
the losses by killed, wounded, and captured of our 
members have been very heavy, but no lists are 
printed and no information, other than of individual 
cases, comes to our knowledge, so we are in complete 
ignorance of the totals. I do know that last spring, 
a year ago, 600 French army doctors, prisoners in 
Germany, were returned to France, via Switzerland. 



Some general idea, however, can be gained by the 
grave sacrifices made by these devoted non-com- 
batants by certain information given in a recent 
publication by Lord Northcliffe respecting the losses 
in June, July, and August during the battle of the 
Somme in 1916. Doctors killed, 53; doctors 
wounded, 208; doctors missing, 4; medical assis- 
tants killed, 2G0; medical assistants wounded, 1212; 
medical assistants missing, 3. 

School has reopened at Cuffies. It is just one of 
dozens of little villages in the liberated districts 
where the schools have been closed for nearly four 
years and are just beginning to reopen. At Cuffiea 
the French Government put up a rough wooden 
barrack to replace the brick building smashed by 
the Germans, and the Red Cross answered a hur- 
ried call for chairs. Cuffies is one of a number of 
towns where the Red Cross has helped reopen 
schools. Pommiers is another little town in the 
Aisne where school has started again. It is the 
only town with a school for miles around, and the 
children walk in from all the surrounding villages. 
This made it necessary to give them their dejeuner 
at school, and the Red Cross answered another 
emergency call, supplying vermicelli, chocolate, and 
condensed milk for the schoolchildren. 

Rebuilding houses, making it possible to reopen 
schools and to resume farm life in a region where 
every farm machine and every cart wheel has been 
destroyed, is all part of the Red Cross work in the 
Somme, Oise, and Aisne. The delegate for the 
Aisne has just reported the arrival of six cartloads 
of supplies, largely wheelbarrows, spades, pitch- 
forks, and shovels. Restoring industry is another 
part of the Red Cross program in the reviving 
regions. Wherever possible, local factories are en- 
couraged to resume production — which helps them 
and saves transportation. The chairs sent to the 
Cuffies schoolhouse were the first products of a fac- 
tory which has stood idle since the war began. 

Many of these towns have difficulty in securing 
adequate food supplies. Cuffies is typical of many 
others. The red Cross recently sent a camionload 
of foodstuffs to Cuffies and unloaded it into the 
cellar of one of the townspeople, whence it was dis- 
tributed by the mayor. There was only one man to 
do the unloading, but a score of the school children 
came to his aid, clambering into the auto and hand- 
ing things down, with a ride in the camion to the 
last house in Cuffies as their ample reward and 
salary. 

The Bureau for the JIutiles under the direction of 
Miss Grace Harper of the American Red Cross is 
developing its reeducational work under three 
heads. The farm that is being put in order prepara- 
tory to receiving the students of agriculture is 
probably the department that will be the most im- 
portant. The second branch includes the propa- 
ganda that is to be carried out by means of lectures 
and cinematograph entertainments to encourage the 
mutilated soldiers of France in attending the 
schools. The third branch is proving of great value 
in the work of making masks for disfigured faces. 
Mrs. Maynard Ladd. the American sculptor, first 
undertook this work and has made such a success 
of it that two other women sculptors have been em- 
ployed to assist Mrs. Lndd. Mile. Jeanne Poupelet 



July 13. 1918] 



MEDICAL RECORD. 



79 



is now engaged in making the galvanic copper cop- 
per masks and another sculptor from America will 
also assist in developing this work. 

The Red Cross furnishes the funds for making 
the masks at a cost of about 100 francs each. The 
surgeons of the Val-de-Grace hospital have recog- 
nized the work so successfully that Mrs. Ladd has 
been given carte blanche in fitting the mutilated 
soldiers of the hospital with these remarkably life- 
like faces. 

The Academy of Medicine has just made a new 
ruling regarding "Academiciens libres," limited to 
ten members who, not having the degree of doctor, 
are recognized because of some notable service ren- 
dered to the cause of medicine. Heretofore these 
member.s were required to post their candidature, 
but by the new ruling they may be named by a 
fixed committee in the Academy and elected by a 
two-thirds vote at a regular meeting. 



to 30 grains of bicarbonate of soda is useful. This 
remedy may also be given by mouth in doses of 60 to 
120 grains in 24 hours. Small doses of aspirin and 
aconite will control the temperature. 



New York Medical Journal. 

June 29, 191S. 

1. The Prevention of Hydrophobia. H. L. Abramson 

2. Defective Vision: Its Pathological Significance. A. Gum 

biner. 
J. Sarcoma of the Corpus Callosum, Joseph Byrne and An 
thony H. Harrigan. 

4. Tetany. C. E. Hyde. 

5. An Acute Febrile Entity with Vomiting, Somnolence, and 

Acetone. Harry Lowenburg. 

6. Dichloramine-T in Treatment of Wounds. Joseph C. 

Seal. 

7. Gastrointestinal Diseases in the Aged. Samuel Floershein 

5. An Acute Febrile Entity with Vomiting, Somno- 
lence, and Acetone. — Harry Lowenburg describes a 
condition occurring in infants and young children and 
exhibiting with marked uniformity the following symp- 
toms: Fever, forceful vomiting, somnolence, and the 
odor of acetone upon the breath. The onset is abrupt 
and is accompanied by fever reaching 101" to 104^ F., 
which lasts for a few days and falls by rapid lysis. 
Acetonuria is present and there is a faint trace of 
albumin. The drowsiness is persistent and amounts 
to a mild stupor. The pupils as well as the deep 
■ and superficial reflexes are normal, muscular rigidity 
is absent, and the child permits himself to be moved 
about without protest. The pulse rate increases with 
the rise in temperature, but does not partake of the 
nature of the slow, full, irregular pulse of meningitis — 
an important point of differentiation. No abnormality 
in the blood was noted in the author's cases, but further 
study on this point is necessary. Catarrh may be 
present and diarrhea troublesome; "cough and vary- 
ing degrees of bronchial irritation have been noted. 
The author is unable to classify this entity. He points 
out that acetone on the breath and the acetonuria may 
be symptoms of an acute febrile process or, on the 
other hand, they, with the fever and somnolence, may 
represent the main and distinctive symptoms of an 
acute acid intoxication depending up some undeter- 
mined etiological factor. Whether or not it is a form 
of influenza cannot be determined until its bacteriology 
has been studied. At the bedside the condition must 
be differentiated from meningitis, pneumonia, appendi- 
citis, typhoid fever, and head injuries. As to prog- 
nosis, all the author's patients recovered, although con- 
valescence was stormy in some. One fatal case, how- 
ever, is reported by Dr. Shmookler, in which the tem- 
perature was 107° F. and death occurred from hyper- 
pyrosis. The treatment indicated is a hunger period 
of 24 hours, calomel administration — 1/20 grain every 
15 minutes placed dry on the tongue for ten or twenty 
doses — with counterirritation over the epigastrium to 
control vomiting, followed by 0.5 ounce of castor oil. 
After free evacuations small amounts of solids may be 
permitted, followed by broths and gruels. No milk 
should be permitted for some days. One or two warm 
baths daily are of service, and an enema of from 20 



The Journal of the American Medical Association. 

June 29, 1918. 

1. Duties of the Dermatologist. H. H. Hazen. 

2. Reliability of Ozone in Swimming Pool Disinfection. 

Wallace A. Manheiraer. 
.3. The Action of Miotic Drugs on Eyes with Incomplete 
Sphincter Iridis. R. J. Curdy. 

4. The Relation of Heredity Eye Defects to Genetics and 

Eugenics. Lucien Howe. 

5. Cultivation of the Meningococcus Under Partial Oxvgen 

Tension : A Possible Explanation of the Poor Success 
of the Usual Cultural Methods. M. B. Cohen. 

6. The Blood Pressure in Gout. Jacob Rosenbloom. 

7. Further Studies on the Preservation of Complement by 

Sodium Acetate B. W. Rhamy. 

8. Chronically Enlarged Spleen (Malarial?). J. C. Van 

Nuys and M. B. Stokes. 

9. An Error of the Wassermann Test. Emanuel Jacobson. 

1 0. The Eyes of the Army. Allen Greenwood. 

11. Optic Atrophy and Multiple Peripheral Neuritis, Devel- 

oped in the Manufacture of Explosives (Binitrotolu- 
ene). Arthur S. Hamilton and Charles E. Nixon. 
i:. Postmortem Findings in Measles-Bronchopneumonia and 
Other Acute Infections. Baldwin Lucke. 

2. Reliability of Ozone in Swimming Pool Disinfec- 
tion. — Wallace A. Manheimer recommends the use <S 
ozone for swimming pool purification for the follow- 
ing reasons: It is reliable as a disinfectant and, un- 
like the halogens, its use results in no objectionable 
odor or taste; it is capable of purifying heavily pol- 
luted pool water; it produces no objectionable sub- 
stances in the water; it improves the appearance and 
transparency of the water, permitting a longer con- 
tinued use of the pool, a consequent reduction in the 
cost of maintenance and a reduction in the hazard of 
drowning; it is inexpensive in application, costing in 
the case of a 60,000 gallon pool only from eleven to 
fifteen cents a day if alternating electric current is 
available, and where direct current must be converted 
into alternating current an additional ten to fourteen 
cents. 



The Lancet. 

June S. 1918. 

1 An Address on Kineplastic Amputations. Delivered on 
May 30. before the Royal Society of Medicine. Pro- 
fessor V. Putti. 

2. Methods of General Anesthesia in Facial Surgery. Lieu- 

tenant R. Wade. 

3. So-called Functional Symptoms in Organic Nerve In- 

juries. John S. B. Stopford. 

4. The Conception of Retrogression in Psychological Medi- 

cine Captain Maurice Nicoll. 
J. Hernia of Urinary Bladder: Notes of Cases, with Re- 
marks on Strangulation of Femoral Herniae and Its 
Treatment. H. Blakeway. 

6. The Effect of Convection Currents on Agglutination- 

(A Report to the Medical Research Committee ) W. 
W. C. Topley and S. G. Platts. 

7. A Note on Oriental Sore. J. B. Christopherson and J. R 

Newlove. 

8. Ulnar Nerve Paralysis. Operative Treatment for the 

Disability of Main-en-Griffe. Captain N. I. Spriggs 
and Colonel Ashley V. Clarke. 

9. A Case of Fracture of the Hyoid Bone. Eaizabeth L. 

Ashby. 

10. A Case of Acute Lymphoid Leukemia. Captain John C. 

Tull. 

11. Acute Intusseption : A Rational Method of Treatment. 

S. W. Daw. 
12 A Case of Congenital Hypertrophic Stenosis of the Py- 
lorus ; Gastroenterostomy at the Age of Six Weeks ; 
Recovery. T. Jason Wood. 

1. An Address on Kineplastic Amputations.— Pro- 
fessor V. Putti reviews briefly the fundamental theories 
of Professor Giuliano Vanghetti's plastic motor flaps 
and indicates the vast field thrown open to the ortho- 
pedic surgeon through the application of these theories, 
which as yet are little known in France, England, or 
America, though they have been studied by Austrian 
and German surgeons. The object of "kinematic ampu- 
tation" is to utilize the functional resources of the 
stump so as to convey movement to the artificial limb. 
The name kinematic plastics, or kirieplastics, has been 
given by Vanghetti to any kind of bloodless or opera- 
tive plastics which tend to economize, restore, or sub- 
stitute muscular masses which can be employed toward 
imparting direct and voluntary movement to an arti- 



80 



MEDICAL RECORD. 



[July 13, 1918 



ficial limb. The term kinetnatisation is now applied to 
every kind of kinematic artificial limb and to the active 
and precocious mobilization of such muscles as are 
involved in kineplastic operation, while every moving 
entity obtained kineplastically is caller plastic-motor 
(motor flap). These motor flaps vary as to their num- 
ber, position, shape, and function, and in order to cor- 
respond with the object for which they are made, they 
must conform to the following requirements: they must 
possess every requisite for withstanding a firm, re- 
sisting, and painless grip, also a traction that may 
attain a high degree; they must be provided with a 
sufficient amount of functional muscular tissue to guar- 
antee the accomplishment of the task that will be de- 
manded of them. The muscles must be sought and 
obtained from among those of which the stump still 
disposes. Skin flaps, muscular insertions, various bone 
and tendinous fragments and segments of limbs, which 
would seem utterly superfluous under ordinary circum- 
stances, must be considered of the greatest value in 
view of future kineplastics, and even in the first aid 
dressing station this must be borne in mind by the 
surgeon. It is evident that the application of kine- 
matization will entail a radical upheaval of all pre- 
conceived notions regarding methods of amputation. 
Although the actual idea was conceived over twenty 
years ago, kinematisation has only been applied on a 
large scale since the beginning of the war and it is 
yet too early to render final judgment. From a con- 
sideration of his own cases, however. Professor Putti 
has come to the following conclusions: (1) The prac- 
tical results that have been obtained through kine- 
matization have shown that the hopes placed in the 
principles and methods of the modern theory of motor- 
flaps are thoroughly justified, and that kineplastics are 
entitled to be placed among the most brilliant of the 
discoveries of orthopedic surgery, deserve to be ac- 
cepted with perfect confidence, and to be tested on a 
large scale by all those whose aim it is to restore to 
the disabled man his functional activity. (2) That 
the preparation of motor flaps is a well-defined surgical 
act that must be performed in accordance with its 
own special technique, the methods of which have 
already stood the test of experience. (3) From a 
physiological point of view motor flaps are actually 
capalble of giving .both the quantity and quality of 
action determined by the muscular masses that actuate 
them. Yet, practically considered, motor flaps will be 
able to yield the full measure of theii value only if 
the artificial limb is perfectly adapted to their shape 
and their strength. (4) As the principal aim is to 
attain the vitalization of the artificial limb, it is essen- 
tial that the surgeon and the mechanic should work 
in harmony in order to solve satisfactorily this most 
interesting, if difficult, problem. 



British Medical Journal. 

June 8. 191S. 

1. The Utilization of the Muscles of a Stump to Actuate .\r- 
tifici:il I^imbs: Kineiiiiitic .\mi)Ut:itions. V. PuttL 

2 The Relation Between Heat-stroke and Malignant Ma- 
laria. Captain C. K. H. Milner. 

3. Basal Lepto-meningitis Resembling Botulism. Sydney T. 

Steward. 

4. The Early and Effective Reduction and Fixation of Gun- 

shot Fractures of the Femur. Major O. Herbert 

Williams. 
fi. .Agglutination in the Diagnosis of Dysentery. Lleut.-Col. 

C. J. Martin, Captain P. Hartley, and Sister F. E. 

Williams. 
G. I'ost-oiierative Pulmonary Kmbolism Due to the Condition 
of the Blond. A. I.apthorn Smith. 

7. Treatment of Oriental Sore. Captain W. S. Rvans. 

8. Persistent Vitelline Duet in Twins. J. R. Carratt 

9. The Treatment of Pernicious Anemia. R. Thnnu- Tlioiiie 

2. The Relation Between Heat-Stroke and Malignant 
Malaria. — Captain C. E. H. Milner suggests that heat- 
stroke as a clinical entity is non-e.\istent and that it is 
nothing more than a symptom of malignant tertian 
malaria. In Mesopotamia during the summer of 1017 
there were two formidable heat waves, one in July and 
the other in August. During the August wave a 
routine examination of blood film for the presence of 
malarial parasites was made in heat-stroke cases. In 
view of the high percentage of such cases in which the 
Laverania mnlariae was found, an intramuscular in- 
jection of 8 or 9 grains of bihydrochloride of quinine 



was administered, with the result that the mortality, 
which during July was as high as 25.65 per cent., 
dropped to 11.76 per cent, in August. This would seem 
to point to malignant malaria as being the primary 
cause of hyperpyrexial heat-stroke. Milner points out 
that it may reasonably be supposed that one of the 
symptoms of an infection with the parasite of malig- 
nant tertian malaria is the intoxication of the heat 
regulating center, and that once this apparatus i.s 
upset the body will assume as nearly as possible the 
temperature of the atmosphere. Heat stroke does not 
supervene because sweating ceases, but the patient 
ceases to perspire because he has got heat-stroke and 
is sufl'ering from paralysis of the heat regulating 
center. 

6. Post-operative Pulmonary Embolism Due to the 
Condition of the Blood. — A. Lapthorn Smith points out 
the value of drinking plenty of water and of frequent 
movement as preventatives of embolism following oper- 
ation or confinement. He believes embolism to be due 
principally to a hyperfibrinous condition of the blood. 
He therefore makes the following recommendations: 
(1) Have the full normal proportion of water in the 
blood before operating. (2) Replace by the rectum 
the amount of liquid lost by vomiting, catharsis, sweat- 
ing, hemorrhage, and urine, either during the operation 
or immedfately after it. (3) Encourage the patient to 
move the lower limbs freely, if not during the first 
two days, at least during the next ten. (4) Give the 
patient abundance of water between meals and during 
the night; it may be hot or cold, sweet, sour, or salty, 
in the form of lemonade, barley water, weak tea with- 
out milk, or beef tea ; a jug and drinking cup with 
spout should be left within reach so that it may be 
taken when wanted without waiting for the nurse to 
come. (5) Speedy operating lessens embolism, be- 
cause it means less hemorrhage, and less sweating and 
less loss of water from the system. (6) Round-pointed 
needles with flat eyes are much less likely to cause 
hemorrhage than ones with cutting edges, and should 
alone be used in the abdomen. 



Berliner klinische Wochenschrift. 

.4p)-il 22. 1918. 

Are There Any Other Bacteria Besides the I'rotous 
of the Weil-Felix Type Which Can Be Agglutinated by 
the Blood of Typhus Patients? — A. Kreuscher, start- 
ing with the supposition that the Weil-Felix reaction, 
specific in typhus fever, does not imply the attributions 
of a causal part to the Proteus X19, asks himself the 
question if other bacteria present in the digestive tract 
of the patients may not likewise be agglutinated by 
their blood. In point of fact, the writer has been able 
to cultivate an organism of the pyocyanic group, from 
the feces of a patient who died from the disease and 
found that this organism was electively agglutinated 
with the blood or typhus patients. This property was 
maintained by the organism down to the 150th genera- 
tion in cultures. The culture and staining properties 
of the bacillus were very labile and changed consider- 
ably from the effects of laboratory manipulations. 
Nevertheless, its agglutination by typhus blood re- 
mained unchanged. The writer recalls the fact that 
the X19 of Weil-F'elix. offers the same constancy in its 
biologic characters for the same variations in its bac- 
teriologic characters. 

Essays in Prophylactic Vaccination for Typhus Fever. 
— P. Neukirch draws conclusions from unfortunate 
essays undertaken by a physician who was later found 
to be insane, with a so-called prophylactic injection of 
defibrinated blood, taken from typhus patients. The 
result was that those inoculated developed the disease 
after an incubation period of about twelve days' dura- 
tion, in all seventy-six cases observed in Anatolia. The 
mortality was 25 per cent, in young and strong men. 
The injection did not give rise to any local or general 
seric phenomena. Neukirch has made essays with a 
serum derived from typhus cases, prepared by shaking 
in chloroform, at the dose of 2 c.c. given twice with 
an interval of from two to three days. Although he 
is unable to offer exact statistics, the writer was able 
to note that the subjects who received prophylactic 
injections were less apt to contract the disease than 
others. Out of a total of 300 subjects who went to 



July 13, 1918] 



MEDICAL RECORD. 



81 



an infected district and who were certainly bitten by 
lice, only twelve contracted the disease and none of 
them died. The writer recommends this procedure 
especially in cases in which the destruction of lice 
cannot be realized. 



Miinchener medizinische Wochenschrift. 

April 16. 191S. 

Radiological Examination of the Duodenum by the 
Use of a New Technique of Radioscopy and Radio- 
graphy. — Chaoul offers the following procedure wnich 
consists in radiographing the duodenum after the in- 
gestion of some opaque powder with the patient lying 
in the right ventrolateral position and exercising a 
certain amount of pressure with the ampoul and its 
tube over the part. He thus causes the pyloric por- 
tion of the duodenum to become displaced to the right 
of the spine, while at the same time the transversal 
portion is compressed between the spine and the photo- 
graphic plate. After about ten minutes in this posi- 
tion the duodenum will have become filled, when a 
radiograph can be taken which will indicate the pres- 
ence of an ulcer with the same precision as that ob- 
tained in cases of gastric ulcer. The writer in the 
present contribution relates the improvements that 
he has been able to realize in the use of his technique 
and he says that he has developed it to such an extent 
that at present he is able to follow on the screen the 
progressive filling of the duodenum and thus to select 
the proper moment for taking a permanent radiograph. 

Treatment of Erysipelas by Silver Nitrate Accord- 
ing to Gangele's Technique. — N. Gondos has tried the 
treatment advocated by Gangele (reviewed in the 
Medical Record, March 2, 1918) and comes to the con- 
clusion that it is valueless. In no instance could this 
treatment be regarded as "specific," as is maintained 
by Gangele. 



Deutsche medizinische Wochenschrift. 

April IS, 1918. 

The Nature and Treatment of Chronic Renal Affec- 
tions. — P. Volhard accepts the modern conception of 
ischemia of vascular origin as the explanation of 
Bright's disease and its manifest symptoms. This 
ischemia can be demonstrated by examination of the 
retina and microscopic examination of the skin of the 
nails (Weiss). The reason for the vascular contrac- 
tion is as yet not understood, but according to the 
writer it is a state of angiospasm. Cerebral ischemia 
and the oedema which results are the causes of the 
nervous accidents ordinarily termed "uremic." Volhard 
draws therapeutic consequences from these considera- 
tions, particularly a hunger cure of three to five days' 
duration, followed by the ingestion of 1500 c.c. of 
liquid, which brings about an upheaval, so to speak, 
of the disturbed renal junctions. A proper diet should 
be prescribed to overcome the nitrogenous retention by 
elimination of meat from the diet, likewise the elim- 
ination of salt when edema is present. In the phase 
of edema arising in Bright's disease fully developed, 
urea is alone active on the condition that it is exhib- 
ited in large doses of 50 to 60 grams, in twenty-four 
hours. 

The Preparation of Antigens for Wassermann's Re- 
action with Antiformine. — I. Freund, starting from the 
supposition that the lipoids constitute the active prin- 
ciple of the antigens extracted from the human heart 
and liver of the syphilitic poetus, the heart and liver 
of calves, etc., treats these viscera with antiformine 
which, as is known, dissolves the organized tissue and 
leaves the active lipoids intact. These lipoids can be 
taken up by the usual dissolvents and result in the 
production of more potent antigens than those now 
generally employed. 

A Painful Spot in Gastroptosis. — A. Alexander de- 
scribes a painful spot which he says is characteristic 
of gastric ptosis. It is seated below the tip of the 
sternum and topographically corresponds to the upper 
portion of the stomach. It is the result of traction on 
the vagosympathetic plexus from dropping of the 
stomach. 



Wiener medizinische Wochenschrift. 

A2iril 20, 191S. 

A Project for Medical Instruction According to a 
New Plan. — R. Stigler criticises the methods of medical 
teaching now cuiTent almost everywhere, and he quotes 
Porter and Flexner, the first of whom concludes that 
German teaching "procures information for the student 
but no knowledge." Stigler points out the utility for 
the student to participate in the intellectual work of 
the professor and this may be attained by a system of 
lectures. 

Infectious Diseases at Belgrade in 1916. — M. Poch- 
mijller offers the following statistics for the civil popu- 
lation: deaths due to infectious diseases, 3.27 per cent, 
as against 9 per cent, in 1911 and 6.29 per cent, in 1901. 
Typhoid fever represents over 25 per cent, of infectious 
diseases. The epidemics seem to be spread especially 
by contact. 

Unilateral Pyonephrosis Following a Bullet Wound 
of the Bladder. — R. Lichtenstern considers the principal 
indications in bladder wounds (1) to assure the flow of 
urine, and (2) free drainage of the wound. The end to 
be attained is the prevention of urinary infiltration. 
Cystitis is an almost constant complication of these 
wounds and among the means at our disposal for 
treating this process is irrigation with a solution of Hg. 
oxycyanide, a salt which may cause irreparable renal 
lesions. Ascending infection of the ureters and renal 
pelvis is, in normal conditions, prevented by the tonus 
of the ureteral sphincters and to uphold this supposi- 
tion, the writer relates two cases of bullet wounds 
involving the ureters, the outcome being a suppurating 
process in the kidney on the same side as the lesion. 
The ureter itself was very hyperemic. The diagnosis 
was made with the cystoscope which revealed an ab- 
normal gaping of the ureteral orifice with a free flow 
of pus. Both cases were cured by nephrectomy. 



Wiener medizinische Wochenschrift. 

April 27, 191S. 

Infectious Diseases at Belgrade in 1916. — M. Poch- 

mijller offers the following statistics particularly of 
tuberculosis and venereal diseases. Tuberculosis is re- 
sponsible for .33 per cent, of the deaths, while acute 
infectious diseases resulted in only 62 deaths out of a 
total of 1300 cases. When the writer turns to the ques- 
tion of venereal infections the kind censor blots out all 
he has to say on the question, which is still another of 
the many endeavors to conceal the fearful spread of 
syphilis in the Germano-.4ustrian armies, well known 
to the profession of neutral European countries. 

A Project of Medical Instruction According to a New 
Plan. — R. Stigler criticises the clinical teaching, prac- 
tical exercises and examinations in European faculties, 
and makes what reads like a strong bid for American 
students to come for study to Germany and Austria 
after the cessation of hostilities. 

Notes on the Etiology of Epilepsy, Particularly the 
"Epilepsy of War." — E. Redlich studies different condi- 
tions which may cause epileptic manifestations to arise. 
(l)Latent epilepsy aggravated by the war. Thus dur- 
ing the siege of Przenysl the admissions to hospitals 
for epilepsy increased 63.8 per cent. In these cases one 
could demonstrate the causative action of the war 
(privation, bombardment, etc.). (2) Epilepsy following 
upon epidemic meningitides. The writer includes under 
this head epilepsies which follow antityphoid or small- 
pox vaccinations. 

A Case of Agjnesia on the Middle Line of the Throat. 
— A. Nagy reports the case of a male patient present- 
ing a vertical fissure filled in by the deeper seated 
structures. The malformation only involved the in- 
teguments and the larynx and trachea were normally de- 
veloped and free from the defect. 



The Oil Pimples of Shell Turners.— Those occupied in 
turning explosive shells on lathes suffer from a pecu- 
liar occupation disease, an eruption of pimples due 
to accumulation of iron in the integument. This accu- 
mulation is made possible by the use of impure oil. — 
Le Progres Medicale. 



82 



MEDICAL RECORD. 



[July 13, 1918 



A Pocket Formulary. By E. Quin Thornton, M.D., 
Assistant Professor of Materia Medica in the Jeffer- 
son Medical College, Philadelphia. Eleventh Edition. 
Revised. Price, $2.00. Philadelphia and New York: 
Lea & Febiger. 
Concerning an eleventh edition there is little to be 
said. The present edition of this Formulary has been 
thoroughly revised by its author, and contributions re- 
lating to new and comparatively new remedies have 
been rewritten. It may be mentioned that the U. S. P. 
term "millimeter" has been adopted in this book to take 
the place of cubic centimeter. It is an extremely useful 
formulary. 

Materia Medica, Pharmacology, Therapeutics and 
Prescription Writing. For Students and Practi- 
tioners. By Walter A. Bastedo, Ph.G., M.D., 
Assistant Professor of Clinical Medicine, Columbia 
University. Second Edition. Price, $4.00 net. 
Philadelphia and London: W. B. Saunders Com- 
pany, 1918. 
The bulk of Bastedo's book is devoted to pharmacology 
and therapeutics. In regard to the materia medica the 
author has wisely left out many things concerning 
drugs that are of more interest to the pharmacist than 
to the physician. In pursuance of this utilitarian plan, 
stress has been laid upon remedies of proven value 
and lengthy discussions on the theories of pharmaco- 
logic action have been avoided. The book is divided 
into three parts. The first part, comprising 63 pages, 
is of an introductory character, being concerned with 
such general topics as pharmaceutic preparations, 
weights and measures, active principles, the pharma- 
copoeia, dosage, methods of administration, scope of 
treatment, etc. Part II deals with individual remedies, 
which might have been arranged in more logical order. 
Part III covers concisely the salient points of prescrip- 
tion writing. The section on digitalis in Part II is 
particularly worthy of note as representing the most 
recent ideas on the pharmacologic and therapeutic 
action of this important drug. The book as a whole 
is well written, is thoroughly up to date, and contains 
an excellent index. It is a sound treatise, especially 
useful to medical students and busy practitioners. 
The paper and printing as well as the convenient size 
all contribute to make an attractive volume. 

The Anatomy and Physiology of the Female Body. 
By Hubert E. J. Biss, M.A., M.D., Cantab., D.P.H. 
Second Edition. Plates by Georges M. Dupuy, M.D. 
Price, $2.00. New York: William Wood and Com- 
pany, 1917. 
This atlas consists of five colored plates, each con- 
taining seven or eight separate colored figures. These 
plates show clearly the skeleton, the vascular system, 
the muscles, nerves, and chief viscera. There is a 
brief but adequate account of the body and its struc- 
ture, and a detailed description of the colored plates. 
For the layman or nurse, and for purposes of teach- 
ing, this little book seems to be about as useful a work 
as can be desired. The colored plates are very clear, 
and they avoid the common error of including too 
many (unnecessary) details. 

Details of Military Medical Administration. By 
Joseph H. Ford, B.S., A.M., M.D., Colonel, Medical 
Corps, U. S. Army. With SO Illustrations. Pub- 
lished with the Approval of the Surgeon-General, 
U. S. Army. Price, $5.00. Philadelphia: Blakiston's 
Son and Co., 1918. 
This book by Colonel Ford comes in the nick of time 
and supplies exactly what is needed. The vast major- 
ity of the medical officers of our army have not been 
trained as army surgeons and consequently lack knowl- 
edge as to the proper performance of the many duties 
which fall to their lot. The administrative duties of 
the military medical officer are by no means light. 
These are set forth clearly in a lengthy chapter writ- 
ten almost wholly by Major Roy C. Hefleblower, and 
the information therein contained should prove of great 
value to the medical officer newly entering the service. 
.\s noted in the preface, the work is a compendium of 
information gathered from many sources both at home 



and abroad, but the greater part of the text pertains 
to the American army. Colonel Gorgas in a short 
introduction to the book exactly expresses its value 
when he says that its publication is specially apt and 
appropriate. With his hope that every medical officer 
in the service will furnish himself with a copy, all 
will join. The work is well arranged and excellently 
illustrated. 

Progressive Medicine. A Quarterly Digest of Ad- 
vances, Discoveries, and Improvements in the Medical 
and Surgical Sciences. Edited by Hobart Amory 
Hare, M.D., Professor of Therapeutics, Materia 
Medica and Diagnosis in the Jefferson Medical Col- 
lege, Philadelphia, assisted by Leighton F. Apple- 
man, M.D., Instructor in Therapeutics, Jefferson 
Medical College, Philadelphia. March 1, 1918. Price, 
$6.00 per annum. Philadelphia and New York: Lea 
& Febiger. 
The March number of Progressive Medicine contains 
chapters on Surgery of the head, neck, and breast by 
C. H. Frazier; Surgery of the thorax, excluding dis- 
eases of the breast, by G. P. Miiller; Infectious dis- 
eases, including acute rheumatism, croupous pneu- 
monia, and influenza, by J. RUhrah; Diseases of chil- 
dren, by F. M. Crandall, and Rhinology, larjTigology, 
and otology by G. M. Coates. The present instalment 
is rather smaller than usual, but whether this is due 
to lack of material or to scarcity of paper we are 
unable to say. The contents are as interesting and 
valuable as usual, and the two first articles are par- 
ticularly welcome, containing, as they do, sections deal- 
ing with war surgery. 

Localisation et Extraction des Projectiles. Par 
L'Ombredanne et R. Ledoux-Lebard. Deuxieme edi- 
tion remaniee. Collection Horizon. Prix, 4 francs. 
Paris: Masson et Cie., 1918. 
The first edition of this volume was reviewed in these 
columns. There is no separate preface to the second 
edition and a comparison shows that it is an abridg- 
ment of the first, with a decrease of forty-four pages 
and twenty-seven cuts. As the number and titles of 
the chapters are the same the authors have evidently 
given the book a uniform downward revision. As no 
new matter has been added the present volume can 
hardly be regarded as a true successor to the first. 

Tropical Diseases. A Manual of the Diseases of 
Warm Climates. By Sir P.4TRICK Manson, G.C.M.G., 
M.D., LL.D. (Aberd.) Fellow of the Royal College 
of Physicians, London; Fellow of the Royal Society; 
Hon. D.Sc. Oxon. ; Foreign Associate of the Academic 
de Medicine, France; Honorary Member of the So- 
ciete de Medicine de Gand ; Hon. Associate of the 
Royal Academy of Medicine, Turin; Consulting 
Physician to the Seamen's Hospital Society; Lecturer 
in the London School of Tropical Medicine; late 
Medical Ad\-iser to the Colonial Office and to the 
Crown Agent for the Colonies, etc., etc. With 12 
Color and 4 Black-and-White Plates and 254 Figures 
in the Text. Si-xth Edition, Revised throughout and 
Enlarged. Price $6. New York: William Wood and 
Company, 1918. 
A NEW edition of this standard work is always welcome. 
In addition to the new material necessitated by the re- 
cent advances in tropical medicine, the book has been 
thoroughly revised. Dengue is shown to be conveyed 
by the Stegomyia calopus; the chapters on mosquitos 
and the articles on tse-tse flies and ticks have been 
brought up to date; and some of the chapters have been 
rearranged or reclassified. The book remains the best 
practical and clinical manual on the subject of Tropical 
Medicine. The chapters on those topics with which Sir 
Patrick Manson's name is chiefly associated are the 
longest and most important in the volume. An entirely 
new section is included, containing a chapter on the 
vomiting sickness of Jamaica. This is, we believe, 
the first time that a description of this disease is to 
be found in any volume on the practice of medicine. 
There are a few misprints in this chapter; the disease 
is known in the island as ackcc poisoning, not acktrs 
poisoning; and the ackee is the fruit of the Dli<ihia 
sapida, not BUg)n sapida. The volume concludes with 
an appendix on some of the commoner parasitic pro- 
tozoa of vertebrates and invertebrates. 



July 13, 1918] 



-MEDICAL RECORD. 



83 



§>atwt\\ sports. 



AMERICAN ASSOCIATION OF IMMUNOLOGISTS. 

Annual Meeting, Held March 29 and 30, 1918. 

John A. Kolmer, M.D., of Philadelphia, Pkesipent. 

{Concluded from ^'ol. 93, page 880.) 

A Method of Preparing Bacterial Antigens. — Lieut. 
J. C. Small, U. S. Army, presented this communication. 
This work was based on the fact that fat-like sub- 
stances occurring- in the bacterial cell greatly inter- 
fered in the aqueous solutions of bacteria. No entirely 
satisfactory method for extraction of bacteria had been 
accomplished. All methods were directed toward dis- 
integration of the bacterial cell, with the idea of ex- 
tracting the fragments, but this would be better ac- 
complished if the fat and liquid constituents of the cell 
could be removed. In the present method a chloroform- 
ether mixture was used to extract the fat-like sub- 
stances from dried bacteria. The residue was sus- 
pended in normal salt solution. The chloroform-ether 
extraction was found to break up the integrity of the 
bacterial cell, so as to facilitate its more ready ex- 
traction by aqueous solution. 

Mr. Charles Weiss of Philadelphia said that the 
idea of removing the lipoid constituents was not an en- 
tirely new one. Some workers did not find it necessary 
to extract the lipoid; in some laboratories the custom is 
prevalent. Had the doctor checked up his results and 
found that they were different with removal of the 
lipoid to what they were without this procedure? In 
regard to heating of antigen, it was found in working 
with streptococcus antigen that heating destroyed the 
anticomplementary qualities. 

Dr. J. A. Kolmer said that with regard to heating 
immune sera at 62° C. he thought there was deteriora- 
tion of specific antibodies present in the serum. This 
was, however, difficult to measure, as it was hard to 
differentiate specific from non-specific factors. Ob- 
servations had shown inhibition of bacterial antigen. 
It might be anticomplementary. It would possess the 
greatest degree of antigenic sensitization after heating 
at 60" C. for 1 hour. Higher temperatures were not 
used. 

Miss M. A. Wilson of New York said that their ex- 
perience had been that there was no deterioration. 
They did not add preservative to the antigen. It 
would depend to some degree upon the sera against 
which it was titrated. That serum might not be com- 
parable at a later date, but the complement had the 
same fixation value at the time of testing. One could 
not say that heating inhibited. 

Dr. H. Von Wedel of New York said that he had 
used tubercle bacilli antigen and had heated it five or 
six times at intervals, and the value remained, as far 
as he could tell, exactly the same. 

Dr. G. H. A. Clowes of Buffalo said if the alkaloids 
were entirely removed the temperature could be raised 
considerably without causing any effect. 

Lieut. Small said he had noticed the non-specific 
factors in a large series of animals which they were 
running for typhoid vaccines. Immunization was being 
carried on and complement fixations and a very large 
percentage of animals showed non-specificity. Sera, 
with the exception of para-A, did not show anticomple- 
mentary effect. In regard to checking up results, by 
using whole antigen, there was one dilution of typhoid 
antigen with lipoid removed, which when mixed with 
lipoid, would not give fixation. 

Study of the Complement Fixation Reaction to Tuber- 
culosis.— Miss M. A. Wilson of the New York City 
Health Department Research Laboratory presented 
this paper. Two points had been found to increase the 
efficiency of the test. First, standardization of the 
g:uinea-pig serum to determine the value of the comple- 
ment; second, testing the patient's blood several days 
after bleeding. In making the test all reagents were 
used in 1/10 the classic Wassermann volumes. Fixation 
period, 1 hour at 37° C. The patient's serum was in- 
activated for 30 minutes at 56° C. Two antigens were 
used. One made from 12 stock cultures of human 
tubercle bacilli, the other from strain No. 305, used 



for production of tuberculin. When prepared the anti- 
gen was standardized to such dilution that 1 c.c. would 
contain 2 standard fixation units. The antigen was 
found not to be anticomplementary and gave uniform 
reactions. The complement was guinea-pig's serum, 
pooled from 6 to 10 pigs. This was done because many 
guinea-pigs do not produce serum which is fixable by 
tuberculosis antigsn. It was found that if in the pool 
of 6 to 10 complements thei-e were several strongly 
fixable, the presence of negative complements did not 
greatly affect the test; a preponderance of negative 
complements, however, would affect a true reaction to 
the patient's serum. The variability in fixability of 
guinea-pig serum was illustrated by tables. 

Dr. H. Von Wedel of New York supplied a paper 
representing the continuation of Miss Wilson's work. 
Briefly stated, his conclusions were: first, the tubercle 
bacillus antigen used was not anticomplementary for the 
majority of active tuberculosis cases; second, pooled 
complement from 6 or more guinea-pigs should be 
used in making the tests; third, double the original 
Wassermann amount of patient's .serum should be used; 
fourth, sera should be kept under sterile conditions in 
the ice chest for 6 days before making the report. 
This six-day interval was necessary to the proper read- 
ing of the test. Fifth, if these points in technique were 
observed, it was found that 100 per cent, of non- 
tuberculous cases gave negative reactions; nearly 100 
per cent, of primary active cases gave positive results 
(exsepting dying cases) ; and about 25 per cent, of in- 
active cases gave weak positive results. Further study 
was needed on inactive and incipient cases, with con- 
trolled sera from non-tuberculous cases, in order to 
complete this work. 

Dr. G. H. A. Clowes of Buffalo said that in working 
on cancer cases and also syphilitic cases, reported 8 
years ago, he had attributed the development of in- 
crease of complement deviation to the change in col- 
loidal particles, due to being held in the ice box for a 
given period. He wished to ask what was the tempera- 
ture of the ice box. Was the serum frozen? 

Dr. Von Wedel said that the ice box probably had 
a fluctuating temperature; it was more to keep the 
complement sterile, not to keep it cold. 

Dr. Paul Lewis of Philadelphia said he had been 
much interested and instructed by these papers. The 
results should be valuable from a diagnostic point of 
view. He could add some data from his own experi- 
ence from work done some years ago. At first he used 
bacterial suspensions of autolysate which, he found, 
lost rapidly in anticomplementary effect. Testing with 
the same serum day after day, it was found that one 
never got the same results on two days running. He 
thought the reaction was weak, and began using strong 
sera, at half an hour. He found one could get stronger 
fixations up to 6 or 8 hours. It was found that the 
complement could be put in the ice box and warmed up 
next morning, but it was necessary to carry controls 
always. The fixation power was titrated against the 
amount of complement which could be fixed, and such 
sera would give 4 + after 2 hours' fixation. It would 
fix 15/100 to 0.2 c.c. of guinea-pig complement. It was 
found that serum could be preserved in glycerin. It 
was probable that it increased in activity for a certain 
time. Guinea-pig complement was found to vary very 
much in its activity. If the animals were etherized, 
the serum must be left in the air till the ether evap- 
orated. Complements could be incubated 4 hours, after 
that there was deterioration. Alcohol was used to 
avoid anticomplementary reaction. 

Dr. Wm. H. Park said that he felt that this work 
should be used for primary cases, and later on they 
would be in a position to use it for a diagnostic basis. 

Dr. J. A. Kolmer of Philadelphia asked if the 
peculiarities of the sera, that is the development of 
fixation properties, were found in the Wassermann and 
gonococcus complement fixation tests. He believed that 
the sera would be of more use in the gonococcus test 
than with T. B. 

Miss M. Olmstead of New York asked if the guinea- 
pigs which gave fixability with the tuberculosis anti- 
gen also gave fixability for the gonococcus antigen. 
How many specimens giving positive gonococcus re- 
sults, were used for the tuberculosis tests. 



84 



MEDICAL RECORD. 



[July 13, 1918 



Miss M. Wilson said tliat they killed ten pigs; ten 
were fixable for meningococcus; four for gonococcus; 
one for tuberculosis. 

Dr. Von Wedel said that there was absolutely no 
non-specific fixation. Every case that was negative 
clinically gave a negative reaction. The test was used 
day after day, and no change was detected in the serum. 
The antigen was heated from 50° to 60' C. for half 
an hour, and there were no antecomplementary re- 
sults. 

Dr. A. F. Coca said that if this work had any value 
it was bound to be practical, the value was not on the 
experimental side. It appeared to have the weakness 
of the Wassermann test, and of tumor reactions; — 
the question was not had the man a tumor, because 
the tumor can be felt, but "is it a malignant tumor?" 
This reaction, it was said, was found only in tubercu- 
losis, so that if it was positive, the individual had had 
tuberculosis. The question "has the man ever had 
tuberculosis" was not so important as "in what stage 
is the tuberculosis?" That is, one wanted to know, 
whether the disease was progressing. The test did 
not show that. It could not be said as yet that it had 
great clinical value. 

Dr. J. A. KOLMER said the antigen seemed to be free 
of antisyphilitic complement. In his experience with 
Miller's antigen, he found it gave some degree of 
fixation to the sera of syphilitics. 

Dr. H. Von Wedel said that no negative cases gave 
a four plus. No one would consider that a one plus 
Wassermann constituted syphilis. A strong positive 
was necessary. This was seen in the primary and 
secondary stages. 

A Study of Controlled Post-mortem Wassermann 
Reactions. — Dr. Stuart Graves of Louisville, Ky., read 
this paper. In sixty-eight cases studied he found that 
post-mortem reactions confirmed ante-mortem Was- 
sermann reactions in 97 per cent, of cases. In cases 
showing anatomic lesions of syphilis, or with histories 
of syphilis, the sera post-mortem was positive in 91.2 
per cent, of cases. Only 2.5 per cent, of sera were found 
unfit for use. Only 2.6 per cent, of three hundred and 
seventy-eight cases showing anatomic evidence of syphi- 
lis gave negative Wassermanns. Reactions were found 
to conform to historic evidence in 80.4 per cent, of 
three hundred and seventy-eight cases. No reason was 
found to suppose that other acute conditions caused a 
positive Wassermann reaction. The positive reaction 
was found twice as much in negroes as whites. The 
final conclusion was that one post-mortem Wassermann 
reaction was practically as reliable a test for syphilis 
as when done ante-mortem, and was of great value in 
pathological anatomy and in medico legal cases. 

Dr. J. A. Kolmer said that he wished to endorse all 
that Dr. Graves had said. It coincided entirely with 
his own experience. He was familiar with the rec- 
ords just described. He thought it was particularly 
unfortunate that reports should be published, and 
should reach the general practitioner, which denied 
the practical value of the Wassermann reaction. No 
one who had dealt with pathological findings would 
deny that a pathologist cannot exclude syphilis on 
the basis of these findings alone. Spirochetes might 
not produce much reaction, yet they would produce 
antibodies, which would be indicated by the Wasser- 
mann reaction. In the last four or five years so much 
had been learned of the technique of the Wassermann 
reaction that one must agree that it was a test of great 
diagnostic value. While they must welcome attempts 
to point out sources of error, criticisms must be care- 
fully controlled. 

Miss M. Olmstbl/vd of New York said that she was 
glad to hear Dr. Graves' statements. It had always 
been her impression that post-mortem Wassermann 
would bear out the ante-morten findings, but she had 
not as yet the figures to prove this point. 

Election of Officers: President, Dr. William H. Park; 
Sec7-etary and Treasurer, Dr. Arthur F. Coca; Cnini- 
cil, Dr. George McCoy, to fill the term of Dr. Weil; 
Dr. Rufus Cole, to fill the vacancy left by resignation 
of Dr. W. J. Stone. 

Observations on the Intraspinal Autosalvarsanized 
Serum Therapy of Cerebrospinal Syphilis. — Dr. Ben- 
jamin A. Thomas read this paper. Cases of tabes 
were found, he stated, that did not respond to treat- 



ment. The spinal fluid sometimes gave a positive 
Wassermann reaction, when the blood was negative. 
In four years' experience the author said he had used 
autosalvarsanized serum. Intraspinous injection was 
given after intravenous injection, under careful sterile 
technique. An amount of spinal fluid was removed equal 
to the amount injected. The foot of the bed was raised 
after treatment. The treatment was continued till the 
spinal fluid was permanently negative. If improvement 
was found to follow intensive intravenous treatment, 
the intraspinal injections were not used. Degenera- 
tion of the cord was not affected by intraspinous 
treatment. Vascular cases were found to respond bet- 
ter to intravenous treatment alone. 

Dr. H. Abrahamson of New York asked was whole 
serum used, or was it diluted with salt solution. 

Dr. J. A. KOL.MER said that at the Philadelphia 
Polyclinic they had a large number of cases of syphilis 
under Dr. Schamberg's care. A number of intraspin- 
ous injections were given. They believed that some- 
thing could be gained by salvarsanizing the serum in 
vitro after Ogilvie's method. 

Dr. B. A. Thomas said they had diluted neither 
serum nor spinal fluid. He thought that was an 
open question. He did not put the patient to the or- 
deal of intraspinous injection, if he could avoid it. 

Experiments upon the Passive Transfer of Antibodies 
to the Cerebrospinal Fluid. — Drs. John A. Kolmer and 
S. Sekiguchi of Philadelphia gave this paper, read 
by Dr. Kolmer. The summary of their work stated : 
The removal of blood from normal dogs, followed by 
intravenous injection of human syphilitic serum (30-50 
c.c. per kilo body weight) , caused small amounts of 
syphilis reagin in the cerebrospinal fluid. This reagin 
was found in the fluid as early as three hours after 
the transfusion of syphilitic serum. The amount of 
reagin found was small. After irritation of the 
meninges by sterile horse serum, more reagin was 
found in the cerebrospinal fluid. All traces of reagin 
disappeared from the cerebrospinal fluid of the dogs 
within forty-eight hours. Dog-typhoid immune serum, 
injected into a normal dog, intravenously, caused traces 
of agglutinin to appear in the cerebrospinal fluid 
within three hours; it disappeai'ed within forty-eight 
hours. It was thus shown that the passage of anti- 
body fi'om the blood to the cerebrospinal fluid was 
possible, when the antibody existed in the blood in 
high concentration. In human syphilis the reagin 
might pass from the blood, but its presence in the 
spinal fluid generally indicated the presence and ac- 
tivity of Treponema pallidum in the nervous organs. 

Dr. A. P. Kitchens said that the question whether 
the antibodies would find their way from the blood to 
the spinal fluid was important, especially in cerebro- 
spinal fever. In severe cases of meningitis in the 
army camps they gave intravenous doses as well as 
intraspinal of the antimeningitis serum. Results of 
the treatment were encouraging. Dr. Kolmer's work 
would show that this line of treatment was of value. 

Dr. J. Bronfenbrenner said it was a question as 
to whether bodies could pass from the blood into the 
spinal canal. He doubted whether this was possible 
when the pressure was higher in the spinal canal than 
in the blood. English workers had concluded that 
there was a toxin produced by the meningococcus and 
that this toxin was forced from the spinal canal into 
the blood stream. If this contained antitoxin it would 
get into the serum and the improvement would be 
due to that. Dr. Kitchens said about every eight hours 
during the severe part of the disease the spinal fluid 
was removed, and with the rapid filling up of the 
canal again there might be some effect. 

Dr. J. F. Kolmer said that the paper simply dealt 
with the passage of antibody from the blood to the 
spinal fluid under normal conditions. In the experi- 
mental animal there was a large amount of antibody in 
the circulation. He could not agree with Dr. Bron- 
fenbrenner's remarks on the spinal fluid. This is a 
secretion of the choroid plexus, at least during health. 
Even when the fluid is high, production continues and 
increases hydrocephalus. Evidence would prove that 
the fluid is produced continuously even after rise of 
pressure. 

Vaccine Dosage. — Dr. Joseph Head of Philadelphia 
read this paper. He stated that in former times he 



July 13, 1918] 



MEDICAL RECORD. 



85 



had been in the habit of giving large doses (as much 
as eleven hundred million) of mixed germs, and in 
90 per cent, of cases he used to get good results. He 
had found, however, that some patients got undesir- 
able sjniiptoms with a dose as low as thirty thousand, 
and he had proved that the tolerance of some patients 
should be carefully ascertained. He thought it was 
better to keep the injection below the point of getting 
reactions. He now began with small doses, which, if 
borne well, were increased. Reactions were of various 
types, and sore throat and colds were often typical 
reactions. A dose just short of a reaction gave the 
best final result. 

Dr. A. P. HiTCHENS said it was necessary to have 
followed Dr. Head's work to appreciate the enormous 
amount of experience that he had brought to bear. 
Vaccine therapy was an instrument which had to be 
carefully studied in order to be used with confidence. 
Dr. Head had been the acknowledged leader in such 
work for many years. Dr. Hitchens had never used 
such small doses, but Dr. Head's experience made him 
think seriously of it. 

Dr. J. A. KoLMER said if it was anyone else than 
Dr. Head he would raise a point of issue, but results 
could guide one here, rather than theory. Dr. Head's 
results were comparable with the use of tuberculin in 
tuberculosis. Large doses would produce rapid tissue 
destruction. 

Dr. Head said that no one had been more surprised 
in finding out these facts than he had been himself. 
He had found that small doses had greater thera- 
peutic effect. They apparently acted in a diflPerent way. 
Perhaps later he would have a theory to explain it. 
Vaccine Treatment of Acne, with Special Reference 
to the Role of B. Coli. — Drs. A. Strickler and J. F. 
ScHAMBERG of Philadelphia presented this communi- 
cation. Thousands of cases of this disease, it was 
stated, never came to the physician at all, it was only 
when suffering from severe forms with great disfigure- 
ment, that the patients sought advice. The lesions 
were chiefly in the sebacious oil glands which were 
very active at puberty. Puberty was, in fact, the 
primary predisposing cause. Anemia and constipation 
were found to be pretty constant accompaniments to 
acne. It often developed after typhoid fever, and 
intestinal intoxication evidently played a role in the 
etiology. In the treatment of acne by vaccines, it 
was found there was a complement fixation in 63 per 
cent, of cases from an antigen prepared from colon 
bacillus isolated from the intestinal tract of the pati- 
ent. The fixation was higher when the antigen was 
from the patient. It was resolved to treat fifty cases 
with no other means than by vaccines prepared from 
an autogenous colon bacillus. These cases were con- 
trolled by cases treated by other methods,— vaccines 
from other germs, therapeutic and hygienic measures. 
The B. coli vaccines were found to possess better cura- 
tive effects than any other mode of treatment. 

Dr. J. F. SCHAMBERG Said he would like to emphasize 
one or two points. Vaccines prepai-ed from B. acne and 
from staphylococci had been used for many years, and 
in some cases had given brilliant results, in others 
they had failed to respond. The present experiments 
were tested out in a hospital clinic with a large num- 
ber of patients. Sixty-three per cent, gave positive 
complement fixation to the strains of B. coli used for 
the vaccines. A large percentage of patients re- 
sponded to a remarkable degree. It was likely that at 
puberty, when there was gi'eat developmental activity, 
that there was liability to infection from the intestinal 
tract. The activity of the intestinal organisms would 
then produce noxious effects. The complement fixa- 
tion tests would incriminate especially the colon bacil- 
lus. 

Dr. A. F. Hitchens said it would be an important 
point to find out which strain of the B. coli was the 
important factor in producing the disease. Had any 
work been done on the sera in this respect? 

Dr. A. Strichler said that, personally, now he wel- 
comed an active case as he felt that a good deal could 
be done for the patient. Formerly he had rather 
dreaded to see such a patient come, as the results of 
treatment were so often disappointing. 

Dr. F. J. Schamberg said that no attemnt had been 
made, as yet, to differentiate strains. The comple- 



ment fixation test showed that there was great speci- 
ficity to the B. coli from active cases. 

Lipovaccines. — Lieut E. Fennel, M. C, U. S. A., read 
this paper, the result of his work with Col. E. R. 
Whitmore. The advantages of lipovaccines were 
stated : — Autolysis was reduced to a minimum, absorp- 
tion was slower; the reaction was far less in sensi- 
tized persons. If oil were used as a vehicle, the en- 
tire amount could be given at one dose, and the 
reaction could be lessened. These latter points 
made this method a very desirable one for army pro- 
cedures. Experiments were, therefore, begun on" triple 
tj'phoid vaccines; triple dysentery; pneumococcus, and 
a meningococcus lipovaccine. It was found, after sev- 
eral series of tests, both on men and animals that these 
conclusions were justified: (1) the lipoid vehicle 
markedly reduces the toxicity of otherwise toxic 
strains; (2) vaccination against vacillary dysentery is 
entirely practicable; (3) a high-grade immunity is 
stimulated. 

Dr. A. P. Hitchens said that this plan for the 
preparation of bacterial vaccines was likely to be of 
immense value. If one could give the entire treatment 
in one day, the economic value was obvious. At Camp 
Beauregard he saw a detachment injected with menin- 
gitis lipovaccines; the reactions were vei-y severe, as 
were also those from triple typhoid vaccine. The men- 
ingitis vaccine caused severe headache and insomnia. 
.411 the sjTiiptoms disappeared next day. He felt great 
confidence in the outcome of the work of Lieutenant 
Fennel. 

Lieutenant Fennel said there was a very severe re- 
action to the first vaccine they used. Since the im- 
provement in technique the severity of the reaction was 
absent. 

A Study of the Immunizing Properties of Bacterial 
Vaccines, Prepared After Various Methods. — Mr. M. W. 
Perry, Dr. John A. Kolmer and Miss S. Levy of 
Philadelphia presented this communication. Both 

specific and nonspecific effects of bacterial vaccines 
were considei-ed, the former being the production of 
specific antibodies, as agglutinins and lysins for the 
bacterial protein; the latter being the temperature, the 
leucocytic response, the mobilization of ferments, and 
other phenomena. The experiments were conducted to 
test the antibody response to each, as well as the non- 
specific phenomena. Rabbits were used, and the dos- 
age was calculated per body weight of the animal. 
The vaccines used were: (1) Autolysates; (2) heat 
killed vaccine; (3) Tricresol killed vaccine; (4) mer- 
curophen killed vaccine; (5) living vaccine, freshly 
prepared; (6) alcohol killed sensitized vaccine. The 
conclusions were: I. All'vaccines of B. typhosus, pre- 
pared in various ways, usually produced slight leu- 
cocytosis and slight rise of temperature, when injected 
subcutaneously into rabbits, in dosage comparable to 
those given to persons. These nonspecific reactions 
were most marked to alcohol killed sensitized vac- 
cines. II. Agglutinin and complement fixing antibody 
production was most marked in response to injection 
of living and autolysed vaccines; next came in order: 
mercurophen killed, tricresol killed, heat killed, alco- 
hol killed sensitized vaccines. III. While agglutina- 
tion and complement fixation reactions showed some 
tendency towards specificity for their particular B. 
typhosus antigen, this specificity was not marked. IV. 
An antigen of B. typhosus, prepared by cultivating 
the organism in plain neutral broth for forty-eight 
hours, plus 0.1 per cent, commercial formalin, ster- 
ilized in a cold, dark place for four days, was the best 
for the macroscopic agglutination test. The various 
vaccines of B. typhosus were arranged as follows in 
order of antigenic sensitiveness: living and autolysed; 
mercurophen killed, tricresol killed; alcohol killed; and 
heat killed. The last was least antigenic. 

Lieut. E. Fennel asked Mr. Perry if he titrated the 
agglutinable culture by the standard set by Oxford. 
If so, the results would be of considerable value for 
the army work. 

Dr. J. A. Kolmer said the culture was secured from 
a German University, sixteen years ago, and was 
standardized for agglutination work. It was highly 
susceptible to agglutination. It was not standardized 
by the Oxford method. 

Dr. A. P. Hitchens said that the number of prob- 



86 



MEDICAL RECORD. 



[July 13, 1918 



lems in connection with vaccines had discouraged many 
in their use. There was no doubt, however, of their 
prophylactic efficiency, as in the case of typhoid. As 
to methods of killing bacteria, heat, and also tricresol 
were efficient. Possibly there would be some other 
method found to make a rapid production of anti- 
bodies. One could produce enormous amount of ag- 
glutinins, but when it came to treatment there were 
many variable factors. The problems, however, must 
be attacked, or they would never get anywhere. 



MEDICAL SOCIETY OF THE STATE OF NEW 

YORK. 

One Hundred and Ttvelfth Annual Meeting Held at 

Albany, May 21, 22, arid 23, 1918. 

(Continued from Vol. 93, page 968.) 

SECTION ON MEDICINE. 

Etiology of Nephritis. — Dr. Charles Jack Hunt of 
Clifton Springs, presented a study of 342 cases of 
nephritis, 60 of which were studied by the methods 
outlined by the author. Of these 60, 47 were sub- 
mitted to corrective and dietetic measures as advised 
and were subsequently restudied. The longest period 
of observation was two years and the shortest 26 days, 
following corrective measures. Correspondence with 
the home physicians of the group secured replies from 
the majority of them or from the patients, and in a 
few instances from both. Of the 23 cases uncorrected, 
3 had died from nephritis, 16 reported advance of the 
disease or no improvement; 4 were not noted. Of 47 
ca.ses submitting to corrective measures, 9 had not been 
noted, 6 reported little or no change, and 30 much im- 
proved or apparently as good as ever. The latter quo- 
tation "much improved" appeared frequently enough to 
be used as a general statement. Culture study showed 
the streptococcus mucosus as the principal pathology. 
Other bacterial forms, in the order of frequency, were 
a diphtheroid organism, bacillus mitis, streptococcus 
candidus, streptococcus viridans, and pneumococcus, of 
47 cases restudied. Thirty-six were reported prior to 
the presentation of the paper. Of these 30 were im- 
proved and had resumed normal modes of living. Of 
23 cases not corrected, 19 were reported, 3 having died. 
and 16 showing advance of the disease. 

Dr. Charles G. Stockton of Buffalo stated that he 
did not know just how carefully or how radically the 
essayist classified his cases of nephritis, but it did not 
seem to make very much difference because as these 
cases were seen they were either primarily from in- 
fection alone or from a mixture of infection and meta- 
bolic defect, and in the management of all cases it was 
up to the practitioner to get rid of infection and cor- 
rect the metabolic defect. 

The Diagnosis of Nephritis. — Dr. Albb3ST A. Epstein 
of New York City stated that on the basis of our 
present knowledge a diagnosis of nephritis was con- 
fronted with two distinct problems. First, the de- 
termination of the pathological processes involved; and 
secondly, the evaluation of the kidney function. An 
accurate diagnosis of nephritis therefore entailed a 
circumspect and complete analysis of all the morbid 
conditions present; the probablp etiological factors in- 
volved, the disturbance in functions and other dis- 
orders which arose therefrom. To regard nephritis as 
an independent condition was a fallacy. The existence 
of acute nephritis, excepting, of course, the chemical 
nephritides and the types occurring in pregnancy, 
pointed usually to an antecedent infection. But renal 
disorders with urinary signs frequently occurred in 
febrile diseases of all kinds, which did not represent 
true nephritis, and thus the problem of differentiat'on 
often arose. In the matter of chronic nephritis, the 
problem of etiology as a source of information was 
much more difficult. No doubt in a certain number of 
cases a history of acute nephritis or recurring infec- 
tions might be elicited, and a diagnosis made, but the 
connection betAveen the two was not always clear. 
Chronic poisoning, tuberculosis, and syphilis might be 
contributorj' factors and required consideration in the 
diagnosis. There was one difficulty that presented it- 
self from the clinical side in investigating the question 
of the connection between acute, subacute, and chronic 
nephritis, and that was, that acute and subacute nephri- 



tis might appear without the development of symptoms 
other than the urinary signs during any infection. 
Furthermore, in the chronic nephropathies it was the 
possibility and the frequent occurrence of compensatory 
processes that created difficulty in arriving at a diag- 
nosis. This was particularly true when the question 
was viewed from the functional standpoint. In the 
application of functional tests in the diagnosis of 
nephritis, two points should be borne in mind, namely, 
that a number of the different functional tests should 
be made and that they should be repeated in each and 
every case. As a prerequisite to the proper inter- 
pretation of the results obtained by functional tests, 
extrarenal factors which were capable of modifying or 
influencing them should be definitely excluded. 

Pathology of Nephritis.— Dr. Herbert U. Willia.ms 
of Buffalo stated that the pathology of nephritis was 
in a rather confused state. Efforts were now being 
made to connect the diseased conditions that were 
found and their structures with the causes of these 
diseased conditions on the one hand, and, on the 
other hand, to connect these diseased conditions with 
changes in substance. The chronic form of glomerular 
nephritis was by many held to be identical with chronic 
interstitial nephritis. There was great difficulty in sepa- 
rating these from the arteriosclerotic kidney, which re- 
sembled it closely in many cases. As a matter of fact, it 
was exceedingly difficult to draw a hard and fast line be- 
tween the different types of nephritis not only clinically 
but anatomically. To be perfectly safe one should 
call every case of nephritis diffuse pretty nearly always. 
In recent years there was a tendency to attribute 
the granular contracted kidney to earlier attacks of 
glomerular nephritis. The formation of new fibrous 
tissue in a kidney leading to chronic interstitial nephri- 
tis seemed more and more to be attributed to the forma- 
tion of fibrous tissue in response to a loss of substance 
rather than as a result of irritation. We were not 
able at the present time to connect the pathological 
anatomy very closely with changes in function. 
The classification of nephritis into glomerular, tubular, 
the late glomerular, the chronic interstitial and the 
arteriosclerotic was quite generally adopted, and the 
most interesting point was that of determining the 
relation of focal infection to glomerular nephritis by 
finding it was actually caused by bacterial emboli and 
not entirely through the agency of toxins. Finally, a 
number of authorities were of the opinion that granu- 
lar contracted kidney was closely connected with the 
arteriosclerotic kidney, and hard to tell from the latter. 
He quoted Mallory as saying that a patient who re- 
covered from his toxemia and from his acute attack 
might suffer almost equally from the reparative changes 
which occurred in the kidney. 

Treatment of Chronic Nephritis. — Dr. JOHN R. Wil- 
liams of Rochester stated that the most common type 
of kidney disease seen was that of the middle aged adult 
who complained of some or all of the following symp- 
toms: tiring easily, occipital headache, shortness of 
breath, high blood pressure, and little or no physical 
evidence of kidney disturbance except frequent and ex- 
cessive urination at night. The blood was commonly 
low in urea, creatinin and phosphates, the blood sugar 
might be high. Edema was usually not present. Death 
was rarely caused by uremia, rather by cerebral hemor- 
rhage or failing heart. This was the well known cardi- 
orenal type. The next most frequently seen type was 
the middle aged or even younger adult who might have 
pronounced eye symptoms, edema, low or high blood 
pressure, very little kidney reserve, urine loaded with 
albumin and casts, blood containing two or three times 
the normal amount of urine, a high blood sugar, in- 
creased blood creatinin and phosphate retention. 
Death was commonly preceded by convulsions and the 
phenomena of uremia. The last and much less fre- 
quently seen type was that of the young or middle aged 
adult who complained chiefly of edema, weakness, pal- 
lor, and not albuminuria, blood urea, and sugar would 
be found low, perhaps lower than normal. The chole- 
sterin content of the blood might be greatly increased : 
edema might or might not be influenced by the salt 
content of the diet. The functional capacity of the 
kidney was fairly normal to the usual clinical tests. 
The patient suffered very little headache or from other 
symptoms commonly seen in kidney failure. The first 



i 



July 13, 1918] 



MEDICAL RECORD. 



87 



and one of the most important steps in the treatment 
of any type of kidney disease was to rid the body of all 
focal infections. The matter of investigating sus- 
picious tonsils, crowned teeth and diseased prostates 
could not be overemphasized. In the treatment of the 
cardiorenal type if one had made sure that the patient 
was not harboring infection, the most important meas- 
ure was rest, both mental and physical. If the patient 
had a good functional kidney capacity he should be put 
on a low general simple diet. All chemical irritants 
in the way of spices, mineral acids, alcohol, and foods 
containing quantities of animal extractions, bacteria 
and bacterial products .should be excluded from the 
diet. The patient should be allowed to have some meat 
and eggs. The second clinical tjTJe demanded quite a 
different therapeutic regime than did the card;orenal 
type. In severe cases the best internal measure was to 
put the patient at rest and give him a limited milk and 
Huid diet as first suggested by Karell. The author pre- 
scribed for the first few days one quart of milk, one 
pint of water, and either another pint of lime water 
or some salt of calcium, either the carbonate or lactate 
in half gram doses several times daily. The tincture 
of iron or ferrous carbonate in liberal doses was also 
given. In the third and last common type of chronic 
kidney disease the diet should be more liberal and 
should contain a large amount of protein. As many as 
8 to 10 ounces of meat may be very helpful. Fluids 
should be restricted. If there was evidence of salt re- 
tention its use should be curtailed, otherwise it might 
be sparingly permitted. 

The Clinical Significance of Congenital .\noniaIies 
of the Kidney and Ureter. — Drs. Joseph R. Losee and 
Henry G. Bugbee of New York City described the de- 
velopment of the organs of the upper urinary tract in 
the human and traced their relationship to various 
anomalies. Among the 22 cases of anomalies reported 
by the authors were one case ct single kidney, one case 
of calculus obstruction of the ureter, three cases of 
horseshoe kidney, one case of fused kidney, one case 
of duplication of the kidney pelvis, and one case of in- 
complete duplication of the right kidney pelvis, and 
colon bacillus infection. Cases of anomalies of posi- 
tion of the kidney were reported. In one case the 
right kidney was low and had not rotated. In another 
case the kidney had migrated to the opposite side. 
Cases of anomalies of the ureters were reported. The 
surgical treatment consisted in relieving pressure, 
placing the kidneys in their normal position, removing 
any obstruction to renal drainage, removing the dis- 
eased kidney when destroyed beyond repair if the op- 
posite kidney was able to carry on its function. If it 
was not possible to make a positive diagnosis of the 
extent of the lesion before operation, operation should 
include exploration of both kidneys. 

Congenital Hydronephrosis. — Dr. John T. Geraghty 
of Baltimore said there was a group of cases which had 
been puzzling practitioners for years. He referred 
principally to so-called primary hydronephrosis. The 
term primary had been used in these cases because 
there had been no etiologic factor that could be easily 
determined as the cause of this kind of hydronephrosis. 
Many of the cases had been considered congenital 
and physicians had been of the opinion until recently 
that most of the cases in which we could actually de- 
termine any cause for the extreme process were con- 
genital. Recent studies, however, had shown that we 
were wrong. There were two types of aberrant ves- 
sels which were most apt to cause hydronephrosis. In 
one instance the vessels aro.se from the aorta behind 
the ureter and entered into the lower surface of the 
kidney at its lower pole. In the second case the ves- 
sel arose from the vena cava, crossed the anterior sur- 
face of the ureter and entei-ed the posterior surface of 
the kidney. These two conditions gave rise to a condi- 
tion which produced obstruction. In a series of lu 
cases, in only two was he able to find aberrant vessels 
as the cause of hydronephrosis. The vessel crossed at 
the uretero-pelvic junction, but further studies showed 
that this possibly was merely a coincidence. Marked 
kinking of the ureter or pressure of a vessel crossing 
over the ureter was not sufficient to produce hydro- 
nephrosis. However, in some cases of unusual mobility 
where the kidney dropped down over the aberrant ves- 
sel, that vessel might play an important role. Even 



though aberrant vessels were found it was well to bear 
in mind that might not be the primary cause. There 
might be other factors that played a casual role. Renal 
mobility was put forward as a common cause and most 
urologists gave it first place. In the author's exper- 
ience it had been the most common cause of hydro- 
nephrosis. In the series of 15 cases, in 10 nephrectomy 
was performed. He had the tissues to study and suf- 
ficient of the ureter removed to study the cause of the 
hydronephrosis. In three cases plastic procedures were 
carried out, and in two cases aberrant vessels were 
divided. In a study of these 10 cases, with one excep- 
tion, there was found at the uretero-pelvic juncture, or 
in the upper part of the ureter, an inflammatory in- 
filtrate. Most of these cases were considered congeni- 
tal beforehand, but sections through the ureter in 
studying the pelvis showed varying amounts of infil- 
tration. Hunner, he said, had called attention to 
pyogenic infiltrations in the lower ureter and he had 
found them common in women in the region of the 
broad ligament. These infiltrations of the ureter 
caused dilatation of the ureter and pelvis which were 
frequently seen and which Dr. Braasch had considered 
an inflammatory dilatation. It represented a narrow- 
ing rather than a definite stricture, with obstruction 
rather than dilatation of the process in the kidney and 
ureter itself. Inflammation did not give rise to dila- 
tation but rather a contraction. The diagnosis of hy- 
dronephrosis was not difficult. With the methods now 
at our command it was possible to make a diagnosis 
of hydronephrosis by pyelogi'aphy and to demonstrate 
the exact point where the hydronephrosis began. In 
most cases the kidney was destroyed when the patient 
was first seen. At any rate, it was either badly in- 
fected or the kidney was destroyed. Nephrectomy was 
the proper treatment. 

The Prognosis of Surgical Renal Tuberculosis. — Dr. 
William F. Braasch of Rochester, Minnesota, stated 
that in considering nephrectomy for early unilateral 
tuberculosis the factors to be considered were age, sex, 
coincident tuberculosis in other organs or tissues, the 
duration of the symptoms, the severity of the infec- 
tion of the urinary tract, and whether there was or 
was not bilateral involvement. The statistics of the 
Mayo Clinic were given. Age was a factor of con- 
siderable importance in the diagnosis. The incidence 
of renal tuberculosis occurred fiom 25 to 40 years of 
age. Beyond the age of 60 or 70 years renal tuber- 
culosis was of rare occurrence. They had operated 
on three cases up to ten years of age. In the mean- 
time they had seen 40 cases in children up to ten years, 
not operated, because renal tuberculosis in children was 
very frequently a part of a general tuberculosis. The 
children on whom they had operated were seen early 
and tuberculosis was not found present elsewhere. It 
was not customary to operate on children at once be- 
cause the majority of cases sooner or later showed other 
evidences of tuberculosis and their resisting power 
would be low. As to the time to operate, it was be- 
tween 25 to 40 years of age, as the mortality increased 
steadily with the advance in years. The greatest mor- 
tality occurred in patients from 50 to 70 years of age. 
The lowest mortality from operative intervention oc- 
curred in patients from 15 to 20. The influence of 
complications on the mortality was important. The 
majority of cases had evidences of tuberculosis in 
other organs of the body. In only 5 per cent, was the 
renal tuberculosis complicated by acute pulmonary 
tuberculosis. Ninety per cent, of the cases of renal 
tuberculosis had evidences of an old pulmonary tuber- 
culosis. Of the cases of pulmonary tuberculosis com- 
plicated by renal tuberculosis, 21 in number, 40 per 
cent, died, which was twice as high as the mortality 
from renal tuberculosis uncomplicated by pulmonary 
tuberculosis. However, if they had not operated on 
patients with both pulmonary and renal tuberculosis 
they all would have died. It was inconceivable to 
think of a spontaneous cure of renal and pulmonary 
tuberculosis. The removal of the epididymis when 
enlarged or markedly inflamed, with secondary in- 
fection, was unquestionably advisable following ne- 
phrectomy. It was their experience at the Mayo Clinic 
that the caseating kidney offered a much better prog- 
nosis and a much less mortality than miliary tuber- 
culosis. In miliary tuberculosis scattered over the 



88 



MEDICAL RECORD. 



[July 13, 1918 



surface of the kidney the mortality was higher than 
where caseation was present. It was almost twice as 
high. 

PHILADELPHIA NEUROLOGICAL SOCIETY. 
Stated Meeting Held March 27. 

Hemianopsia. — Dr. Francis X. Dercum presented 
this patient. The case occurred in a man, 67 years old, 
who came under treatment for a diverticulum of the 
esophagus. While under observation he became aware 
rather suddenly of loss of vision in the right visual 
field of each eye, without other accompanying symp- 
toms. The blood-pressure was high and the superficial 
vessels were tortuous and resistant. The Wassermann 
reaction was negative and there were no visible changes 
in the fundus oeuli. Under treatment with potassium 
iodide gradual improvement was taking place in vision. 
The conclusion was reached that there had been a tem- 
porary occlusion of the blood-supply to the cuneus on 
the left side of the brain. 

Tremor Following Wounds Inflicted in the Russo- 
Japanese War. — Dr. Dercum also presented this pa- 
tient, a married tailor, 36 years old, who had received 
multiple injuries while serving as a soldier in the Rus- 
sian army in 1905. Since that time he has exhibited 
tremor in diff'erent parts of his body, in addition to a 
subjective sense of tremor at times without objective 
manifestation. 

Tumor of the Brain. — Dr. Alfred Gordon presented 
this case. The patient was a man, 29 years old, who 
illustrated, among; other things, the extraordinary tol- 
erance of the brain to surgical operation. Some" 3 or 
4 years before he had suffered from severe headache, 
with vomiting and attacks of fainting. On one occa- 
sion he fell on the street and was taken to a hospital, 
where a trephine opening was made in the right parietal 
region. No lesion was discovered, but great relief from 
the previous symptoms followed. However, left hemi- 
plegia developed, with convulsions confined to the left 
upper extremity, sometimes with, other times without, 
loss of consciousness. In the course of time a consider- 
able hernia cerebri developed and headache returned. 
At this time a Wassermann reaction yielded a negative 
response, and papilledema was found in each eye. In 
the hope of affording relief a segment of skull was 
removed from the left parietal region, again with relief 
from the headache. However, transitory weakness on 
the right side Of the body, with temporary aphasia, 
appeared, while bilateral optic atrophy developed to- 
gether with paralysis of the left external rectus and the 
right internal rectus and there was a tendency to fall 
toward the right side. With recurrence of the head- 
ache, and having in mind the possibility of a cerebellar 
lesion, a subtentorial occipital operation was performed 
and again with temporary relief from the distressing 
symptoms. Finally the headache again became intol- 
erable and hernia cerebri becoming pronounced on the 
right side the opening on that side of the skull was 
enlarged. The patient still exhibits weakness on the 
left side of the body with occasional convulsive seizures 
confined to the left upper extremity, preservation of 
tactile sensibility in the left hand, but with astere- 
ognosis and loss of sense of position in this member, 
and optic atrophy; but otherwise he is in good health. 
The belief was expressed that the underlying condition 
is a slowly developing new growth in the right fronto- 
parietal region. 

Intrauterine Poliomyelitis (?). — Dr. Charles S. 
Potts presented this case, which occurred in a man, 
54 years old, who from birth exhibited muscular and 
bony deficiencies and deformities in different parts of 
the body with electrical changes, and whose origin was 
attributed to an attack of poliomyelitis during intra- 
uterine existence or perhaps to developmental aberra- 
tions. 



Mxstiiim^, 



Chloroform Deaths. — Auvray in 3500 surgical oper- 
ations performed during the present war, reports 3 
anesthetic deaths. After the last of these he changed 
to ether, the inconveniences of which are negligible in 
comparison with the stigma of Causing death. — La 
Presse Medicate. 



The Society for Legal Medicine and Criminology 
of Bahia. — The study of medical jurisprudence is 
evidently a favorite one in Bahia. A course of 
legal medicine is given at the University there, 
vt^hile the State conducts a School for Police and 
the Nina Rodrigues Medicolegal Institute pub- 
lishes official archives at the State's e.xpense. 
These several bodies are closely affiliated under 
central control. Up to 1915 there had been de- 
fended at the University of Bahia 121 theses on 
medicolegal subjects, the oldest going back to 
1839. At first but few were published — twenty up 
to 1859, an annual average of one. There was 
then for some reason a complete interruption un- 
til 1884. During the six years, 1884-1889, in- 
clusive, twenty theses appeared. They then be- 
came scattered until 1897, since which year a 
good average has been maintained. Over half of 
the theses have appeared since 1900. 

In reviewing the titles we are impressed by the 
small role played by insanity, while criminality is 
well represented. Personal identity, finger prints, 
tattoo marks, and anthropometry, stigmata of de- 
generation, the criminal instinct, behavior of 
prisoners, insanity, and crime are considered 
equally with criminal abortion, rape, criminal 
poisoning and other more familiar themes. In 
other words, the professional criminal as well as 
the incidental or amateur offender receives full 
consideration, something which the older foren- 
sic medicine largely ignored. 

Prophylaxis of Venereal Disease. — Sabouraud, 
in an article abstracted in the Journal de viedecine 
et de chirurgie pratiques for March 10, laments 
that the efficacious methods of venereal prophy- 
laxis in the American Army and Navy which were 
originally devised by the French have not until 
recently been utilized by the latter. These dis- 
eases continue to increase in soldiers and civilians 
alike. The American soldier is fully enlightened 
and threatened with punishment for certain in- 
fractions and actually punished for disobedience. 
After coitus he must at once present himself at a 
prophylactic station. This resource, only recent- 
ly introduced in France, has been operative in the 
United States Army since 1911-12. At the outset 
the soldier was punished only when he failed to 
report for prophylaxis at all and later he was 
punished when he did not appear with the re- 
quired punctuality. Otherwise stated, he is now 
punished for allowing himself to become infected. 
Contamination is evidence of breach of discipline. 
In addition there are regular days of inspection 
in the barracks and a soldier found contaminated 
is subjected to a sort of court martial. He may 
have his pay suspended for two or three months. 

The general result of prophylaxis is the con- 
tamination of onl#- one-half of one per cent, of 
those exposed. Since the establishment of stations 
in Bordeaux there has been but one contamination 
for 1,000 exposures. The alternative is, perhaps, 
as many as 15 contaminations for every 100 men 
exposed. Good results are seen wherever the pro- 
phylaxis is used and the latter was devised many 
years ago in the Pasteur Institute by Metchnikoflf 
and Roux. 



Medical Record 



A Weekly Journal of Medicine and Surgery 



Vol. 94, No. 3. 
Whole No. 2489. 



New York, July 20, 1918. 



$5.00 Per Annum. 
Single Copies, 15c. - 



(l^ruunal Arlirbfi. 

THE VALUE OF DICHLORAMINE-T CHLOR- 
COSANE SOLUTION (DAKIN-DUNHAM) 
IN THE TREATMENT OF INFEC- 
TIONS OF THE UPPER 

AIR PASSAGES. 
Bt d bryson delava.v. m.d. 

NEW YORK. 

The present war has brought a distinct advance in 
our knowledge of surgical infections and of the 
means for their prevention and relief. Of recent 
measures none has deserved greater attention than 
the so-called Dakin method for the disinfection of 
wounds. The advantages of this have been widely 
tested and convincingly proved. Of its value there 
can be no doubt. 

The basis of the solution by means of which the 
Dakin treatment is carried out is a greenish-white 
crystalline substance possessing a sweetish, rather 
pungent, chlorous odor, stable in the solid state, 
especially when kept in the dark. It is known as 
dichloramine-T ( toluene-p-sulphon-dichloramine) . 
It has an intense germicidal action corresponding 
with its high content of chlorine. It is difficult, 
however, to find satisfactory solvents for it which 
will yield stable solutions. The experiments car- 
ried on by Dr. Dakin, in company with Dr. Edward 
K. Dunham of New York,^ have proved that the 
best medium thus far found by them is an oil ob- 
tained by the chlorinization of paraffin wax, to 
which has been given the name "chlorcosane." 
Other solvents which they have experimented with 
are a mixture of eucalyptol and paraffin and one 
made by the prolonged chlorination of eucalyptol. 
Chlorcosane has seemed decidedly preferable. Dakin 
and Dunham thus describe the way in which the 
antiseptic action of dichloramine-T in the solution is 
exerted: "It is well recognized that antiseptics in- 
corporated with or dissolved in oily substances 
usually possess little if any antiseptic activity, be- 
cause intimate contact with the infected matter is 
hindered by the oil. When, however, such oil solu- 
tions of dichloramine-T as will be described are 
brought in contact with aqueous media, the parti- 
tion coefficient between the oil and the water is* 
such that a certain amount of the dichloramine-T 
passes into the water and there exerts its germi- 
cidal action. The amount of dichloramine-T thus 
passing from the oil is enhanced by the presence in 
the aqueous medium of substances capable of taking 

*A Handbook of Antiseptics by Henry Drysdale 
Dunham and Edward Kellogg Dunham, New York: 
The Macmillan Co., 1918. 



up chlorine, so that the oil solution serves as a 
score for the antiseptics, which is drawn upon to 
maintain the germicidal activity of the aqueous 
medium with which it is in contact. Thus the 
amount of antiseptic leaving the oil solution is, to 
a certain extent, dependent upon the rate at which 
it is used up in the aqueous medium." 

The dichloramine-T oil solution may be sprayed 
upon wound surfaces or poured into accessible parts 
of deep wounds. It yields a moderate amount of 
the antiseptic to watery media, such as secretions 
from wounds or mucous membranes. It is suitable 
for cases requiring prolonged antiseptic treatment 
and for first dressings of wounds which do not re- 
quire irrigation. The application of the oil is ex- 
tremely simple and in the treatment of wounds it 
ordinarily need not be renewed more than once in 
twenty-four hours. 

The highly active germicidal qualities of dichlora- 
mine-T having been demonstrated in general, it be- 
comes a matter of great interest to study its value 
in the upper air passages, regions especially liable 
to infection, prone to harbor germs of dangerous 
character, abounding in recesses difficult of access 
by the ordinary means of application, and often be- 
coming foci of infection threatening extreme dan- 
ger. 

Of the various parts of this region the upper 
half of the nasal cavities, the tonsils, and the vault 
of the pharynx seem the most susceptible to infec- 
tion and the hardest to reach. They may be invaded 
by a wide variety of harmful microorganisms, in- 
cluding the staphylococcus, the streptococcus, the 
pneumococcus, the meningococcus, the bacilli of 
diphtheria, and, in fact, almost any of the active in- 
fections, not excepting those of measles, scarlet 
fever, and grippe. The successful disinfection of 
these parts therefore becomes a matter of wide in- 
terest and serious importance. 

Applied for this purpose in the upper air pas- 
sages, the dichloramine-T may be used with advan- 
tage under three diff'erent conditions: (1) To pre- 
vent the development of newly acquired infection; 

(2) to overcome the acute results of infection; and 

(3) to abolish the bacilli persisting in carriers. 
Thus, it has been found effective in the preven- 
tion of cerebrospinal meningitis and of measles 
through its early aplication in subjects who have 
been exposed to those diseases, and in other anal- 
ogous situations it has proved a valuable safeguard. 

Its value in acute infectious conditions of the 
tonsil has been tested by the writer and others dur- 
ing the past winter. There are many like condi- 
tions of the nasal cavity in which its use has al- 
ready been found advantageous. 

A third and very interesting situation promising 



90 



MJDICAL RECORD. 



[July 20, 1918 



important results is the disinfection of co-called 
"carriers." Recent investigations in the medical 
service of the U. S. Government and elsewhere have 
proved that carriers of infection are commonly met 
with, that their presence is associated with great 
danger to others, and that the means heretofore 
used to disinfect them have often proved unsatis- 
factory. In the Dakin-Dunham solution we have a 
germicide which has already proved itself superior 
to tho.<e in ordinary use in that its disinfectant ac- 
tion is more powerful, its activity more profound, 
and its local effect less irritating. The best results 
to be obtained from it, however, have not always 
been secured. In order to insure them, the anatomy 
of the tonsil and of the nasal cavities must be 
clearly under.'^tood and the inaccessibility of their 
parts recognized. 

The value of the method must, of course, depend 
in an important degree upon the thoroughness with 
which the disinfectant is applied to the ultimate re- 
cesses in which the germs are lodged.* Brushing 
the surface of the tonsil or spraying the lower sec- 
tion of the nasal cavity with the solution cannot 
possibly be effective as long as the remote parts are 
not reached. The reason why the attempted disin- 
fection of infected throats and nasal cavities has 
sometimes failed is because this all-important prin- 
ciple has not been recognized. The writer has been 
experimenting for some time past with various 
methods calculated to secure the intimate contact 
of the oil solution with foci of infection in the 
upper air passages too remote to be reached by the 
ordinary methods. He has adopted a procedure 
based upon the simplest mechanical principle, 
which has yielded the best practical results thus 
far obtained. Its neglect is a frequent cause of dis- 
appointment. This principle consists in the most 
complete possible exposure of the parts, preliminary 
to the application of the oil. As far as can be 
learned, this suggestion heretofore has not been 
advanced or carried out. In the case of the tonsil, 
it is the crypts which harbor the most persistent 
of the offending organisms. It is absolutely essen- 
tial therefore that these crypts should be disin- 
fected to their lowest depths. In the nose the com- 
plicated structure of the superior half of the nasal 
cavity necessitates that it receive especial attention. 

For example, to secure the thorough treatment of 
the tonsil it should first be cleansed with some mild 
alkaline or salt solution by means of a spray car- 
ried into the crypts. Immediately following this, 
a spray of adrenalin or other similar astringent 
should be carefully applied for the purpose of con- 
tracting the tonsil and thus exposing its recesses. 
When this has taken effect, the crypts should again 
be sprayed with the cleansing solution to rid them 
of all obstructing secretion. Finally the dichlora- 
mine-T solution, driven in the form of a spray, 
must be applied to all crypts and pockets of the ton- 
sil and caused to penetrate to their lowest depths. 
This is usually not difficult of accomplishment, as 
the force of the air current from the spray tube 
causes the crypt entrances to open widely and the 
crypts themselves to balloon out until they are dis- 
tended to their capacity, in which position the oil 
can enter with complete thoroughness. This course 
of action is absolutely necessary, since attention 
♦Gordon and Flack, Brit. Med. Jour., Nov. 18. 1016. 



alone to the surface of a thoroughly infected tonsil 
can not succeed. 

What is true of the tonsil is even more positively 
the case with the upper nasal region. The parts 
lying above the inferior margin of the middle 
turbinated body are not often freely accessible to 
any spray. Under the influence of infection they 
become still less so, by reason of the turgescence 
and swelling of the soft parts. To be effective, 
the spray must be driven directly into the affected 
recesses, for should it impinge upon any projecting 
angle in its course the current will at once be de- 
stroyed and will not enter the parts beyond. In 
all cases where disinfection of the upper nasal 
cavity is required, the following practice is recom- 
mended : 

First cleanse the mucous surfaces within reach 
with some simple alkaline spray. Follow this with 
a spray of adrenalin, the adrenalin spray to be re- 
peated until the upper parts ha\'e been successively 
opened and the whole way to the roof of the nasal 
cavity is clear. Then, and not until then, and 
guided by a clear demonstration of the parts by a 
good light and a nasal si)eculum, the dichloramine-T 
spray can be thrown to the remote upper parts 
which most stand in need of it, and the disinfec- 
tion of the region made complete. While it may be 
said that this method, thorough as it is for the 
nose, does not reach the nasal sinuses, it neverthe- 
less has proved more practically effective than any 
other method of which we know. 

The disinfection of the vault of the pharynx may 
be secured by first applying the adrenalin to the 
soft palate and the lateral walls of the pharynx, 
thus facilitating the complete introduction of the 
spray. 

Used in the strength of 2 per cent., the solution 
of the dichloramine-T is seldom irritating. In the 
case of stronger solutions it may become so, pro- 
ducing a sensation of smarting or burning. This is 
easily obviated by reducing the percentage of di- 
chloramine-T of the solution to as low as 1 or even 
lo per cent. Otherwise than this, the oil is well 
tolerated and free from any injurious effect. For 
its application in the form of spray, an atomizer 
must be used which will throw the spray in all 
directions. It should be made of some medium 
which will not be acted upon by the chlorine, and 
the compressed air should be supplied from a good 
condenser. 

Theoretically, the most complete possible ex- 
posure of the affected ai-eas should permit the best 
contact of the disinfectant. Practically, this is 
found to be true, as proved by the speedy success of 
the treatment, two or three applications often suf- 
ficing to sterilize the parts. Where success is de- 
layed, there will usually be found enlargements of 
the tonsils or of the adenoids, or marked obstruc- 
tion of the nose. In such cases, after a reasonable 
number of local treatments have been given with- 
out avail, the removal of the offending lymphoid 
tissue or suitable attention to the nasal cavity must 
be considered. 

Dr. Stanton A. Friedherg, in his excellent theses 
(Trans. Am. Laryngological Ass'n. 1917 and 1918^, 
has ably set forth the value of the operative treat- 
ment in diphtheria carriers, and concludes with the 



July 20, 1918] 



MEDICAL RECORD. 



91 



statement: "When the bacilli persist in spite of any 
local treatment beyond a period of three to four 
weeks, the removal of tonsils and adenoids is the 
most effective treatment and the most uniformly 
successful that has yet been proposed." The same 
treatment has been found true in the case of men- 
ingococcus carriers. 

In cases where no obstruction exists or where 
for any reason the immediate removal of adenoid 
enlargements is not advisable, the dichloraniine-T 
chlorcosane solution seems to offer the best hope of 
a speedy cure. If, as is the fact, complete disin- 
fection can be accomplished in uncomplicated cases 
with as few as three, two, or even one treatment, 
the superiority of the method over others is be- 
yond question. 

As to the relative merit of the application of the 
oil solution as compared wirh the inhalation method, 
the results seem to show that the former is more 
prompt in its action and that in uncomplicated cases 
the number of treatments required is far less. 
Again, an important advantage is the simplicity of 
the outfit. An inhalation room could hardly be es- 
tablished at any but a hospital of some importance 
and at considerable expense, while its apparatus is 
sufficiently complicated to require e.xpert care. My 
desire is to offer a method so simple in itself as to 
be readily carried out by the average practitioner, 
with the aid of apparatus inexpensive, dm able, .ind 
clean, very compact of form nnd light of weight, 
and therefore conveniently available for use under 
all circumstances of medical practice, .vhether at 
home, in the hands of the prai.-titioner ard the 
health officer, or in the various branches of hos- 
pital and field service of the army and '.he navy. 
All that is necessary for this is: 

1. The recognition of the principle upon which 
success absolutely depends, namely, that in order 
to carry the dichloramine-T chlorcosane solution to 
the chief foci of infection these fo<n must fiv^t be 
thoroughly exposed, as described above. 

2. The application of the dichloramine-T solution 
by means of a properly constructed spray atomizer, 
the air current being supplied if possible from an 
air condenser and not by means of an india-rubber 
handball. 

3. The devotion of time and painstaking care to 
the effective carrying out of the treatment. 

I have personally used this method sufficiently 
to believe that in it we have a means for over- 
coming infections of the upper air passages which 
is more simple, safe, prompt, and successful than 
any hitherto known. 

4 East Forty-First Street. 



SHELL SHOCK AND OTHER WAR NEUROSES.- 

By EDWARD LIVIXGSTOX HUNT. JF D.. 

NEW YORK. 

ASSISTANT PROFESSOR OF CLINIC.iL NEUROl.OOY. COLUMPIA 
UNIVERSITY. 

The subject of this talk is shell shock and other 
war neuroses. The term shell shock has been 
used to so great an extent that I think you will 
form a much better conception of the condition if 
you classify all of these war conditions under the 

*Read before the M. O. R. C. at Camp Mills, N. Y., 
May 16, 1918. 



one heading <jf war neuroses. Shell shock, then, is 
a war neurosis. .4 loar neurosis is a nervotis dis- 
order, icithout necessarily a pl,i/sical disease or in- 
jury, the cause of ivhich is modern warfare. An 
other definition of it is hysteria, occurring in a 
person free from hereditary or personal psycho- 
neurotic antecedents, but with a mind more re- 
sponsive to psychical stimulus than the normal. 

There are many types of symptoms — among 
them are hysteria, tremors, paralyses, confusion, 
stupor, temporary blindness, temporary deafness, 
temporary loss of speech, hallucinations, night- 
mares, states of anxiety, gait disturbances, head- 
aches, vertigo, insomnia, and sweat disturbances. 

To understand shell shock one must form a con- 
ception of a distinct disease, just as one would 
understand pneumonia, typhoid fever, or a broken 
leg. It is a disease which is, however, nervous in 
origin, nervous in symptoms, and nervous in its 
general course. Bear in mind that these nervous 
conditions are just as much complete diseases as 
are the medical and surgical conditions. Shell 
shock, therefore, must be regarded as a condition 
which has a history, a cause, a period of incuba- 
tion, a course, a set of symptoms, a prognosis, and 
treatment. I think if .vou will start with this con- 
ception that you will find the study of shell shock 
simpler, easier, and more interesting. 

The history of shell shock is as old as that of 
some of the most ancient diseases. When this war 
began a great many of the English and French 
writers began to describe a new condition and to 
give a new name to the condition. As time ad- 
vanced and the war progressed men's minds began 
to crystallize and settle down so that in a very 
short time the medical men who had described 
this new condition recanted what they had said 
and realized that in giving the name shell shock 
to a certain set of symptoms, they were simply 
dressing an old idea in new words. The symptoms 
of shell shock are not limited to the present war, 
nor to the Civil War, nor to the Revolution. In the 
history of Ancient Rome and Greece you will find 
that in the days of Xenophon and Caesar the sol- 
diers engaged in battle complained of the same 
symptoms as those which are to-day described 
under the name of shell shock. Again, if you will 
reflect that shell shock is the result of unusual 
conditions, of violence, and of noise, you will rea- 
lize that the same symptoms occur in our modern 
functional conditions. There were many of these 
cases in the Civil War, but at that time they were 
not classified as neurotic or as functional condi- 
tions, but rather were they called organic dis- 
orders; it was thought at that time that these con- 
ditions were produced by the impact of the air 
from the passing shell against the body. In other 
words, it was thought that impact with the con- 
cussion produced by a large moving force of air 
was able and did cause organic changes in the 
brain, the spinal cord, and the nervous system. 
The result of such conditions was, in the opinion 
of the medical mind of that day, actual paralyses, 
real choreas, and organic tics. 

It was not until the war between Japan and 
Russia that a conception of shell shock and war 
neuroses became manifest. The present war has 
magnified the cases, has enlarged this idea, and 



92 



MEDICAL RECORD. 



[July 20, 1918 



now it is recognized that there are an innumer- 
able number of functional conditions which form- 
erly were thought to be organic. 

The next point which I wish to bring out is the 
similarity ichich the icar neuroses present to the 
hysterias and neurasthenias of civilian life. The 
two conditions are practically alike. The man on 
the street will react in the same way as the man 
on the battlefield. The woman caught in the ele- 
vator shaft, and the engineer who goes through 
the wreckage of his train, whether these two be 
physically hurt or not,, will present the same 
psychic condition as the soldier in the trench. 

Several years ago Dr. Pearce Bailey wrote a 
book on accident and injury. The book came out 
long before the present war, yet, if you will glance 
over the pages and read some of his neuroses and 
hysterias you will find a very strong similarity to 
the cases of the present day which are described 
as shell shock. 

The fact that this war differs so from all that 
have preceded it both in magnitude and type, in 
methods of warfare, and in organization, makes 
it inevitable that it should produce what at first 
was thought to be a new medical condition. This 
accounts for the appearance of the term shell 
shock. The title is catchy. It arrests and holds 
the attention and this accounts for its permanence. 
Although I prefer to use the word war neuroses, 
shell shock has caught the public fancy, and shell 
shock has come to stay. In our time there will be 
many cases. Bear in mind that it will not be a 
waste of your time to understand the subject of 
war neuroses because not only will you see many 
cases in this war, but you will see many cases 
after the war. The American people are especially 
a neurotic race. They are, in my opinion, becom- 
ing more and more so. We live in an intensely 
artificial way and in the next ten years we shall 
probably be more artificial, so that neuroses and 
hysterias will be more frequent. You will see 
many, both during and after the war. 

The first question which will suggest itself to 
your mind is: why should there be so large a pro- 
portion of shell shock cases as occur in the pres- 
ent war? The reasons for this are numerous. In 
the first place, the war is on a larger scale than 
any preceding it; in the second place, more is at 
stake than in any previous contest; in the third 
place, there are more prolonged offensives and bat- 
tles. Again, the human race is more neurotic than 
it has ever been. One must recognize at the start 
that the armies of the world show an enormous per- 
centage of constitutional inferiors, of neurasthenics, 
of psychopaths, and of men with markedly neurotic 
temperaments. Here in New York there is a very 
large population which is Hebraic in race, and as 
you know, there is no more marked attribute to 
the Hebrew than a neurotic temperament. There- 
fore, the present emergency which this country 
finds itself in is one which is the result of two 
important factors which go to produce the war 
neuroses, namely, the enlarged battlefield and 
the suitable soil in which the neurosis may de- 
velop. It is an emergency which presents the two 
important factors of heredity and environment; 
factors both of which are admirably suited to 
bring about the war neuroses of the present day. 



Not only do there exist these two important fac- 
tors, but also there occur numerous subordinate 
causes, all of which tend to accentuate the two 
principal ones. I want to call your attention to 
some of these subordinate factors because of the 
importance which they occupy in bringing about 
the condition. Never before in the historj' of the 
world have soldiers been subjected to such horrible 
sights, never before have such large numbers 
been destroyed, mutilated, and never before have 
such unusual and terrible means of warfare been 
waged. The modern machine gun, underground 
trench life, the presence of vermin and rats, are 
all factors which have tended to make the environ- 
ment more unusual, more abnormal, and one which 
would more than ever destroy the normal tempera- 
ment as well as the neurotic. In this war the 
length of the battles, extending, as some of them 
do for several weeks, has rendered it difficult for 
soldiers to obtain regular rest, has rendered it 
difficult for them to escape great fatigue, and low- 
ered vitality. Therefore many factors have upset 
the individual. 

I am trying to convey to you the fact that the 
present war is waged under different conditions 
than any preceding, and that the soldiers engaged 
in it have been obliged to lead more unusual and 
abnormal lives. That, in addition to this, a large 
number of soldiers engaged in the present war are 
more highly civilized and therefore more highly 
neurotic than soldiers of preceding generations; 
and, again, trauma received by the soldier, whether 
it be physical or mental, is greater and more dam- 
aging than any such trauma received in preceding 
wars. Incidentally, these are reasons why such 
great care should be exercised in eliminating the 
conscripted men. 

If possible, the number of war neuroses should 
be held down to as small a number as possible. 
Therefore, the neurologist and psychiatrist must 
play an important part as eliminants before the 
final army is chosen. 

The great difference which occurs between the 
war neuroses and the neuroses of the civilian is 
that the civilian has periods in which he can sleep, 
periods in which he can rest, periods in which he 
can have those about him whom he loves, to divert 
his mind and help him to get control of his nerv- 
ous system. The soldier in the modern war has 
none of these aids. He is continuously under fire 
and he is continuously among those who are sub- 
ject to the same environment and the same shocks. 

I listened, only a short time ago, to a very 
interesting analysis of the figures of the con- 
scripted men. from a neurological point of 
view. Lieutenant-Colonel Bailey of the National 
Army, gave us a very interesting lecture at the 
Academy of Medicine, in which he collected the 
statistics of the men in the arm.v. It was very 
surprising to see how few had organic nervous 
diseases, how low down in the list ranked alcohol 
and addiction, how small were the figures for 
syphilitic infections, and how enormously great 
were the statistics of constitutional inferiors, 
psychopaths, and mild dementia prsecox cases. I 
cannot remember exactly his figures, but it seems 
to me that the percentage of constitutional in- 
feriors was something like 20. With so large a 



July 20, 1918] 



MEDICAL RECORD. 



93 



percentage as this and with such tremendous 
shell fire as we read of, how could it be otherwise 
than that traumatic functional conditions should 
develop and predominate? 

Causes. — The causes of the war neuroses can be 
classified under two major headings: (1) Me- 
chanical, (2) Psychological. 

(1) The mechanical heading does not necessarily 
mean a blow to the individual, because war neu- 
roses occur in many cases in which the soldier is 
not wounded. It means the jolt — that is to say, 
the shock which the individual received from 
the noise, from unusual conditions, or from the de- 
struction of everything about him. Secondly, 
there is the fatigue. Very few cases develop that 
have not previously been tired out, exhausted, 
cases in which the general system was considera- 
bly below par. As predisposing causes which can 
be placed under the heading of mechanical, I am 
going to place the excessive use of alcohol, nico- 
tine, and the infectious diseases. The exces- 
sive use of alcohol and tobacco serves to lower the 
vitality and therefore acts as a predisposing cause. 
It superinduces fatigue; it renders the nervous 
system less liable to withstand unusual conditions 
and shocks ; when the jolt comes the patient de- 
velops a neurosis. 

(2) The psychological. The four headings under 
which I have subdivided the psychological causes of 
the war neuroses are: (1) acute situations, (2) 
suggestions made by the physician, (3) the en- 
vironment, (4) personal problems. The acute situ- 
ations which may develop and precipitate a neu- 
rosis are such conditions as bad news from home, 
death of wife or mother, and distressing letters 
from sweethearts. 

There is considerable responsibility to be as- 
sumed by the physician who suggests removing a 
man from the front line and sending him to the 
rear. Even the doctor's tone and manner of han- 
dling a soldier at the front is fraught with re- 
sponsibility. 

The environment is probably the most important 
of the three factors. The presence of vermin, wet 
clothes, fatigue, hunger, and horrible sights, all 
tend to disturb a man's equilibrium and act as 
predisposing causes of bringing about war neu- 
roses. 

Symptoms develop as to time and place very con- 
siderably. Apparently this is dependent upon the 
personality of the individual and the extent to 
which he is neurotic. Some cases may develop in 
the camp before the soldier has started for the 
front, others may develop back of the line, and 
finally many develop at the front. The usual time 
is just before the attack and practically very few 
develop during hostilities. The onset may be 
gradual or sudden. When it is gradual, and this is 
the most frequent method, it is possible to fore- 
see the approach of the attack. The patient be- 
comes restless, somewhat morose, and does not do 
his work in the usual way. His increased nervous- 
ness may continue for several days. 

In order to understand the s>-mptoms of any 
condition, whether it be medical or neurological, 
organic or functional, we must have a distinct clas- 
sification under one or two headings, and then enu- 
merate the symptoms in the order of their impor- 



tance under each heading. I should classify the 
symptoms of shell shock under the two main head- 
ings of physical and mental. 

I. The physical symptoms may be placed under 
the headings of (a) motor symptoms; (b) special 
sense symptoms; (c) symptoms connected with the 
autonomic system. 

•The motor symptoms include tremors, tics, paral- 
yses of the various extremities, and gait disturb- 
ances. 

The special sense symptoms include those symp- 
toms which may arise from a perversion of any 
one of the five senses ; blindness, in connection 
with the sense of seeing; partial or complete deaf- 
ness in connection with the sense of hearing; anes- 
thesia or paresthesia in connection with the sense 
of touch or feeling; and absence or perversion of 
the senses of smell and taste. 

The symptoms of the autonomic system may be 
classified under palpitation of the heart, shortness 
of breath, cold, clammy hands and feet, purplish 
and mottled extremities, and profuse sweating, to 
the extent that a man's clothing may be soaked. 

The motor symptoms, as I have said, include 
tremors, tics, paralyses, and gait disturbances. 

The tremors can be divided into two classes: 
(a) typical, (6) atypical. 

The typical tremors are those which resemble the 
well knovra tremors which are characteristic of the 
nervous system. The atypical tremors are irregu- 
lar, disorderly, and in no way resemble any of the 
well recognized types of tremors. 

The typical tremors are imitative, whereas the 
atypical ones appear to be wholly imagined by the 
patient, that is to say, they originate in the men- 
tality of the sufferer. These atypical types are 
more apt to affect all of the muscles than any 
group or extremity. In general the physiognomy 
expresses indescribable terror. There is rapid heart 
action and marked flushing, alternating with pal- 
lor in the face. The various secretions of the body, 
such as the sweat, the tears, the saliva, and the 
urine, are increased. The type of the tremor is dis- 
tinctly coarse, with an extensive excursion, and re- 
sembles more the twitching characteristic of chorea 
than the classic tremor. The movements are initi- 
ated by any slight stimulation, even by the touching 
of the patient by the bed clothes, or by a violent 
noise, as the slamming of a door. Everything 
seems to suggest the noise of the battlefield. 

The determining factor is evidently the emo- 
tional sphere which has been upset by the shells 
and which is in such a disordered condition that 
anything suggestive of a shell will precipitate a 
complete disorder of the motor system. The 
typical tremors resemble those which are charac- 
teristic of the organic nervous diseases and can 
be classified as such. There are the pseudo-paral- 
ysis agitans type, multiple sclerosis type, toxic 
type, exophthalmic goiter type, cerebellar type, and 
general paralysis type. 

The onset of these tremors at times varies. The 
most common onset is following a slight loss of 
consciousness. A man may be in the trenches, at 
a listening post, or resting in one of the canton- 
ments, when suddely a shell falls at a short dis- 
tance. He is thrown into the air, falling back upon 
the ground with a loss of consciousness. So soon 



94 



MEDICAL RECORD. 



[July 20, 1918 



as he recovers consciousness, either at the evacua- 
tion hospital or in the ambulance, he is seized with 
a marked tremor involving his entire body. The 
more unusual manner is for the tremor to occur- 
immediately after the e.xplosion without the pa- 
tient losing consciousness. In the still rarer cases 
the condition may present itself only after an in- 
terval of hours or days. This has been described 
by Charcot as the phase of meditation. 

There is still one other type in which the tremor 
does not present itself until the patient has gotten 
up and is practically cured of his wounds. In 
the.se instances, the tremor is of the nature of a 
reminiscence of the preceding shock and can there- 
fore be classified under the heading of retrospective 
emotions. Many of these tremors are aggravated 
by inspection, by the appearance of the medical ad- 
viser, and by attention. It is evidently a disturb- 
ance of the emotional element which is at once 
stimulated by contact, touch, the appearance of 
someone, noise, or any unusual event. In other 
words, there is an abnormal state of the emotional 
sphere which is easily thrown into abnormal func- 
tion by the stimulation of any one of the five 
senses. 

The tks are of two types, tonic and clonic. The 
latter, clonic tic, or spasmodic movements, is far 
more common than the former. So far as their dis- 
tribution is concerned, those affecting the head 
are the ones which one sees most constantly. They 
take the form of head nodding of either affirmation, 
or lateral movements of denial. Again, there may 
be a spasm of the face, either onesided or bilateral. 
Another common type of tic is that in which there 
is a shrugging of one or both shoulders. These 
tics vary greatly in their development, course, and 
termination, offering many variations, so that it is 
difficult to give you a typical picture. The dura- 
tion is probably unusually long and the course of 
the tics varies greatly, dependent on the early diag- 
nosis and subsequent care. 

The paralyses which occur in shell shock are 
probably the most frequent and important of the 
neuroses. They simulate very much the organic 
paraly.ses and may be either spastic or flaccid. 
Probably the flaccid type is the more common, just 
as in the hysterical paralyses we get almost in- 
variably the flaccid type. There are monoplegic, 
hemiplegic, and paraplegic. The etiological factors 
in each one of these paralyses are very similar. 
Like most of these motor disturbances in shell 
shock, the paralyses occur in those cases where a 
great shock has been received, but no wounds. It is, 
therefore, a form of cerebro.spinal emotion. They 
may present themselves immediately after the 
traumatism or not until the patient has recovered 
consciousness, again illustrating what Charcot de- 
scribed as the phase of meditation. 

Two points I want to call to your attention in 
regard to the paralyses are, first, that they are 
very frequently preceded by pain. Thus, mono- 
plegia of the leg may be preceded several days by 
pains in the knee and ankle. Secondly, the point 
at which the traumatism strikes the patient has no 
bearing whatever on the appearance or the loca- 
tion of the paralyses, thus, a blow at the shoulder 
may very readily produce a paralysis of the leg, 
And just as much of the leg as of the arm. The 



arm is more often affected than the leg. The trunk 
is sometimes affected, but the face and tongue 
rarely. The physical signs which accompany the 
hysterical paralysis of shell shock are identically 
like those of hysterical paralysis seen in civilian 
life, that is to say, the member hangs flail-like, 
the reflexes are normal, and the muscular tonicity 
is equal on both sides. The superficial reflexes al- 
so remain normal. Bear in mind, esptecially, that 
Babinski's reflex is never present in an hysterical 
paralysis. Therefore, the symptoms which accom- 
pany the paralysis of shell shock are variations in 
sensibility, loss of power, trophic disturbances, 
vasomotor changes, and electrical changes. 

The hemiplegia is the least common of the three 
types, the monoplegia being the most common. In 
addition to these paralyses, there occur, but less fre- 
quently, paralyses, circumscribed in character, af- 
fecting one particular portion of the body — thus 
it is not uncommon to have a complete paralysis of 
the foot, of the hand, or of certain portions of the 
body. These paralyses will be more clearly pic- 
tured to you if I use the word contracture. The 
contractures of the trunk are very remarkable and 
interesting. In some the trunk is at right angles 
to the body, in others it is bent to one side, in still 
others the patient stoops forward or backward, re- 
maining in that condition for an indefinite time. 

Gaits. — The fact that there are disturbances of 
gait is proof that a particular patient may have an 
emotional state which is not itself active, others a 
state of suggestibility, in which there is fixed an 
upheaval or disturbance of the function of walk- 
ing. Like the tremors, the gaits may be typical 
or the reverse. The typical gaits are those which 
imitate the classic, ataxic, hemiplegic, drop foot. 
and choreiform gaits. There are four or five 
at\T>ical forms which are difficult to describe and 
which do not resemble any particular type of walk- 
ing. 

There is also the condition known as astasia- 
abasia. This, as you probably know, is a condition, 
in which, when lying down or sitting, the patient 
can use his legs or feet in any way he desires and , 
is able to perform any sort of motion, but when he 
stands up and attempts to walk it is impossible for 
him to take a step, and he has to push or drag his 
legs and can only progress with the aid of a cane, 
and then only for a short distance. 

There are also instances in which the patient is 
typically lame and limps or drags one foot. These 
patients pretend to be lame because they suffer, 
whereas in reality they suffer because they are 
lame. 

Special Sense Disturbances. — The sensory dis- 
turbances can be divided into two large headings — 
the pains and the anesthesias. 

The pains are of course the more important be- 
cause they interfere more with the usefulness of 
the patient, because they are more lasting, and be- 
cause the patient who suffers from them demands 
relief. The pains involving the lower extremities, 
the legs, are the most frequent, the most easy to 
feign, and the most difficult to control. The onset 
of these pains is variable. They may be sudden 
and spontaneous in their onset, or they may fol- 
low some slight illness and then persist, or they 
may follow directly a shock or blow. The previous 



July 20. 1918] 



MED[CAL RECORD. 



9.5 



condition of the patient seems to play but little part 
in their onset, and they appear in soldiers of 
all ages, from the youngest to the veterans, in 
those who are apparently without a neuropathic 
taint, as well as in those so predisposed. 

It is best to adopt the following classification 
and put them down as : ( 1 ) Pains in the legs, 
by far the most frequent; (2) pains in the arms, 
the rarest; (3) pains of the trunk and spine, 
fairly frequent; i4) pains of the neck and head; 
( 5) visceral pains. 

The pains of the lower leg are of several types — 
sciatic, coxalgic, and the neuritic type. There are 
also pains which appear only when the patient 
v.alks or makes use of the legs. The pains in the 
arms are much less frequent and usually unilateral. 
The characteristics of these hysterical pains are 
that they are illogical in their appearance, irregu- 
lar, and erratic in their localization. Thus, there 
may be pain of the hands, whereas the patient has 
a complete paralysis of the entire arm. The distri- 
bution of these pains does not follow any nerve, 
plexus, or any sensitive point. They are mobile, and 
shift from day to day in their localization. They 
are inconstant, sometimes producing slight, and 
sometimes severe sensations. There are of course 
no physical signs which accompany the appearance 
of these pains. The pains in the trunk, and those 
of chest and abdomen, take the form of pleurisy, 
intercostal neuralgia, and appendicitis. 

The anesthesias are far less important than the 
pains because they are not observed by the patient 
and only appear following a medical examination. 
There is of course not sufficient reason for placing 
the patient in a hospital. It is difficult, well nigh 
impossible, to say anything about the onset of 
these conditions, because you will readily realize 
that they are not perceived by the patient. There 
may be small spots or vast zones. Whether it is 
anesthesia or analgesia, hyperesthesia, or hyper- 
algesia, it is rare to find them occurring separately, 
and they usually form part of a complex syndrome 
in which motor troubles predominate. 

The Autonomi<^ Symptoms. — The sj-mptoms re- 
ferable to the autonomic system, that is to say, re- 
ferable to the parts of the body that are not under 
voluntary control, are very common. There is no 
soldier in the trenches who does not have, to a 
slight extent, some of these symptoms. They are: 
palpitation of the heart, profuse perspiration, rest- 
lessness, and sleeplessness, without any organic 
lesion. Another prominent symptom which occurs 
in connection with these is the "all-gone sensation" 
which one feels in the abdomen. This is largely 
due to a change in the distribution of the blood 
supply under the stimulus of fear. 

II. The mental symptoms of shell shock and 
other war neuroses are numerous, variable, and 
unless systematically arranged, confusing. Ames 
in his book says that they vary from the extremes 
of the ideational to the emotional. I think you will 
find it easier, however, if j,-ou divide them into two 
large groups, and call one the mental and the other 
the emotional. 

Under mental I would place five symptoms, and 
under emotional five. I am going to tnumevflte 
these various symptoms to you and then I am going 
to take up each one in turn and say a few words 



about it. If you are taking notes I would suggest 
that you simply put down these five headings: 

(1) Speed of thought; (2) sluggishness of 
thought; (3) confusion; (4) memory disturb- 
ances; (5) anxiety. 

Under emotional symptoms : ( 1 ) Restlessness ; 

(2) crying; (3) general discontent; (4) great ir- 
ritabilit}-; (5) phobias; (6) fatigue. 

Let us now take up each one of these symptoms 
in detail and for a moment talk about it. By the 
speed of thought, I mean exhilaration, the same 
condition which presents itself in the manic stage 
of manic depressive or circular insanity, and in 
acute mania. As you probably know, in these con- 
ditions the patient has a constant flow of ideas. 
He is rapidly changing from one subject to an- 
other, never completely finishing one. His speed 
of thought is also accompanied by rapidity of' 
movement, a constant desire to do things, great 
mental stimulus, simulating, only much more so, a 
state of mind following a small ingestion of alcohol. 

The second symptom is sluggishness of thought, 
and is just the reverse. It is known as depression 
and is the symptom which follows the depressed 
stage of circulation insanity and is the leading char- 
acteristic of melancholia. In this condition there 
occur great mental inertia and great physical in- 
ertia; the cerebration is slow, new ideas come with 
great difficulty, and old ones can hardly be com- 
pleted or their plans executed. Procrastination ac- 
companies the condition and the patient may sit 
in front of a clock and let hours go by without 
having carried out a single plan. 

The third symptom, that of confusion, arises 
somewhat as a complication resulting from either 
the exhilaration, the depression, or the mental 
fatigue. It is especially noteworthy following 
marked periods of either one or the other. It 
becomes worse as the condition-advances and is most 
harassing to the patient and distressing to the 
onlooker. The sufferer becomes confused as to his 
environment and surroundings, especially confused 
as to his actions. He is at a loss to know what he 
should know, what action he should take, and he 
begins to wonder if he is in any way following 
out the right course. 

The fourth symptom, that of memory disturb- 
ances, is one which may take the form of loss of 
memory either for recent events or for those of 
several years back. I should say that it was more 
apt to take the place of recent events. It may be 
one of many grades, ranking from a slight impair- 
ment to one which is complete. The memory may 
be intact for events which happened previous to 
the shock, while at the same time the patient re- 
members nothing in regard to events occurring sub- 
sequent to the shock. To compare this with ci- 
vilian life, to emphasize the resemblance of the 
shell shock suffered by the soldier and the shell 
shock suffered by the civilian, I am going to tell 
you of an instance which has recently been brought 
to my attention. A lady lost her husband, who 
dropped down dead. She attended his funeral, 
put on mourning, and arranged all his affairs. Two 
days afterward she became exhilarated, then de- 
pressed, and a week later absolutely denied that 
he was dead. She became confused and her mem- 
ory for the two days following his death was com- 



96 



MEDICAL RECORD. 



[July 20, 1918 



pletely lost, whereas she remembered everything 
of her early life up to the day of his death. 

Anxiety, the fifth symptom, while I place it last, 
is one of the most important and one of the most 
common. It resembles the well-known anxiety con- 
dition seen in civilian life which we call the anxiety 
psychosis, a psychosis which is particularly evident 
in people of advanced age. The patient suffering 
from anxiety becomes a pessimist, sees no hope 
in anything, considers that his life is over, that 
the world is to be destroyed, and that all his ef- 
forts have been wasted and will come to naught. 

Treatment. — War neuroses are curable. The 
treatment is a success from the medical point of 
view but a failure from the military standpoint. 
The mere fact of this statement will serve to em- 
phasize the condition, to bring to your minds more 
closely just what is a war neurosis. These pa- 
tients can be made well, but may have a recurrence 
of the same condition. The rule is that the patient 
who has suffered from shell shock or a war neurosis 
inevitably under the same conditions and environ- 
ment will suffer a second attack. Here is another 
reason for the importance of eliminating these pa- 
tients before they reach camp, and especially before 
they reach the battle front. 

To understand the treatment of shell shock you 
must understand psychology. It is eminently a 
problem in psychological medicine. Dr. Salmon, 
who has been abroad and who has studied this 
question at length and in detail for the United 
States Government, puts the matter very aptly 
when he says that the first step is a careful study 
of the individual, an understanding of the per- 
sonality. He means by that that each case is a 
law unto itself, and to be successful one must 
thoroughly understand the idiosyncrasies, the pe- 
culiarities, and the unusual trend of mind of the 
patient. The man who intends to treat shell 
shock must understand human nature and must be 
able to analyze and classify his individual patient. 

There are several forms of treatment, several 
aids which can be brought to your assistance. I 
shall enumerate these and then discuss them. 
They are: (1) Suggestion ; (2) Re-education of 
the patient; (3) Persuasion; (4) Hypnotism; (5) 
Occupation; (6) Hydrotherapy; (7) Electro- 
therapy. In attempting the first of these, sugges- 
tion, one must grasp the mentality, the caliber, 
and the possibilities of the patient. You can i-ead- 
ily see that when you adopt suggestion as a meth- 
od of treatment, you will have to use different lan- 
guage and make different appeals to the commis- 
sioned officer than that which you would use to 
the private; different to the man of education than 
to him who is ignorant; different to the man who 
has human feelings and affections than to the man 
who is cold, unresponsive, and without ties. 

The next point is to lay especial stress on the 
incident which precipitated the neurosis. It may 
have been a shell explosion, or it may have been 
a crisis in discipline. The method of talking will 
be somewhat different in each case. During this 
psychological examination the physician must be 
careful not to disclose any too great chagrin or 
surprise at the revelations made by the patient. 
Suggestion means causing the patient to acquire 
confidence in his recovery, confidence in his physi- 



cian, enthusiasm, interest, and desire to get well. 
Similar cases may be cited in which recovery has 
taken place. A general optimistic view of the 
whole situation should be imparted. Suggestive 
measures may be outlined whereby the patient 
may help with his recovery. In all of these the 
suggestions must not surpass the mental caliber 
of the patient. If this is done not only will you 
waste time and energy, but you will inspire con- 
fusion where confidence should exist. Suggestion 
must, of course, have a proper environment. The 
country is superior to the city and there is no 
doubt that suggestion near the battle front is 
more dramatic and more convincing than that 
which is undertaken hundreds of miles away with 
a hospital ward as the scene. It is in the acute 
cases that suggestion is especially valuable. When 
suggestion has failed, when the case has become 
chronic or of long duration, the next step is re- 
education of the patient. 

Reeducation means to teach the patient the use 
of the apparently lost faculty. If it is that he 
cannot walk, take him by the arms and teach him 
each step, each motion of the foot and leg as you 
would a child. If it is that he cannot speak, begin 
with sounds, syllables, words, and finally sen- 
tences. Reeducation takes patience, a phleg- 
matic temperament, and time. I do not believe that 
every man is capable and competent to undertake 
the reeducation of nervous patients. One must 
have great resources of time, energy, enthusiasm, 
and interest, and no outside disturbing factors. 
Drills and physical exercises are part of the re- 
education of some cases, and from here it is but a 
step to occupation. 

Nothing helps a nervous patient more than a 
suitable occupation. Again I refer to Salmon, who 
divides the occupations into bed, indoor, and out- 
door. There are certain pastimes which the pa- 
tient, who is bedridden from his neurosis, can 
follow. These are basket weaving, net making, 
and even knitting. For those who are up and 
about and yet unable to go out there are all the 
little occupations which can be done about the 
hospital and house, such as making the surgical 
dressings, sand papering, polishing, woodcarving, 
carpentering, bookbinding, cigarette making, and 
many others which your ingenuity and good sense 
may suggest. The best occupations of all, how- 
ever, are those followed out of doors, such as 
farming, gardening, wood sawing, and wood chop- 
ping. Gymnastic exercises are, of course, always 
of value, but bear in mind that the practical and 
productive occupation is of much more importance 
and aids the patient both physically and mentally 
to a much greater extent than the non-productive. 
Therefore, as soon as possible, do away with that 
form of occupation which is only suggested for the 
purpose of killing time and assign to the patient 
an occupation which is productive, practical, and 
one in which he can see evident results. Nothing 
helps these patients more than an occupation 
which they feel is necessary and is doing some 
good and accomplishing some results. Among 
these occupations none is moi'e valuable than 
swimming. You can readily see that when one 
of these patients is in a tank of water he has to 
make an effort in order to keep afloat, and nothing 
is better for the paralyses and gaits. This is espe- 



July 20, 1918] 



MEDICAL RECORD. 



97 



cially so because all of these conditions, whether 
organic or functional, are less severe in water 
than in the air. You know that the treatment 
of locomotor ata.xia can be, to a great e.xtent, 
helped under water more than in the air. 

Persuasion is so much akin to suggestion and 
the time for this discussion is so limited it seems 
to me that I can pass it over with a ver\- few words. 
Persuasion, to be of value, must also take into ac- 
count the type of patient, and must be carried out 
with skill. 

Hypnotism is of some value. Personally, I am 
opposed to hypnotism, principally because it in- 
jures the morale and the mental control of the 
subject. If I hypnotize one of you there is no 
doubt that I exercise a certain control over you 
which I can exercise at any time I desire. 

Hydrotherapy has a distinct value. It is espe- 
cially good when applied in the form of spinal 
douches, when it exerts the double effect of shock 
and tonic to the nervous system. It is of more 
value when it is used in the form of the hot bath 
for the rigid backs, the contractures, the tics, and 
the paralyses. But both patient and physician must 
recognize its limitations. Too many people L're 
apt to think that both water and electricity, when 
applied to a nervous patient, can be a cure-all. 

Finally, in the treatment of these conditions, 
the environment of the patient is essential. The 
patient with shell shock and war neurosis ought 
not to be allowed to lounge about a sunny yard or 
to remain idle in a hospital ward. His mind should 
be constantly occupied as well as his body. He 
must be enthused with the idea that cure is possi- 
ble and that cure is essential. He must be taught 
that he is still of %-alue in the world and that if 
he cannot go to the front he can still go back to 
civilian life and there be of service. Shell shock 
produces a condition which is essentially infan- 
tile and childlike. The patient must, therefore, 
be treated as a child, led along, and slowly but 
steadily induced to think that he is better. 

I think that it is the opinion of most men who 
follow these conditions that many of the present 
cases of shell shock will recover when the war is 
over. The important point, however, now is to re- 
duce the cases and therefore there should be men 
skilled in this work, psychiatrists and psychol- 
ogists, as near the front as possible who can take 
these cases and by the methods of suggestion, re 
education, persuasion, hydrotherapy, and occu- 
pation exert an immediate cure. Many cases have 
been cured in a very short time. Of course prob- 
ably most shell shock cases would be better away 
from the battle line, but bear in mind that if this 
is done to a great extent you will encourage many 
of the milder nervous cases to acquire and feign 
the war neuroses. 

Drugs are of very little value in treating shell 
shock. Digitalis has practically no effect on the 
pulse rate. So far as using bromides in quiet- 
ing the patient, their result is not satisfactory, 
as they serve rather to depress than quiet. Veronal 
is probably the only drug which has the slightest 
effect. It does help the insomnia and does induce 
sleep. It is needless to add that there are no con- 
ditions in shell shock in which opium is warranted. 

41 East Sixtt-third Street. 



THE MEDICAL TREATMENT OF EXOPH- 
THALMIC GOITER.* 

Bt JAMES FRANXIS RICE, .A.M., M.D., F.A.C.P.. 

BUFFALO. N, T. 

If you will allow me tonight the luxury of an etio- 
logical theory merely as a working basis, it will 
help us, I believe, in the review of what must be 
done for the unfortunate patient and it will fur- 
nish a working basis for the relations of internist 
and surgeon in the solution of the thyroid prob- 
lem. 

Crile's theory of the kinetic drive' has been, I 
believe, probably the most helpful of recent con- 
tributions to the study of this problem; and, with 
your kind indulgence, I wish briefly to recall the 
main features of this theory. 

The kinetic drive, according to Crile, is the ex- 
cessive excitation of the kinetic system. The kine- 
tic system is the brain and the muscles, together 
with the suprarenals, liver, and thyroid. 

"The organs," says Crile, "which from moment 
to moment varj- and control, accelerate and retard 
the driving force of the brain are the suprarenals, 
the pacemaker of the kinetic system is the thyroid, 
and the final act of adaptive energy transformation 
is performed by the muscles." 

The activators of the kinetic system are: physi- 
cal injury, heat and cold, emotions, infection, auto- 
intoxication, pregnancy, excessive food, poisons, 
and others. 

Crile tells us, "perhaps the most typical of the 
kinetic diseases is exophthalmic goiter. In exoph- 
thalmic goiter the kinetic system is driven by a 
continuous activation, because in this disease there 
has been established a pathologic interaction be- 
tween the brain and the thyroid, whereby the 
threshold of all stimuli is kept continuously low 
* * *. The principal phenomena of exophthalmic 
goiter are identical with the leading phenomena of 
any other kinetic drive of a corresponding degree 
of intensity, and may be duplicated by fear, anger, 
sexual excitation, physical exertion, overwork or 
acute infection. Conversely, many of these activa- 
tions cause h\-perplasia of the thyroid. Thus fear, 
anger or se.xual emotion may cause temporary en- 
largement of the thyroid; there is hyperplasia of 
the thyroid in pregnancy, in chronic infections, and 
perhaps in intestinal autointoxication as well." 

The recognition of a disease as a process rather 
than a condition calls not so much for a remedy as 
it demands a program. 

Viewing the process of exophthalmic goiter as one 
form of the kinetic drive, the problem of its control 
becomes the question of blocking the effect of the 
activators of the kinetic system. This may be 
accomplished quickly and easily, but only tempor- 
arily, by the use of opium, which raises the thresh- 
old of effective stimulation of the kinetic system. 
Similarly the diminution of the blood supply to 
the thyroid or the removal of part of the gland, 
serves to restore normal equilibrium by diminish- 
ing the supply of activating substance delivered by 
the thyroid to the blood-stream. The difference 

*Read before the Surgical Section of the Buffalo 
Academy of Medicine, April .3, 1918, as part of a Sym- 
posium on Goiter. 



9S 



MEDICAL RECORD. 



I July 20, 1918 



between these two methods of control suggests 
their different use in the treatment of the disease. 
Should we not restrict the use of opium to the 
paro.xysmal periods of the disease process, and 
should we not consider surgery curative because 
it effects an internal readjustment? The surgical 
intervention which breaks the vicious circle can- 
not, however, accomplish the patient's restoration 
to health, unless the favorable situation it pro- 
duces is made use of for the prolonged medical care 
of the patient's mental and physical hygiene. There 
must be accomplished, not only the anociation of 
the patient, that is, the blocking of the effect of 
the activators of the kinetic system, but also the 
removal of these e.xcitants, in order to prevent re- 
establishment of the same vicious circle. The pa- 
tient's trouble is originally a medical problem ; 
and, if the surgeon's work is successful, it becomes 
again a medical problem. Does this not suggest 
earlier recourse to surgery, with more definite 
acknowledgment of the chief responsibility of the 
internist? 

A rough classification of cases of exophthalmic 
goiter for the purposes of this paper, may be made 
as follows: 

(1) Incipient Graves' disease, in which the diag- 
nosis must be made by the family physician or in- 
ternist; 

(2) Advanced mild cases, including cases even of 
marked exophthalmos and very prominent goiter, 
in which the disabling symptoms occur in brief 
paroxysmal periods; 

(3) Rapidly developing severe cases, and 

(4) Advanced severe cases. 

Incipient cases of Graves' disease should be rested 
and environmental readjustment made. Hygiene 
should be corrected, diet should be supervised, auto- 
intoxication and any focus of infection should be 
remedied; but the fundamental requirements are 
rest and environmental readjustment. For example, 
a girl of sixteen; ambitious, overworking at school, 
active in outside interests, and harassed by her re- 
sponsibilities at home, was not much helped by 
dropping a few of her studies at school, or by gen- 
eral hygienic measures, but she was promptly re- 
lieved of symptoms by the return of her father. 
The father had been away for months, leaving the 
patient as the eldest daughter in actual charge of 
the house, because the mother is mentally defective. 
This patient was evidently driven by anxiety, one 
of Crile's "activators." She was undoubtedly a 
fit case for the care of an internist. The case is 
cited as illustrative of the correctness of the prin- 
ciple of readjustment, and not because its course 
is typical. Usually the process of restoration to 
health takes much longer. There is often evidence 
of intestinal toxemia, there may be focal infection. 

An advanced mild case of exophthalmic goiter 
can sometimes be carried along with a minimum of 
treatment and helped over the crises by a few doses 
of morphine. 1 remember the case of a woman of 
about 50, a widow with a family of grown children, 
who sent for me on two or three occasions when 
she had been made worse by some emotional excite- 
ment, responding very satisfactorily to a half-grai'i 
of morphine in the course of 24 or 3G hours by 
mouth, given in solution with the direction that a 
teaspoonful (containing gr. 1 24) be taken every 



hour or two until she felt better. (She was not 
told what she was taking, and the drug was dis- 
pensed by the physician himself, who left this lim- 
ited amount for her to use either within a few 
hours or "spread out" as she might prefer.) This 
case is cited as an extreme instance of how little 
need of a physician seems to be felt by some of the 
most slowly developing cases. 

A rapidly developing severe case should be seen 
at once by both the internist and the surgeon for 
this reason: if delay is caused by the use of any 
other than surgical measures, the integrity of the 
myocardium is endangered. Of course, rest and 
environmental readjustment should be carried out 
as far as possible; but may we not consider that in 
this group of cases such procedures are properly to 
be undertaken after surgical intervention has im- 
proved the prognosis? Before operation medical 
measures are needed by way of preparation ; but, 
when careful medical preparation is not feasible, an 
early operation seems to have less risk than a delay 
of weeks or months with the resulting inevitable 
impairment of cardiac reserve. 

An advanced severe case should probably be con- 
sidered a neglected case. Tlie outlook for relief is 
equally dubious, whether medical or surgical meas- 
ures are recommended. There is so little left to 
work with. Heart, liver, and kidneys have been too 
severely punished. 

Does it not seem, therefore, as if we should 
follow our early diagnosis with the prompt summons 
of the surgeon? To block the vicious circle, should 
not the thyroid be thrown promptly out of gear, so 
that the careful application of recognized measures 
of medical care may restore to complete health a 
much larger percentage of our cases? If the kinetic 
drive be interrupted by the surgeon's work upon 
the thyroid, its control must still be continued for 
weeks and months, and the patient, whose coopera- 
tion in this program of medical care is essential, 
will be encouraged to recovery by the confidence 
developed by the knowledge that his heart has not 
been exhausted nor the rest of his kinetic system 
worn out. 

Diet. — The accelerated metabolism which is char- 
acteristic of exophthalmic goiter makes necessary 
the closest attention to the problem of nutrition. 
Some authorities tell us that the hyperthyroid case 
should have a low-protein diet, while others empha- 
size the need of forced feeding and a diet rich in 
proteins. May we not consider diet one of the un- 
settled problems of the disease? For practical pur- 
poses the prominence of either an intestinal toxemia 
or a glycosuria should often prove to be the deter- 
mining factor. 

Certainly there will have to accumulate a much 
greater volume of recorded observations of metabo- 
lism in Graves' disease before we can generalize 
upon the dietary requirements of this disease. 
Meanwhile the acute cases will have to be fed what- 
ever they will retain. A milk diet will continue to 
be our sheet-anchor. 

Water. — All authorities apparently agree in the 
advice that the patient should drink water different 
from that of the locality in which he lived during 
the development of the disease. 

Climate. — It has been suggested that the proper 
climate for patients suffering with exophthalmic 



July 20, 1918] 



MEDICAL KHCOKD. 



99 



goiter must be cool and dry, with sunshine and no 
fogs, only moderate winds, and an elevation of from 
1500 to 2000 ft.' At any rate, a change of climate 
from that of the patient's home is apt to be of value, 
for the sake of a different water supply. 

Psychotheiapij. — There are few diseases in which 
the patient is so dependent upon the medical coun- 
selor for optimism and the will to survive. Fatigue 
is a cardinal symptom of exophthalmic goiter, and 
peace of mind is a fundamental feature of successful 
treatment. 

Rest. — Rest must precede operation ; it must follow 
operation. The opinion of an eminent surgeon' that 
90 per cent, of all goiters can be so improved by 
medical treatment as to make operation unnecessary 
was probably based upon observation of the effect of 
rest, for rest is the common element in all the vari- 
ous forms of treatment that have proved successful, 
i That opinion, by the way, is Kocher's, indorsed 
by Charles H. !Mayo. ) Rest in bed is inevitable in 
the severe cases. If improvement is accomplished, 
the comparative rest secured by a change of scene 
must be ordered. The theory of the kinetic drive 
helps us to remember how indispensable to success 
is rest — rest of mind and body. 

Exercise and Gymnastics. — We must be careful 
in carrying out the essential rest of the patient that 
we do not neglect the business of first passive and 
then active exercise, and later perhaps gymnastics 
under careful supervision. This is a very long and 
tedious chapter. 

Hydrotherapy. — The use of the various applica- 
tions of water certainly has its place in every com- 
plete scheme of treatment of so long a process as the 
uphill climb to health of these patients. In the acute 
stages the sedative effect of water-applications is of 
the first importance, and it is probable, if hydro- 
therapy were more frequently employed then, that 
the problem of nutrition would be less troublesome. 
In the long process of recovery, hydrotherapy has 
undoubted value in its stimulant and tonic phases. 

Massage and S'on-surgical Mecha)iical Measines. 
— These procedures have a share in the restoration 
of muscular tone and strength, which is so large a 
part of the program of recovery, after the acute 
stage has passed. 

Heat and Cold; Light and Electrotherapeutics. — 
Under this head there should be mentioned the use 
during the acute stage of an ice-bag or Leiter coil 
over the thyroid, over the heart or in both places. 

Electrotherapeutics and the use of light have, of 
course, their part in the coaxing of the patient back 
to health and strength. 

Radium. — There are a few who seem to be en- 
couraged to believe in this agent for the destruction 
of thyroid tissue. Abbe of New York, Turner of 
Edinburgh, and Wickham of Paris have made con- 
tributions to the study of this comparatively recent 
addition to our resources.' I think you will agree 
with the view, however, that any new procedure in 
the treatment of exophthalmic goiter must be tested 
through a series of years before it can have any 
standing as a remedy for the disease. 

Roentgen Ray. — It is possible that a field for the 
use of the Roentgen rays in Graves' disease will be 
found in those cases of retrograde thymus following 
strumectomy, especially in young patients, of which 
Halsted has reported six cases with favorable re- 



sults." Halsted quotes Capelle, assistant to Garre, 
as finding thymus persistens hyperplastica at au- 
topsy in 95 per cent, of fatal cases of Graves' dis- 
ease. Halsted's cases had failed to recover after 
extirpation of the thyroid, and promptly got well 
after Roentgenization of the thymus. 

Drugs. Organotherapy, Vaccines, and Serums. — 
We come to the side of our problem which presents 
so many different aspects to the student of medical 
history. It would be an unwarranted trespass upon 
your good nature and kindly endurance, to attempt 
even an outline of the changing customs in the use 
of chemical and biochemical agents that have been 
employed in times past and present in the treatment 
of exophthalmic goiter. 

Each of these many remedies has had its suc- 
cesses and its period of popularity. To each has 
been attributed some part of the large percentage 
of recoveries that would probably regularly occur in 
the absence of all treatment. It undoubtedly is be- 
cause of the usually favorable prognosis in this dis 
ease that we still find in the text-books lists of 
"things to be tried." 

At present we may not conclude the consideration 
of the medical treatment of exophthalmic goiter with 
the reflection that, just as opium is the agent of 
temporary relief in the paroxysmal crises of the 
slowly developing cases, so surgery is probably the 
agent of internal readjustment which should be 
promptly and early invoked in the rapidly develop- 
ing cases for the release of the threatened heart 
from the vicious circle of a process which, though 
sure in most cases to come to an end of itself, in- 
evitably and inexorably, while it lasts, injures the 
heart. 

If this point of view be generally adopted, we 
shall care less about recovery from goiter, but much 
more shall we strive for the protection of the endan- 
gered myocardium. We shall be unwilling to allow a 
disabling disease to run its unabbreviated course, 
and we shall have fewer nominally recovered pa- 
tients carried off by the accidents that are fatal in 
the presence of myocardial degeneration. 

REFERENCES. 

1. Crile: Journal of the American Medical Associ- 
ntion, Vol. LXV, p. 2129, et seq. 

2.' Beebe: Hare's Modem Treatment, Vol. II, p. 490. 

3. Quoted by Musser: Aytierican .Journal of the 
Medical Sciences, Vol. CXLIII, p. 814. 

4. Forchheimer: Therapeusis of Internal Diseases, 
1914, Vol. I., p. 482. 

5. Johns Hopkins Hospital Bulletin, Vol. XXVI, p. 5-5. 

441 ELMWOOD AVENtE. 



EXPERIMENTAL TEST WITH COPPER AND 
POTASSIUM CYANIDE IN TUBERCULOSIS. 

Bt M. J. FINE, M.D. 

NEWARK, N. J. ^ 

CHIEF OF TCBEKCCLOSIS CLINICS OF NEWAP.K BOAHD OF HEALTH ; 

ASSOCIATED E.KAMINING PHYSICIAN FOR THE ESSE.X 

MOUNTAIN SANATORIUM AT ^irRONA. N. J.. AND 

CHIEF OF THE TUBERCULOSIS CLINIC OF 

THE BETH ISRAEL HOSPITAL, 

NEW.U5K, N. J. 

Inasmuch as Dr. Koga's cyanocuprol has been 
brought to the attention of the medical profession 
as a curative agent in tuberculosis, and has elicited 
favorable comment in some of the medical journals, 
particularly in the article of George H. Evans in 



100 



MEDICAL RECORD. 



[July 20, 1918 



the October 6, 1917, issue of the Medical Record, 
I deemed it my duty to avail myself of my oppor- 
tunities of reporting the preliminary findings after 
giving a fair trial of this remedy so liberally fur- 
nished me by the Kitasato Institute. 

This report is based upon twelve cases divided as 
follows : Six pulmonary, three pulmonary with 
laryngeal involvement, one kidney case, and two skin 
cases. Tubercle bacilli were found in all the cases 
excepting those of the skin. Six of these cases were 
in a sanatorium during the treatment. All the 
other cases were treated at home. The remedy was 
administered intravenously at intervals of two 
weeks in the pulmonary, laryngeal, and kidney cases 
and every week in the skin cases. After each in- 
jection, the patient was confined to bed for six 
days; no other medication was given during the 
course of treatment, except an occasional dose of 
codeine in those with an unusual racking cough ; 
all the other directions contained in Dr. Koga's 
circular were strictly adhered to. 

Some of the cases received decreasing doses, 
others increasing doses ; the kidney case received 
the same dosage during the entire course of treat- 
ment. This course of treatment was followed as 
outlined by Dr. Otani. 

The preparation is claimed to be composed of the 
salts, copper cyanide, potassium cyanide, and cal- 
cium chloride, used in doses varying from 4 to 24 
milligrams. 

Case I. — Hubert D., American, white, age 28, clerk. 
Admitted to the Verona Sanatorium August 10, 1916. 
Father and mother dead. Cause not known. The dis- 
ease dates back five years when he was operated upon 
for mastoid trouble. Denies venereal disease. Does not 
drink. Complains of weakness, cough, shortness of 
breath, and a slight hemorrhage occasionally after 
coughing. Weighs 124 pounds. Temperature 99 a.m. 
to 100° P.M. Pulse 90. Did not improve while in sana- 
torium. Sputum positive. Poorly nourished, anemic ; 
has extensive bilateral involvement; moist rales at both 
apices extending to the third rib anteriorly on the right 
side. Probably a small cavity on the left side at the 
angle of the scapula. No complications. 

First injection, March 31, 1917, 4 c.c. of copper and 
potassium cyanide. 

Second injection, April 14, 1917, 4 c.c. No reaction. 
Temperature as usual. 

Third injection, April 28, 1917, 4 c.c. No reaction. 
Lost 1 pound. 

Fourth injection. May 11, 1917, 3 c.c. No reaction. 
Lost Vz pound. 

Fifth injection. May 26, 1917, 3 c.c. Slight hemor- 
rhage next day. 

Sixth injection, June 6, 1917, 2 c.c. No reaction. 
Lost 2 pounds. 

No change in the condition of chest. Patient feels 
the same. Sputum still positive. 

Case II. — Eugene P., American, while, male, age 34, 
metal worker. Admitted to sanatorium December 6, 
1916. Mother and brother died of tuberculosis; wife 
also has the disease. Patient had pneumonia and pleu- 
risy two years ago and was subject to colds. Present 
disease started about eight months ago, with a cough 
and pain in the chest. Weighs 120 pounds. Temper- 
ature 98.3" A.M. to 99.2^ P.M. Sputum positive. Patient 
is comewhat emaciated. Chest very little involved. 
Expansion limited, with dullness and bronchovesicular 
breathing on the right side. A few rales after cough- 
ing, extending from apex to second rib. Rough breath- 
ing on left side, a few rales after coughing. 

The first injection was given March 31, 1917, 4 c.c; 
the second on April 14, 1917, 4 c.c. On April 20 he sus- 
tained an injury of the head and went to the hospital. 
Returned with same condition in chest. 

Third injection was given May 6, 1917. 2 c.c; three 
days later complained of pain in stomach. 



Fourth injection on May 20, 1917. No change in 
weight, chest or sputum. 

Case III. — Edward F., Irish, white, age 31, advertis- 
ing agent. Admitted to the sanatorium January 24, 
1917. Father died of tuberculosis. Patient had pneu- 
monia five years ago. Present condition started three 
year ago with a cough, followed by a hemorrhage. 
Drank moderately. Denies venereal disease. Temper- 
ature 99° A.M. to 101.3= P..M. Sputum positive. Phys- 
ical examination showed the patient quite emaciated; 
disease moderately advanced ; retraction above and be- 
low both clavicles, dullness extending from apex to 
fourth rib on right side, and hjTDerresonance on the left 
side. Moist rales over both sides of the chest; cavern- 
ous breathing at the angle of scapula on the left side. 
No applications. Was losing weight gradually since he 
entered the sanatorium. 

First injection, March 28, 1917, 4 c.c in reaction. 
Gained 1 pound between time. 

Second injection, April 14, 1917, 4 c.c. Lost 1 pound. 

Third injection, April 28, 1917, 4 c.c. No change. 

Fourth injection. May 11. 1917, .3 c.c. Lost 2 pounds. 

Fifth injection. May 26, 1917, 2 c.c. Lost 1 pound. 

Sixth injection, June 6, 1917, 2 c.c. Lost IM pounds. 

Patient died November 16, 1917. Sputum was posi- 
tive until death. 

Case IV. — Elsie V., Italian, white, age 14, school 
child. Admitted to the sanatorium December 19, 1916. 
Family history could not be obtained. Had pneumonia 
some time ago. Present disease started with a cold, fol- 
lowed by a hemorrhage while the patient was on the 
way to this country. Examination shows patient well 
developed and fairly nourished. There was muscular 
rigidity on both sides of the chest, limited expansion 
on the right side, few rales after coughing at the apex 
on the right side, bronchovesicular breathing on left 
«ide. No complications. Sputum positive. 

First injection, April 14, 4 c.c No change. 

Second injection, .A.pril 29. 4 c.c. Lost 2 pounds. 

Third injection. May 11, 3 c.c Lost 1 lb. 

Fourth injection. May 26, 2 c.c. Lost 1 pound. 

Fifth injection, June 9, 2 c.c. Lost 1% pounds. 

Condition much worse, weaker, has night sweats and 
chills. Rales extending on the right side as far as the 
base. 

Case V. — Chester C, Italian, white, age 16, school- 
boy. Admitted to Verona Sanatorium for the second 
time October 8, 1916. Father and mother died of 
tuberculosis. Two brothers are in the sanatorium now. 
Had pneumonia twice. Present condition started a 
year and a half ago as a result of pneumonia. Exam- 
ination shows patient's general condition fairly well 
developed. Physical signs of an active tuberculosis 
extending from the apex to the lower edge of the 
shoulder blade on the right side. Moist rales on the 
left side and cavernous breathing between the third 
and fourth ribs on the same side. No complications. 
Tubercle bacilli numerous. 

First injection. March 31, 1917. 4 c.c. No reaction. 

Second injection, April 11, 1917, 3 c.c. No reaction. 

Third injection. May 26, 1917, 2 c.c. Felt weaker. 

Fourth injection, June 9, 1917, 2 c.c. 

Patient has grown much weaker since the first injec- 
tion; lost 7 pounds. Chest and sputum the same. 

Case VI. — Felix S., Irish, white, age 37, single, 
leather worker. Father died of tuberculosis. Had 
nephritis about three years ago, otherwise was never 
sick. Had been a heavy drinker. Denies venereal 
trouble. Present disease started about eight months 
ago with a cough, weakness, loss of weight, and hoarse- 
ness. Coughing. Examination shows patient quite 
emaciated. Disease in the chest moderately advanced, 
both sides involved, moist rales over the entire right 
side and on the left side as far as the fourth rib. 
Larj-nx on examination showed marked infiltration of 
the epiglottis, erosions of both cords, and a thickening 
at the interarytenoid space. Sputum positive. 

First injection, February 28. 1917, 4 c.c. 

Second injection, March 14, 1917. 4 c.c. 

Third injection, March 2S. 1917, 4 c.c 

Patient claimed he felt better and could eat better 
right after the first injection, and after the third injec- 
tion he lost four pounds and was much weaker; by 
the advice of his regular physician eyanocuprol was 
discontinued. 



July 20, 1918] 



MEDICAL RECORD. 



101 



Case VII. — Bessie N., Hebrew, white, age 23, single, 
dressmaker. Admitted to the sanatorium June 6, 1916. 
Patient complained of hoarseness and pain in the chest. 
Family history negative. Was never sick before. Pres- 
ent disease started with a considerable hemorrhage 
three and a half years ago. General condition of pa- 
tient fair. Examination of chest shows both apices 
infiltrated. Rales after coughing on both sides extend- 
ing to the third rib. Examination of larynx shows 
infiltration of entire epiglottis and ulceration of the 
right half of the cord. Sputum positive. 

First injection, April 21, 4 c.c. No reaction. 

Second injection, May 4, 4 c.c. No reaction. 

She lost two pounds and requested to discontinue in- 
jections. Chest and sputum the same. 

Case VIII. — Stefan F., Russian Pole, white, 34 years, 
metal worker, married. Habits good. Family history 
negative. Was never sick. Had been six months in 
the sanatorium, leaving there six months ago. Pres- 
ent disease started a year ago with hoarseness and 
shortness of breath. Physical examination of chest 
shows disease moderately advanced, involvement on 
both sides. Moist rales over the entire right and partly 
the left side. A probable cavity at the angle of scapula 
on right side. Examination of larynx shows erosion 
of right cord with infiltration at the right ventricle. 
Sputum positive. 

First injection, February 21. 4 c.c. 

Second injection, March 8, 6 c.c. 

Third injection, March 23, 6 c.c. 

Patient stopped coming. After the second injection 
he complained of losing weight and not feeling as well 
as before. Chest was the same and sputum positive. 

Case IX. — Harry H., American, white, single, 36 
years, electrician. Brother died of tuberculosis. Was 
never sick in his life with the exception of gonorrhea. 
Present disease started nine months ago, when he no- 
ticed he was losing weight and was getting weaker. Was 
since then in a sanatorium and felt much better. Ex- 
amination shows patient's general appearances good. 
Is only six pounds below his normal weight. Physical 
examination shows infiltration at the right apex; a few 
rales after coughing; harsh breathing and prolonged 
expiration at the left side; sputum positive. 

First injection, February 21, 6 c.c. No reaction. 

Second injection, March 7, 8 c.c. No reaction. 

Third injection, March 21, 10 c.c. No reaction. 

Fourth injection, April 4, 12 c.c. No reaction. 

Xo change in chest, general condition, or weight. 
Patient refused further treatment. 

Case X. — Richard M., Italian-American, white, age 
19, student. Referred to me by Dr. Miningham for 
treatment with the diagnosis of tuberculosis of both 
kidneys. Family history negative. Two years ago 
was operated on for a double inguinal hernia ; since 
then has lost about twenty pounds. Complains of a 
dull pain in the inguinal region and a boring pain at 
the dorsal region. Examination of chest negative. 
Cystoscopy and catheterization show that both kidneys 
are involved. Examination of urine found tubercle 
bacilli and a great deal of pus. 

First injection, March 28, 4 c.c. No reaction. 

Second injection, April 14, 4 c.c. Lost 1 pound. 

Third injection, April 28, 4 c.c. No change. 

I'ourth injection. May 11, 4 c.c. Lost 2 pounds. 

Fifth injection. May 26, 4 c.c. Lost 2 pounds. 

Sixth injection. June 6, 4 c.c. No change. 

General condition slightly improved. Less frequent 
urination, and on examination of urine tubercle bacilli 
could not be found. No decrease in the amount of pus. 

C.\SE XI. — Evelyn H., colored, age 8 years. Referred 
to me by Dr. Wallhauser with diagnosis of lupus vul- 
garis. Mother died of tuberculosis. Patient was never 
sick before. Present disease started five years ago 
as a small tubercular eruption on the middle of the 
left cheek. The tubercles gradually ulcerated and re- 
solved, leaving scar tissue. New crops appeared and 
spread, developing the same ulcerations as the original, 
until the entire side of the face was involved. Exam- 
ination shows patient well developed, chest negative. 

The lesion involving the left side of the face about 
the orbit extending down the cheek presents an aggre- 
gation of ulcerating tubercles, outlining a cicatrized 
area corresponding to the original site from which 
gradual extension occurred. 



First injection, March 3, 2 c.c. 

Second injection, March 11, 3 c.c. 

Third injection, March 20, 4 c.c. 

Fourth injection, March 30, 5 c.c. 

Patient did not show any change and it was advised 
by her physician that she be put on tuberculin. 

Case XII. — Julia S., Austrian Pole, white, age 28, 
single. Referred by Dr. Wallhauser with the diagnosis 
of lupus %Tjlgaris. Family history negative. She was 
never sick before. Started four years ago as a small 
tubercular eruption at the middle of left cheek. These 
tubercles gradually ulcerated and spread peripherally 
until the entire cheek was involved. Examination of 
the patient shows general appearance good, chest nega- 
tive. Lesion consists of numerous apple-jelly tubercles 
with pale granulation between, extending from the 
angle of eye to the ear above and the angle of the 
mouth below. 

First injection, March 7, 6 c.c. No change. 

Second injection, March 14, 6 c.c. 

Third injection, March 21, 4 c.c. 

Ulceration became more pronounced and started to 
spread very rapidly. Injection discontinued. 

Conclusions. — I did not notice any focal reaction 
in any of the cases. Pulse, temperature, sputum, 
and chest were practically running the .same course 
as they were before the treatment was instituted. 
The weight (as to loss or gain) was also the same. 
One of the pulmonary cases was always subject to 
slight hemorrhages and these occurred during the 
time the injections were given. None of the pa- 
tients complained of pain at the seat of the injec- 
tions, nor in any other part of the body, during the 
trial with the remedy. 

The kidney case shows some improvement. The 
patient w'as sent to the country two days before 
starting the treatment, and therefore it is very hard 
to determine whether the improvement was due to 
the change of climate and rest, or to the treatment. 

In only one case was noticed a psychological ef- 
fect after the first injection, the patient claiming 
he felt better and could eat better immediately. 

From the experience with the above remedy, I 
cannot subscribe to the favorable reports that have 
been advanced from this treatment. On the other 
hand, I did not notice any detrimental effects. I 
therefore would say that a further trial may be 
justifiable. 

362 Clinton Avenue. 



THE STIGMATA OF ABRAMS IN HEREDITARY 
SYPHILIS. 

By albert ABRAMS, A-M., M.D., LL.D., 

S.\N FRANCISCO, CAL. 

My contributions to the Medical Record' have en- 
gendered so much correspondence on the part of 
physicians desirous of learning more concerning the 
"Electronic Reactions of Abrams,'" that the writer 
is prompted to place on record, several new signs 
heretoTore unrecorded w-hich are frequently en- 
countered in hereditary syphilis. 

Electronic Reactions — Sufficient evidence has ac- 
cumulated warranting the assumption that these 
reactions may be accepted as diagnostic of syphilis 
and to enable the cognoscenti to differentiate hered- 
itary from acquired syphilis. Geo. 0. Jar\-is,^ found 
the electronic tests of Abrams positive in nearly 
100 per cent, of syphilitic affections hereditary 
or acquired and he comments as follows: "In the 
diagnosis of syphilis, the Wassermann reactions 
were not positive in every case in which the elec- 



102 



MKDICAL RECORD. 



[July 20, 1918 



tronic tests showed the presence of syphilis and in 
which the clinical history and therapeutic results 
showed beyond reasonable doubt that the Wasser- 
mann reaction was at fault." 

\V. .J. Cae.sar has published a report of 192 blood 




Fig. 1. — Auricular sign. 

tests made at the State Hospital, Stockton, Cal., 
(March 6. 1918) using e.xclusively the 'electronic 
reactions." The specimens were submitted by 
physicians of the hospital including the pathologist, 
under rigorous conditions, with the object of elim- 
inating any previous knowledge on the part of the 
executant relative to the disease or the patient from 
whom the blood was derived. 

The specimens included syphilis (congenital and 
acquired), tuberculosis, carcinoma, syphilis and tu- 
berculosis, and syphilis, tuberculosis, and carcin- 
oma. In the latter instances, the specimens of blood 
on the same paper were derived from different pa- 
tients. The electronic reactions were absolutely 
correct in 186 in.stances among 192 specimens of 
blood submitted for examination 1 3 very .small speci- 
mens were not examined, making 189 actually ex- 
amined). 

Reference to the foregoing is made with the ob- 
ject of emphasizing the correlation of the signs to 
be cited in hereditary syphilis. The value of a posi- 
tive Wassermann test in hereditary syphilis may be 
seriously questioned considering the beneficial re- 
sults of antisyphilitic treatment in cases with a 
negative Wassermann. Syphilitic infection must 
always be considered in all chronic diseases. Stoll' 
avers that in "late" hereditary syphilis, the patient 
may present no sign of syphilis but a single ob- 
scure symptom which may be so distressing that 
more or less complete invalidism results. Jarvis' 
quotes Kaskell, who observes, that while a positive 
Wassermann can be elicited in about 40 per cent 
of the wives of paretics and tabetics, yet only a 
small percentage of their children yield a positive 
reaction to that test. 

"Familial syphilis" may be suspected or predi- 
cated if any of the following statements are made 
as to the cause of death in relatives: (1) Tabes, 
(2) Paresis, (3) Aneurysm, (4) Apoplexy (before 
50 years of age), (5) Cardiorenal disease, (6) 
Headaches (not relieved by the usual means), (7) 
Nervousness (without obvious cause), (8) Rheu- 
matism (obscure), (.9) Tuberculosis in several 
members of the same family. Hereditary syphilis 
according to Fournier, strongly predisposes to tu- 
berculous infection later in life. 

UbiquUji of Syphilis. — The electronic reactions 
demonstrate the ubiquity of syphilis and emphasize 
the dictum of Fournier. that general pathology 
should be made a mere annex to .syphilography. 



That the world is becoming civilized is debatable, 
but that it is syphilized is unquestionable. 

I have recently found that when the voltage of 
the radioactive energy of the blood of any individual 
is augmented about 1300 per cent., the electronic 
reaction of congenital syphilis is always present. 
The writer has shown experimentally (Medical 
Record, Oct. 6, 1917) that the .spleen is the usual 
nidus for the luetic virus. This heterodox concep- 
tion is sustained by William J. Mayo, in his Car- 
penter lecture (Oct. 18, 1917) as follows: "Hiberna- 
tion of spirochetes in the spleen permits luetic rein- 
fection of the body." 

Sabouraud" makes a practice of applying the Was- 
sermann test in all dubious affections in children, 
and observes that all who do this will be appalled at 
the findings. The German diagnostician avers: 

"Was man nicht diagno-stieren kann, 
Sieht man als n' syphilis an." 

In free translation, the latter may be expressed 
as follows : 

When your diagnosis goes amiss. 
Always think of syphilis. 

It was said of Ricord, who was a confirmed skep- 
tic as to the morality of the race, that he would 
have submitted Diana to treatment with his min- 
eral specifics and pre.scribed a course of blue pill.-; 
for the vestal virgins. 

Fournier observed that 98 per cent of the chil- 
dren of syphilitic parents are syphilitic. The elec- 
tronic reactions show that they are all syphilitic. 

The tale of syphilitic parents may be inscribed as 
follows: sterility, stillbirths, miscarriages, abor- 
tions, progeny dying in infancy of marasmus, men- 
ingitis, convulsions, etc. Hochsinger's observations, 
embracing 208 children of syphilitic parents, show 
that 89. or 43 per cent, had some affection of the 
nervous system. Among these, which is in vivid 




i 



Kio. 2. — Digital sign. 

contrast with my observations as will be shown 
presently, in only G was the Argyll-Robertson pupil 
demonstrable . Congenial syphilis is unfortunately 
identified with its manifestations at birth and we 
are liable to forget that it may not develop until 



July 20, 1918] 



MEDICAL RECORD. 



103 



adolescence or late in life. Congenital is practically 
a replica of acquired syphilis. 

Certain anomalies in physical structure have 
been sufficiently emphasized and attention is here 
directed to new signs in heredosyphilis. 

Argyll-Robertson Pupil. — This sign is regarded 
by many as positive proof of nervous syphilis. No 
attention has been directed to the slow or sluggish 
pupil (reflex to light) which the writer finds to be 
fairly constant in hereditary syphilis, irrespective 
of implication of the nervous system. It may be 
equally a unilateral or bilateral phenomenon. Al- 
though the light response may be fairly good in 
the first test, subsequent tests show its rapid ex- 
haustion, a phenomenon almost as important as a 
partial Argyll-Robertson. 

Auricular Sigji. — This consists of a distinct ridge 
(Fig. 1) running from the antitragus downward to- 
ward the lobule. Localized elevations of the skin 
in the region in question must not be accepted as 
evidence of the auricular stigma. It may be uni- 
lateral or bilateral. In the Da Costa Edition of 
Gray's Anatomy (Fig. 752) , there is a picture of the 
external ear which reproduces my auricular sign. 

B 




Pig. 3. — Vasomotoria! sign. A and B, sites of pallor in lieredo- 
syphilis ; B, site of pallor in acquired syphilis. 

This must be due either to a faulty execution of 
the artist or to the selection of a supposedly normal 
ear. The auricular sign is fairly constant in here- 
dosyphilis. 

The ridge is felt to be of cartilaginous consis- 
tency when palpated between two fingers. This 
morphological anomaly like all deformities of the 
auricle is essentially always the result of othema- 
toma. 

Digital Sign. — This consists of an incurvation of 
the little finger, usually implicating the second 
phalanx (Fig. 2) and is fairly constant. 

Vasomotorial Sign. — If the subject faces the 
geographical west with feet on a grounded plate 
and the hands are elevated in proximity to a win- 
dow, it will be noted after thirty seconds that a cir- 
cumscribed pallor is demonstrable at the terminal 
phalanges of all the fingers, notably the little fingers, 
at definite points. At the palmar surface of the ter- 
minal phalanx and on the inner surface and ex- 
treme end in heredosyphilis (Fig. 3). In ac- 
quired syphilis, the circumscribed pallor on 
the palmar surface is not demonstrable but 
is seen in the other area only (extreme end). It is 
evident that mere elevation of the hands is 
productive of some anemia but the latter is uni- 
versal and not circumscribed. The hands should 
be manipulated in relation to the light so as to 



bring the anemic areas into evidence if not readily 
seen. Other vasomotorial signs are present in other 
diseases and have been explained elsewhere.' 

Ocular Pigmentation. — This sign is tentatively 
submitted and refers to an intense bluish pigmenta- 
tion at the sclerocorneal juncture. While this pig- 
mentation may be present in the norm, it appears 
to the writer that it is specially evident in heredo- 
syphilis. 

REFERENCES. 

1. Abrams, Albeit: Medical Record, Oct. 6, 1917, 
and Feb. 16, 1918. 

2. : International Clinics, Vol. 1, 27th series; 

New Concepts in Diagnosis and Treatment; and Spon- 
dylotherapy, 6th edition, 1918. The reactions hereto- 
fore ascertained by percussion are now demonstrable 
galvanometrically by a new apparatus of the writer. 

3. Jarvis, G. 0.: American Journal of Clinical Medi- 
cine and Physico-Clinical Medicine, December, 1917. 

4. Stoll: Jour.~A. M. A., Dec. 23, 1916. 

5. Jarvis: Pacific Dental Gazette, February, 1917. 

6. Sabouraud: Presse Mcdicale, May 17, 1917. 

7. Abrams, Albert: Physico-Clinical Medicine, De- 
cember, 1917; Medical Record, Feb. 16, 1918. 

2135 Sacramento Street. 



SOME OBSERVATIONS ON THE BLOOD SUP- 
PLY OF THE UTERUS— WITH SPECIAL 
REFERENCE TO THE OPERATION 
OF VAGINAL HYSTERECTOMY. 

Bt HOWARD CRUTCHER, M.D., 

TtTLAROSA, NEW MEXICO. 

Considering the immense importance of the 
uterine artery from a practical standpoint, it is 
surprising how small a space it usually occupies in 
anatomical literature, and of the small space that 
it does occupy much of what has been printed con- 
cerning it is unconsciously misleading. Anatomical 
works, whose unchallenged authority has become a 
proverb, describe the origin of the vessel with com- 
mendable precision, but its course after its arrival 
at a point near the uterine neck is not only the op- 
posite of precise, but is befogged by demonstrable 
absurdities. Our first knowledge of this artery is 
more than likely to have been derived from a 
familiar old print in which the vessel is pictured as 
running a zigzag course, from below upward, to 
disappear in a more or less remote network of 
diminishing anastomotic threads. Some of which 
is true, but is only true in those cases in which the 
original course has been altered for the most defi- 
nite of natural reasons. In the virgin subject no 
such course is pursued. In the virgin state the 
artery follows a tolerably straightforward course 
from its origin to a point at which its identity is 
blended through numerous branches with anas- 
tomotic twigs that spring from the ovarian artery 
above. 

During the years of 1892-94, and occasionally in 
subsequent years, I performed a series of pains- 
taking dissections of the uterus in virgin subjects, 
preserved careful notes covering my work, and 
meant to present my conclusions to the Medical 
Record had not the loss of a valued letter file pre- 
vented my doing so. While I must speak from 
memory, I may say that in none of the subjects 
examined did the uterine artery describe anything 
approaching a tortuous course. And, indeed, taking 
a broad survey of the larger works of nature, is 



I 



104 



MEDICAL RECORD. 



[July 20, 1918 



there a single instance, in all the realm of general 
anatomy, in which nature prefers a sharp curva- 
ture to a gentler course, unless there be some defi- 
nite purpose to be served by so doing? A series 
of zigzags appearing in the course of the uterine 
artery is no more in harmony with the general de- 
sign of nature than are those gigantic bends in the 
channel of our great inland river, both arising in 
response to evolutionary forces and not because of 
a preexisting design. 

In the case of a uterus that has undergone ripen- 
ing and fruition, its principal arterj' presents a re- 
markable series of angles and curvatures, and for 
the simplest and most conclusive of reasons. At 
full term the artery traverses a course a foot or 
more in length. Within a few hours, possibly 
within a few moments, that course is reduced to a 
few inches, and the vessel is thrown of necessity 
into a series of folds by the forces of muscular 
contraction, precisely as a dangling rope, suddenly 
released from its fastening above, is hurled into 
loops by the power of gravity when it meets with 
a resisting surface at the end of its descent. Gen- 
erally speaking, the uterine artery is relatively 
straight in the virgin subject, it undergoes great 
growth in length during the progress of gestation, 
and is thrown into unavoidable curves by the forces 
that promote fetal expulsion. This teaching is not 
only supported by strong natural analogy, but by 
the revelations of everyday practical experience. 
It is also in full accord with available konwledge 
and with common sense. 

In a former paper (Medical Record, April 
13, 1918), I directed attention to the exten- 
sive lacerations that often involve the uterine 
tissues to an almost incredible degree. During the 
performance of hysterectomy I have frequently 
been impelled to express astonishment that spon- 
taneous recovery should have followed childbirth in 
many such cases. Enormous tears sometimes ex- 
tend laterally far into the broad ligaments and up- 
ward almost to the dome of the organ. In this 
great wreckage of soft tissues the uterine artery 
must escape dangerous injury for obvious reasons, 
or the patient would die speedily from bleeding. 
Subsequent processes of repair may involve the ves- 
sel in irregular masses and planes of scar tissue, 
which are likely to prove highly distressing at 
times to those who are impelled more by adherence 
to some mechanical ritual than they are by a whole- 
some respect for the principles of operative sur- 
gery. In all cases of laceration followed by ex- 
tensive scarification it must be borne in mind that 
the artery is subject to the widest variations, both 
as to its supposed course and to its immediate re- 
lations. 

The earnest and capable student of one branch of 
natural science will usually find the subject so stim- 
ulating and profitable that he will develop a keen 
desire to pursue the wider fields of general scien- 
tific knowledge. The great sciences of physiology 
and pathology, so vital to higher human welfare, 
are mere branches of those greater sciences of 
growth and decay, which are fundamental to all 
forms of life. Nature's resources are so im- 
measurably rich that prodigal waste is disclosed on 
every hand. Many of nature's general processes, 
however, are directed to the ultimate elimination 



of waste, and it is the true mission of science to 
penetrate the secrets of nature for a similar pur- 
pose. The mightiest convulsion of nature recorded 
in our national existence occurred in the heart of 
the Mississippi Valley in the year 1811, one nota- 
ble effect of which was the reversal of the current 
of the great river for nearly an hour, that a vast 
chasm in the crust of the earth might be filled with 
water. But no familiar convulsion of nature, how- 
ever violent, may justly be compared in magnitude 
with those alterations wrought in the human 
uterus by the processes of reproduction. From a 
small pouch of modest dimensions, the womb rises 
to the exalted dignity of the first of bodily organs. 
It is in perfect accord with nature's wasteful meth- 
ods that so great an upheaval of human tissues 
should be productive of occasional irreparable 
damage. Muscular tissue, nerve tissue, blood-ves- 
sels, and connective tissue are involved in a common 
wreckage. The uterine artery, despite its extraor- 
dinary powers of resistance, does not always es- 
cape serious injury or possible destruction in such a 
turmoil of conflicting forces. Moreover, a vicious 
curvature in the nutrient artery, wholly trivial 
from a mathematical standpoint, ought to be quite 
as significant in principle to the pathologist as 
some stupendous freak in the course of a great 
stream is to the student of another department of 
natural science. Above all, it must not be taken 
for granted that the uterine arterj- pursues any- 
thing approaching an unalterable course from its 
source at the anterior trunk of the internal illiac 
until it disappears as a definite tissue somewhere 
within the variable folds of the broad ligament. 
Its variations are fully as pronounced compara- 
tively as are those of other structures of the human 
body. 

So far as uncomplicated vaginal hysterectomy 
is concerned the uterine artery ought no more to 
be involved in the procedure than the internal 
pudic is in the usual operation of perineal lithot- 
omy. This vessel does not normally penetrate the 
uterine substance at any point, but flows through 
the loose connective tissue more or less distant 
from the body of the womb, and it may easily be 
pressed clear of all danger in the earlier part of 
its course by the finger of the operator, precisely 
as the ureter, the base of the bladder, and other 
structures of lesser importance may be dealt with 
in similar fashion. The splendid and harmonious 
design of nature does not admit of the coursing of 
a blood-vessel through the heart of muscular tissue, 
where its channel would be obstructed by the exer- 
cise of the normal functions of the muscle. Just 
why it should occur to any operator to plunge head- 
long into the needless and dangerous exploit of 
ligating the trunk of the uterine artery, when no 
such course is indicated, nay. when all the princi- 
ples of rational surgical practice condemn it, may 
well be left to those who are more concerned with 
the obsen'ation of the letter of some ritual than 
they ought to be in the useful work of conserving 
human vitality. My conception of a classical 
hysterectomy is an operation pursued with the 
fixed determination of removing whatever tissues 
may threaten human life, with the least possible 
disturbance to those tissues that bear no such 
odium, and in the simplest, safest, and shortest 



July 20, 1918] 



MEDICAL RECORD. 



105 



manner possible to human skill. If the uterine 
artery, or any other vessel, obstruct the main pur- 
pose of the operator, the artery must be sacrificed 
in the interest of sound surgical practice. But the 
whims of no operator, however celebrated, must be 
permitted to befog the luminous teachings of scien- 
tific surgery. The large and beneficent additions 
to the surgical art that have sprung from the labors 
of Kocher and Bassini are founded upon the clear- 
est principles of natural science, and not upon the 
trivial likes and dislikes of individual students of 
natural principles. Art may assist nature by imi- 
tating her methods, but the highest art is admittedly 
that which most perfectly conceals its own exist- 
ence. 

Of all the dangei's that arise from the opera- 
tion of hysterectomy, unchecked bleeding stands 
preeminent; but the greater risk from this cause 
comes properly from branches above, and not right- 
fully from the main trunk below. The most dan- 
gerous field for copious bleeding will be found most 
probably in those dense upper bands of the broad 
ligament that are attached to the body of the 
uterus, when all reasonable danger to the main part 
of the uterine artery, the ureter, and other struc- 
tures has been passed in safety. Through this pail 
of the broad ligament the artery often lies in a 
series of loops, certainly none of which when sev- 
ered can bleed when all have been securely com- 
pressed within the blades of a dependable clamp. 
To be more specific, after the main stem of the 
uterine artery has been driven from the field of 
operations, the danger of possible bleeding in- 
creases as we proceed upward, where a network of 
anastomotic twigs, quite variable in size, are gen- 
erally found. The fundus of the uterus having 
been drawn well forward into the wound, the clamp 
is pressed home from below upward, closed se- 
curely, and well locked, where every movement is 
under the eye of the operator. I use the word 
clamp, being fully conscious of some of the absurd 
objections that have been raised against it, even by 
those who have never employed it. My preference 
for that instrument is based upon the reasons that 
it can with ease be employed in situations where 
no ligature can be applied, and generally in a frac- 
tion of the time that a man of the highest skill can 
tie a secure knot. The practical results of the op- 
eration speak for themselves. 

This is not the time for a full consideration of 
vaginal hysterectomy, with its important compli- 
cations, or even for a more extended word on the 
subject in hand. I am, however, gathering the 
essential materials for a more complete survey of 
this great topic, beginning perhaps with the work 
of the celebrated von Langenbeck, and presenting 
it in such form as may prove helpful to those who 
love science for its own sake and art supremely for 
its value in the saving of human life. 



iMild Type of Typhus in Portugal. — Cases of exanthe- 
matic typhus have appeared in various parts of Portu- 
gal. They appear to be well scattered and thus far 
without mortality. The disease seems to have spread 
from the cities to the rural districts and a number of 
the cases were traced to a prostitute of Oporto. Sev- 
eral cases developed in the medical and sanitary per- 
sonnel. — El Sir/lo Medico. 



TESTING FACTS AND THEORIES OF 
HEREDITY. 

Br CASPER L. REDFIELD, 



We observe that an unsupported thing will fall to 
the ground. By investigating the matter we find 
that there is a law, called the law of gravitation, 
which controls falling bodies. By studying that 
law, and by making some tests under it, we become 
satisfied that it is universal in its application to 
physical bodies, and that there is no such thing as 
an exception to the law of gravitation. But some 
person who is ignorant of the facts, or who wants 
to play upon the ignorance of others, might point 
to a rising balloon as evidence that the law of 
gravitation was a mere hypothesis not sustained by 
the facts. But, by reason of our knowledge of the 
fluidity of air, and the relative specific gravities 
of air and balloons, we know that the rising balloon 
is itself an illustration of the action of the law of 
gravitation. TTie contradiction is apparent and not 
real, and is due to the fact that the lighter of two 
bodies is visible to the eye and the heavier is not. 
When observation makes contradiction apparent, we 
may know that more than one factor enters into the 
problem. 

It has been demonstrated that superior offspring 
come from older parentage, and that inferior off- 
spring come from younger parentage. It may also 
be shown that inferior offspring come from older 
parentage, but it cannot be shown, except in a very 
qualified and limited sense, that we can get superior 
offspring from younger parentage. The term 
"parentage" here refers to the age of the parents 
at birth of children in several successive genera- 
tions. "Superior" and "inferior" applied to off- 
spring refer to their mental and physical powei-s 
and not to such things as the color of their hair or 
the shape of their toenails. It also refers to im- 
provement or degeneracy continued through several 
generations. The fact that we may get both su- 
perior and inferior offspring from older parentage 
makes it clear that more than one factor enters 
into the problem. The statement that I have ad- 
vanced the age of parents as the one ovenvhelming 
factor in heredity and evolution is a misrepresenta- 
tion. 

My friend says: "Mary is a superior girl. She 
is at the head of her class in school, and is a fine 
musician. She was born when her mother (Jane) 
was about seventeen years old ; her mother was born 
when her grandmother (Susan) was about seven- 
teen; and the grandmother w-as born when her 
mother (Nancy) was about seventeen. How about 
it?" 

The question is a fair one and is entitled to a 
fair answer. That answer must necessarily touch 
upon methods by which facts are determined 
scientifically. But that touching must be both light 
and brief, as we cannot here give a treatise on 
scientific methods. 

When we speak of Shakespeare, Franklin, and 
Humboldt as being superior men we are referring 
to completed life histories, and not to the relative 
standing of school boys. Shakespeare had "small 
Latin and less Greek," Franklin had almost no 
schooling, and in childhood Humboldt gave no in- 



106 



MEDICAL RECORD. 



[July 20, 1918 



dication that he might later become one of the 
master intellects of the world. The fact that Mary 
is at the head of her class in school is no indication 
that she will become another Hypatia, Madame de 
Stael, Charlotte Bronte, or Harriet Beecher Stowe. 
The superiority ascribed to Mary is not sufficient 
for us to take her alone and compare her with the 
ages of her mother, grandmother, and great-grand- 
mother. But I will not dodge the issue in that way. 
While there is nothing in the facts presented to 
show that Mary will become a remarkable woman, 
there is nothing to show that she will not. Some 
day, when this matter is better understood, the ages 
of these female ancestors will be considered as 
sufficient for us to say that Mary could not possibly 
become one of the remarkable women of the world, 
but we are not warranted in using that argument 
at the present time. We will simply concede that 
Mary is a bright girl and may become a woman who 
is rather more intelligent than the average woman in 
the community. 

Mary is a bright girl, but the evidence presented 
by my friend does not indicate that she is any 
improvement over her great-grandmother, Nancy. 
In fact, she may be inferior to her great-grand- 
mother. If we are to test the effect of ages of 
parents on offspring we must know whether there 
has been improvement or the reverse. When we 
pick such a monumental intellect as Sir Isaac New- 
ton we know that there must have been an improve- 
ment, as it is out of the question that his ancestors 
several generations previously should have been his 
equal. 

My friend gives the ages of Jane, Susan, and 
Nancy — female ancestors in three generations. But 
in the same generations, Mary had eleven other an- 
cestors, the ages of whom are not given. These all 
have their influence on Mary's heredity, and for all 
that my friend says, the average age of the four- 
teen ancestors in three generations may be above 
the average for the community. Practically every 
pedigree extended for three generations shows some 
young parents in it, and these young persons may 
be at any places. The most that is set forth for 
Mary's pedigree is that there are unusually young 
persons in three-fourteenths of the places. 

The age of parents is one factor in the problem. 
The other factor is the intensity with which Mary's 
ancestors were educated. When we know how hard 
those ancestors studied, and how many years that 
study continued, then we know how much they were 
educated. When we know how much they were edu- 
cated, then we know to what extent their mental 
powers were developed by mental exercise, and the 
degree of that mental development is the real thing. 

Mary is now a high school girl. If her mother 
had had as much as five years of schooling, then 
that mother had received considerable more school- 
ing than was received by the average American 
child of the same date. If the grandmother re- 
ceived as much as four years of schooling, and the 
great-grandmother received as much as three years 
of schooling, then they also received more than the 
average children of their days received. The state- 
ment of my friend gives no information on this 
point for the three ancestors mentioned, and, of 
course, nothing for the eleven not mentioned. 

When we take a large number of cases, properly 



classified with respect to some particular thing, we 
may concentrate on some particular point for the 
purpose of learning if that particular point is a 
factor in that particular thing. But when we have 
only one case, and want to measure it, we must 
know all of the factors, or at least, the principal 
factors. One of the factors in determining the 
weight of a body is its bulk, and one of the factors 
of bulk is length. But if we tried to determine the 
weight of a body by length alone we would find a 
kite string to be heavier than a cannon ball. In 
the case of Mary we have only part of the factors 
in one case, and, consequently, the question is in- 
determinate. We cannot say anything about Mary 
except that, with part of the factors small, she can 
not possibly be that kind of an extraordinary indi- 
vidual which is produced only when all factors are 
large. To show what effect age of parents has w-e 
must use entirely different data. 

The eminent men of the world are superior indi- 
viduals to whom our attention has been directed. 
The fact that our attention has not been directed 
to Smith of Jonesville is not evidence that Smith 
is lacking in qualities of superiority. It is well to 
bear that point in mind, as many persons go on the 
assumption that there is no existence to what they 
do not know. If we pick out several hundred of 
the most eminent men of the world we have a large 
number of persons classified under the head of 
intellectual power. With such a group we may di- 
rect our investigation to one possible factor, like 
the age of parents, and when we do so we find that 
these men were produced by fathers who averaged 
over forty years of age at the times when their 
eminent sons were born. We may also direct it to 
education as such, and when we do so we find that 
the eminent men not only came from fathers who 
were educated for many years, but fathers who 
were intensively educated. 

But the most gigantic mass of reliable informa- 
tion on this matter to be found anywhere in the 
world is in the history and records of the American 
trotter during the nineteenth century. Analyzed 
and digested those records throw a flood of light 
upon what is necessary to bring about improvement 
in the human race. For example, the improvement 
in trotting speed was continuous and nearly uniform 
for a century of time. We have hundreds and thou- 
sands of animals which we may classify and which 
we may use to determine what factors enter into 
this improvement. We also have pedigrees in full 
for several generations for indvidual animals, and 
we may test these factors by applying them in indi- 
vidual cases. When we do these things we find that 
what we do for the development of the mental and 
physical powers of the race is exactly what we do 
for the development of the mental and physical 
powers of the individual. If a man wants to de- 
velop strong and powerful arms he must exercise 
the muscles of his arms. He cannot accomplish that 
result by studying law or wiggling his toes. 

With trotters, improvement in trotting power 
from generation to generation came from sires and 
dams who developed their trotting muscles by hard 
trotting work before reproducing, and never came 
in any other way. Furthermore, the rate at which 
this improvement occurred in any particular line 
from generation to generation is proportional to 



July 20, 1918] 



MEDICAL RECORD. 



107 



the extent to which sires and dams developed their 
own muscles by work before reproducing. 

When Sir Isaac Newton said that bodies attracted 
each other directly as their masses and inversely 
as the square of the distance between them, he 
stated a mathematical proposition which was sus- 
ceptible of direct proof or disproof. In saying that 
improvement in trotting powers from generation to 
generation was proportional to the extent to which 
sires and dams developed their own trotting powers 
before reproducing, I am stating a mathematical 
proposition which is susceptible of direct proof or 
disproof. 

It is quite true that the amount of development 
acquired by exercise before reproducing cannot be 
determined exactly for any sire or dam, but it can 
be determined approximately in thousands of cases. 
When we make such determinations for the differ- 
ent animals in successive generations, we get the 
substantial equivalent of exact determinations. It 
is also true that there are some peculiarities in 
transmission which tend to obscure the relationship 
between parent and offspring, but when an improve- 
ment is traced through several successive genera- 
tions, these are practically wiped from the slate. 
The thing to be noted here is that I am stating a 
thing which may be tested mathematically, and I 
am pointing to the records by which any one may 
verify my statements. In a way. such verification 
is simple, but it is not so simple that one can ignore 
half of the factors entering into the problem. 

525 MoxADNOCK Block. 

Hypothetical Questions — Evidence to Support — Read- 
ing from Books on Cross-Examination. — In an action 
against a school of osteopathy and a member of its 
faculty, who, it was alleged, while treating the plaintiff, 
negligently broke her sternum, what was said by the 
president and dean of the faculty of the school while 
making a diagnosis at the request of the defendant 
member, with reference to the condition of the plaintiff's 
sternum, ribs, etc., was admissible ; it not being denied 
that such member treated the plaintiff as the agent and 
employee of the school. The statement of the defendant, 
while treating the plaintiff a day or two after the in- 
jury, to the effect that he was the cause of all the suf- 
fering, was admissible against him. It was held the 
trial court properly permitted the plaintiff to relate a 
conversation to the effect that, when she charged the 
defendant member with responsibility for her injuries, 
the accusation was not denied by him. 

Every party has the right to put before the jury the 
scientific inferences properly deducible from such facts 
as the evidence tends to prove, and subject to the con- 
tingency that the jury shall find such facts to be as 
claimed. The rule is that the court will permit counsel 
to put to the expert, after his competency has been es- 
tablished, a question in which the. things which the evi- 
dence adduced tends to prove, and which counsel claims 
to have proved, are stated as a hypothesis, and the wit- 
ness is asked to state and explain the conclusions which. 
in his opinion, result. Then, if the jury should find 
that the facts assumed in the question have been proven 
by the evidence, they may use the technical informa- 
tion and instruction obtained from the expert in deter- 
mining the ultimate facts; but, if they should find that 
the facts assumed in the question are not true, then, of 
course, the opinions based on them should be wholly 
disregarded. 

It was objected for the defendant that the trial court 
erred in permitting counsel for the plaintiff to ask a 
medical witness the question as to whether or not Hu- 
lett (whom the witness had already testified was a 
recognized authority among osteopaths) in his book 



did not make the statement that "direct violence may 
cause depression, in which case there is likely to be a 
fractured cartilage, occasionally the row of cartilages 
on one side will be more prominent than those on the 
opposite." The objection was that it was "hearsay." 
Hulett's book, from which the statement was read, is 
a book recognized and used as a textbook by the de- 
fendant school for ten years, and the witness in ques- 
tion had so stated, and previously thereto had testified 
that according to the teachings of the defendant school 
there could be no fracture of the cartilage of the ribs. 
There was, therefore, it was held, no error in submit- 
ting che question. It is permissible in cross-examina- 
tion to read to the witness statements contradictory to 
his opinions, found in books which he admitted to be 
authoritative, and to ask him to explain the contra- 
diction. This practice is allowed on the theory that the 
books are referred to merely to test and discredit the 
knowledge of the witness. — Atkinson v. American School 
of Osteopathy, (Mo.) 202 S.W. 152. 

Evidence in Malpractice Cases. — The Illinois Appel- 
late Court holds that, in an action against a physician 
for damages for negligence in placing hot water bottles 
on the plaintiff's body during childbirth without pro- 
tecting her body and limbs, the burden of proof of negli- 
gence is on the plaintiff. Evidence that the physician 
used a brass pin in opening a blister, caused by the use 
of a hot water bottle without adequate protection to 
the body of a woman at the time of childbirth, is in- 
admissible in such an action, where the only negligence 
was in negligently placing hot water bottles on the pa- 
tient. The error was not cured by instructions of the 
court, where the only negligence charged was in neg- 
ligently placing hot water bottles on the patient, and 
the purpose of the admission of the evidence was to 
inflame the minds of the jury. It was held that the 
defendant should be allowed to cross-examine a medical 
witness for the plaintiff, who attended the plaintiff 
after the injury and testified that on an examination 
he found the plaintiff's kidneys affected and that ab- 
sorption from burns affects the kidneys, as to what 
diseases might have affected the kidneys. The gist of 
the action against a physician for malpractice is negli- 
gence and not the violation of the contract of employ- 
ment. 

The plaintiff, in such an action, must allege in 
her declaration her freedom from contributory negli- 
gence. Her failure to do so is not caused by verdict 
where an instruction directing a verdict and referring 
to the declaration is given that in effect informs the 
jury that it is not necessary for the plaintiff to prove 
that she was in the exercise of ordinary care. An 
instruction that the jury found for the plaintiff, then to 
enable the jury to estimate the amount of damages to 
the plaintiff for injury to her person it was not neces- 
sary that any witness should have expressed any opinion 
as to the amount of such damages, but the jury them- 
selves must make such estimate from the facts and cir- 
cumstances in proof was held to be misleading in re- 
ferring to the damages as charged in the declaration, 
which enumerated physicians' bills, nurse hire, medi- 
cines, and being hindered and prevented from trans- 
acting her business affairs, as well as pain and suffering 
and weakness of body and mind caused by the injury. 
The damages for liabilities incurred and damages to her 
business affairs must be based on evidence of debts nec- 
essarily incurred and evidence showing the value of her 
mind and body are to be estimated by the jury in con- 
nection with their knowledge and experience in such 
matters.— Peters v. Howard, 206 111. App. 610. 

Hypothetical Questions. — A party has the right to the 
opinion of an expert witness on the facts of the case as 
he claims them to be, and he may propound hypothetical 
questions assuming as proved all facts which the evi- 
dence in the case tends to prove. 

It is a general rule that an expert witness should not 
be permitted to give his opinion upon the ultimate fact 
to be found by the jury. It is also another well-settled 
general rule that an expert may give his opinion upon 
any question within the realm of scientific knowledge. 
When the ultimate fact to be found by the jury is a 
scientific question, these two principles necessarily come 
into confusion, and one or the other must give way. — 
Sullivan v. Minneapolis, St. P. & S. S. R. Co., Wisconsin 
Supreme Court, 167 N.W. 311. 



108 



MEDICAL RECORD. 



[July 20, 1918 



MilUarg Mpiirinf. 



Medical Work in the British Army. — At a spe- 
cial meeting of the Toronto Academy of Medicine 
held on Monday, June 17, under the presidency of 
Col. A. Primrose, C. A. M. C. A., Col. Sir Arbuthnot 
Lane, R. A. M. C, gave a description of the re- 
markable plastic surgery and cosmetic work now 
being done in the special hospital at Sidcup near 
London. It was pointed out that face disfigure- 
ments were the worst, in that facial mutilations 
were so obvious. Men who had been wounded in 
the body or arms or legs returned to their fam- 
ilies and received a hearty welcome, but in the 
case of face disfigurements it was an altogether 
different matter. The man who was thus disfig- 
ured often frightened his own children. Before 
the war plastic surgery was almost entirely un- 
known to British medical men, the only place in 
which Sir Arbuthnot had seen it was in Vienna. 
However, English surgeons had now learned the 
art thoroughly and this was demonstrated by 
the clear description given by the speaker of the 
remarkable manner in which the surgeons at 
Sidcup in collaboration with dentists, artists, and 
modellers in clay were able to build up or in many 
instances make a new face. It was described how 
the artist made a drawing of the face either from 
a photograph or from his inner consciousness as 
to what the face should be, after which it was 
modelled in clay and the parts lacking were sup- 
plied by bone, cartilage, and flesh taken from 
other portions of the body. Especially did the 
speaker lay stress on the bone grafting, drawing 
attention to the fact that while bone grafting in 
the extremities was a very uncertain procedure, 
because of the tendency to infection, in the head 
and jaw it was attended with quite extraordinary 
success. A "big chunk" of bone could be taken 
from the ischium, shaped and fitted into the jaw 
with no untoward consequences whatsoever. Em- 
phasis was also laid upon the point that large 
pieces of epithelial inlay graft taken from the 
most suitable parts of the body could be used for 
the face with a very large measure of success. 
As for a lost eye not only could a very good sub- 
stitute be supplied, but it could be made to move 
or rotate in so natural a manner that it was difli- 
cult frequently to believe that it was not a real 
eye. 

Sir Arbuthnot Lane then spoke of the organi- 
zation of the large military hospitals at Alder- 
shot, the largest in Great Britain. His view as 
to the organization of such hospitals may be 
summed up in the statement that economy of labor 
makes for efficiency and such economy can only 
be gained by specialization. That is, each man 
should be given a certain line of surgical work to 
which he should wholly devote his time. It must 
be remembered that the ordinary medical practi- 
tioner is not called upon except in exceptional cir- 
cumstances to do major surgery and therefore he 
is not a skillful surgeon. However, the exigencies 
of the war have rendered it imperative that all the 
available medical and surgical material of the 
entire medical profession of Great Britain should 
be called into service. Now it would be mani- 
festly impossible, however apt to learn a man 



might be that he could cover the whole range of 
surgery, or even a considerable part of it in the 
comparatively short time at his disposal. But, if 
he specialized in a particular branch of surgerj- 
he might in a few months become competent and 
perhaps really proficient by thus concentrating 
his faculties. For example, an instance was cited 
of a general practitioner well endowed with this 
world's goods, who before the war had conducted 
his practice in a laissez oiler kind of manner. 
When he was nailed to a specialty under the stress 
of endeavor and earnest hard work his hidden tal- 
ent was discovered, and he has developed into not 
only a skillful operator but into one of the ac- 
knowledged authorities in Great Britain on genito- 
urinary diseases. 

Col. Herbert Bruce, R. A. M. C, then gave a re- 
view of the medical and surgical work done at 
the front. With regard to the treatment of 
wounds it was pointed out that at the beginning 
of the war surgeons attempted to treat wounds 
on aseptic principles in the same manner as 
they had been accustomed to treat them in the 
hospitals at home. Under the conditions of war 
the results were exceedingly bad and for a time 
antiseptic treatment pure and simple held sway. 
This, too, was found to be unsatisfactory and 
various measures of one kind and another have 
been tested in order to discover a reliable means 
of combating sepsis. None of these has proved 
entirely successful. Wright's method has its ad- 
vocates, and the Carrel-Dakin method is largely 
employed. However, it appears to have been dem- 
onstrated that effective drainage is of more con- 
sequence than the application of any antiseptic 
or of the use of any method for controlling sepsis. 
If a wound is thoroughly cleansed, however, it 
may be closed and frequently will heal by first in- 
tention. Attention was drawn to the fact that 
trench fever has been found to be infective, and 
that suspicion, almost amounting to certainty, has 
been directed to the body louse as the infecting 
agent. 

Colonel Bruce held the opinion that the discov- 
ery that transfusion of blood is of the highest 
value in overcoming hemorrhage and hemorrhage 
plus shock was one of the most valuable results 
of the war from the medical standpoint. It was 
pointed out that not only fresh blood but citrated 
blood kept in cold storage could be employed for 
this purpose, and to Major L. Bruce Robertson 
must be given a great deal of the credit for estab- 
lishing this mode of treatment. In the retreat of 
the Fifth Army a large number of bottles of 
citrated blood were captured by the Germans 
and it was suggested that it might be used by 
them to purify their owti blood. 

The great need for medical men was dwelt on 
and it was related how in the attempt to econo- 
mize the time of the limited supply of doctors 
nurses were being trained to act as anesthetists. 
Especial praise was accorded to the work of the 
sanitarians and hygienists at the front and be- 
hind the lines. It was stated that at the pres- 
ent time there were only twenty-seven cases of 
mild typhoid fever in the entire British Army 
in France, a result due to inoculation and to efli- 
cient sanitary measures. The statement was made 



July 20, 19181 



MEDICAL RECORD. 



109 



by the speaker to the effect that while anti- 
typhoid vaccination was not compulsory in Great 
Britain, when the British soldiers were removed 
from home influence all opposition to the pro- 
cedure seemed to vanish and vaccination was 
practically universal in the army in France. 



Long Beach Hotel Taken for Army Hospital. — 

The Government has signed a contract for the 
use of the Hotel Nassau, at Long Beach, L. I. It 

li is expected that the property will be taken over 

I early in September. It is planned to use the build- 
ing for a convalescent hospital for soldiers. 

The Red Cross Organizes Overseas Communi- 
cation Service. — The Atlantic Division of the 
American Red Cross announces that a communi- 
cation service has been organized and that men 
are being sent to France in quest of casualty in- 
formation. These men gather information con- 
cerning men in hospitals, write letters for them, 
and send news to the home folks. They also lo- 
cate prisoners, seek the missing, and mark graves. 

j Casualties of the American Expeditionary Force. 

I — The figures of the War Department, on July 12, 
show that up to that date there have been 1,629 
men killed in action, 587 have died of wounds, 
1,336 of disease, 501 have died from accident or 
other causes, 5,340 have been wounded in action, 
and 508 are missing. It is worthy of note that 
not as many men have died from disease as have 
been killed in action. 

i Mobile Hospital Units Ready to Sail. — Hospital 
units ready to sail or able to embark on two 
weeks' to a month's notice include base hospitals, 
evacuation hospitals, ambulance companies, rail- 
road hospital trains, convalescent camps, and med- 
ical supply depots. All these are in addition to 
the regular medical department units. Fifty rail- 
road hospital trains of sixteen cars each are on 
order in Europe or already delivered to the Amer- 
ican Expeditionary Forces. Each of these trains 
has a capacity of 400 patients, with operating 
rooms, kitchens, etc. Each base and evacuation 
hospital comprises the personnel and equipment 
for a hospital with a normal capacity of 1,000 pa- 
tients. Each ambulance company consists of 37 
men and an officer and operates 29 ambulances. 
A convalescent camp is organized to care for 
about 10,000 patients and includes a 1000 bed hos- 
pital. Its personnel, as formed on this side, con- 
sists of 10 officers and 90 enlisted men. This is 
merely the medical personnel and will be aug- 
mented and later largely replaced by medical offi- 
cers and enlisted men from among those conva- 
lescing. At these convalescent camps consider- 
able reconstruction work will be carried on. 

Wounded Soldiers in Scottish Woman's Hos- 
pital. — The Committee on Public Information, Di- 
vision on Woman's War Work, states that fifty 
wounded American soldiers are being cared for 
in the Scottish Women's Hospital, Abbaye de 
Royaumont. America contributed $750,000 to the 
Scottish Women's Hospital, which was opened in 
December, 1914. The hospital started with 200 
beds and has since increased the number to 500. 

Elks Give Reconstruction Hospital. — Announce- 
ment was made at the fiftieth grand lodge reunion 



of the Benevolent and Protective Order of Elks, 
held in Atlantic City, on July 8 and 9, that a 
gift of a $350,000 reconstruction hospital had been 
made to the Government. Three weeks ago the 
cornerstone of a similar institution, costing $250,- 
000, was laid in Boston. The second institution 
is to be located in New Orleans. The war relief 
commission of the Elks has charge of the distribu- 
tion of $1,000,000 relief fund. 

Women Health Officers for Munition Plants. — 
The Ordnance Department makes the announce- 
ment through the War Department that women 
health officers will be assigned to the munition 
plants to see that the women workers are kept 
healthy and their output of war material thus 
maintained at the peak of production. For the 
training of these inspectors an eight weeks' course 
of study is being given at Mount Holyoke Col- 
lege, South Hadley, Mass. The course is under 
Dr. Kristine Mann. The women taking the course 
are college graduates or women of equivalent tech- 
nical education and almost all have had experi- 
ence in dealing with working women. Many of 
the plants now have physicians and nurses to care 
for the workers when they are ill, but this work is 
to be done along entirely new lines, being entirely 
constructive and preventive. 

Student Nurses Wanted for Training in U. S. 
Hospitals.— The Council on National Defense an- 
nounces that 25,000 student nurses are wanted at 
once for training in American Hospitals. This 
call is for women between the ages of 19 and 25 
years and is being issued jointly by Surgeon Gen- 
eral Gorgas, Surgeon-General Rupert Blue, H. P. 
Davidson, chairman of the War Council of the 
American Red Cross, Dr. Franklin Martin, chair- 
man of the General Medical Board, and Dr. Anna 
Howard Shaw, chairman of the Woman's Com- 
mittee, Council of National Defense. The enroll- 
ment will begin July 29, and those who register 
will thereby be subject to call for training in the 
army nursing school or in civilian hospitals until 
April 1, 1919. The enrolling will be done by the 
Women's Committee of the Council of National 
Defense. 

Four Schools Opened for War Cripples. — The 
first group of these schools has been in operation 
for some months and is known as the Red Cross 
Institute for Crippled and Disabled Men, at 311 
Fourth Avenue, New York. This school teaches 
the manufacture of artificial limbs, linotype and 
monotype operating, mechanical drafting, and 
oxyacetylene welding. Similar schools are being 
organized in Chicago and St. Louis. The Smith- 
Sears bill recently passed by Congress provides an 
appropriation of $2,000,000 to be used at the dis- 
cretion of the Federal Board of Vocational Educa- 
tion, which is working out plans in New York City. 
The law authorizes the commandeering of private 
and public institutions for the reeducation of 
crippled soldiers and sailors and, where necessary, 
the building of new schools. 

Health of the Camps Excellent. — The weekly 
army health report, issued on July 11, states that 
health conditions at home camps are very satis- 
factory. Deaths during this week numbered 112, 
during the preceding week 81. 



110 



MEDICAL RECORD. 



[July 20, 1918 



New Manhattan School Building Will Not Be 
Hospital.— The Board of Education of New York 
City has been notified by Surgeon-General Gorgas 
that the Government will not take over the new 
Manhattan Trade School for Girls as was an- 
nounced some time ago. The reason for rescind- 
ing this order is that the arrangements for tak- 
ing over the school were made without due author- 
ity. Surgeon-General Gorgas states that it is not 
the policy of the Medical Department to take over 
school buildings. 

Ambulances Ready for Air Raid. — Five ambu- 
Inaces for use in connection with the Emergency 
Relief Organization in the event of an attack on 
the City of New York by enemy aircraft, sub- 
marines, or disaster of any kind, have been do- 
nated to the Police Department and have been 
placed in Police Department garages in various 
parts of the city. The donors of these ambulances 
are the Calvary Episcopal Church, Church of the 
Ascension, Knights of Columbus, Friars' Club, 
and the Fifth Masonic Division. The name of the 
donor appears on each ambulance. 

Navj- Has Plenty of Medical Supplies. — Secre- 
tary Daniels has made an official denial of the 
rumors that the United States Nav>' is short of 
medical and surgical supplies. He states that 
there is an abundance of all medical supplies on 
all ships, and that the medical supply depot at 
Brooklyn is packed with enough supplies to last 
for months to come. Private individuals should 
not attempt to supply ships unless requested to 
do so. 

Girls Killed iiv Hospital Air Raid. — In a recent 
German air raid on the Belgians more than fifty 
girls were killed by air bombs launched upon an 
ambulance park at La Panne, behind the Yser 
front. The girls were engaged in making band- 
ages and repairing linen for the wounded. 

Shore Drives for Sick Soldiers. — A new line of 
war service work has been initiated by the Brook- 
lyn branch of the National League for Women's 
Service. This organization has established a con- 
valescent home for soldiers and sailors on the 
Shore Road at Eighty-ninth Street, Brooklyn, to 
w^hich are brought convalescents from various 
military and naval hospitals for a day's outing. 
The home has received a letter from Secretary 
Daniels expressing appreciation of the work. 

Sisters of Charity Join Red Cross. — American 
Sisters of Charity, for the first time since the 
beginning of the war, have enlisted as Red Cross 
nurses. St. Vincent's Hospital of Birmingham, 
Ala., has organized the Loyola Unit, known as 
Base Hospital 102, consisting of ten sisters, in- 
cluding a dietician, laboratory assistant, secre- 
taiy, and 90 Red Cross nurses. The sisters wear 
the habit of their order but in all other respects 
submit to the rules of the Red Cross. 

Army Doctor Sentenced for Neglect of Duty. — 
Charged with having contributed to and accele- 
rated the death of a soldier through gross neglect 
of duty, in that a careless diagnosis was made with 
the result that proper medical relief was not fur- 
nished, an officer of the Medical Reserve Corps, 
stationed at Camp Dix, has been sentenced to be 
dismissed from the Army and to serve one year 
imprisonment at hard labor. 



Influenza Among German Soldiers. — According 
to a cablegram to the Associated Press, it has been 
learned, through captured documents and state- 
made by German prisoners, that the Germans are 
suffering extensively in numerous zones from the 
influenza which is running through Europe. The 
affection is said to strike down the men so quickly 
that they drop in their tracks while on duty. 
They have high fever for two or three days and 
are usually laid up in the hospital for six days. 

Roumania Honors American Physician. — Dr. J. 
Breckinridge Bayne of Washington, D. C, who re- 
cently arrived in Berne, Switzerland, after having 
been held a prisoner for a time by the Germans, 
had brought with him a decoration bestowed upon 
him by King Ferdinand of Roumania for his effi- 
cient work in fighting typhus in that country. 

Dental Surgeon Killed. — Dr. Weeden E. Osborne, 
a Dental Surgeon of the Navy during the advance 
in Bouresches, France, on June 6, at great risk to 
his life, performed heroic deeds in aiding the 
wounded. He was struck by a shell while carrying 
an oflScer to a place of safety. He has been cited 
posthumously by Gen. Pershing for a Distin- 
guished Service Cross. 

American Wounded in London — American 
wounded are arriving in London in considerable 
numbers from the sections in France where Ameri- 
cans are brigaded with the British. As soon as 
they reach the hospital their arrival is reported to 
the American Army Medical Service and to the 
American Red Cross. It is expected that as soon 
as the Americans take over the two hospitals 
which the Red Cross recently announced were to 
be used exclusively for Americans most of these 
men will be transferred from the hospitals where 
they are to a hospital which has a staff of Ameri- 
can doctors and nurses. 

Rest Houses for Sick Soldiers. — The American 
Red Cross has opened its rest house in connection 
with the Walter Reed Army Hospital in Washing- 
ton. This is one of forty-four such homes which 
the Red Cross has built or is building in connec- 
tion with every camp hospital. These rest houses 
are being provided in connection with the army 
hospitals at the request of Surgeon-General 
Gorgas. They will also be built at all important 
naval hospitals. For the erection of the fifty or 
sixty that will be needed the Red Cross has set 
aside ^512,000. In addition to that at the Walter 
Reed Hospital, houses are now open at Camp 
Upton, L. I., Camp Devens, Mass., General Hos- 
pital No. 1, New York, and Camp Di.x, N. J. 
Thirty-nine similar houses are being rushed to 
completion at other camp hospitals. 

Knights of Columbus Extend Work. — The 
Knights of Columbus now have 150 buildings in 
France and are rapidly increasing the number 
as the American Army expands. The organization 
announces that it has 350 secretaries in France 
and is now appealing for 2,000 more to man the 
100 additional buildings now under construction. 
The organization now plans to expend $50,000,000 
in its work for the coming year. 

Another German Victor>-. — German aviators 
bombed the American Red Cross Hospital at Jouy, 
France, on July 15, killing two and wounding nine, 
among the latter a nurse. Miss Jane Jeffrey. 



July 20. 1918] 



MEDICAL RECORD. 



Ill 



Medical Record. 

A Weekly Journal of Medicine and Surgery. 



THOMAS L. STEDMAN, A.M.. M.D., Editor. 



PUBLISHERS 
WM. WOOD <tc CO.. 51 FIFTH AVENUE. 



See fonrth page following reading matter for Rates of Subscription 
and Information for Contributors and Subscribers. 



New York, July 20, I9I8. 



ONE HUNDRED CASES OF ICTEROHEMOR- 
RHAGIC SPIROCHETOSIS. 

XOLF and Ficket report this series in the Archives 
Medicales Beiges for April. The material was seen 
during 1917. In regard to epidemiology the order 
of incidence is naturally of significance. But four 
cases were seen during the month ending June 20. 
and twenty-six the following month, with a drop to 
eighteen in the third, and a rise to twenty-seven in 
the fourth month. The monthly figures then fell 
respectively to eleven, ten, and four. There seems 
from this to be a relationship, then, between sum- 
mer w-eather and disease incidence. The ten-day 
figures show two maxima at June 20-30 and Sep- 
tember 10-20. Each of these periods was preceded 
by very hot weather. At the same time animal ex- 
periment makes it very probable that the sewer 
and trench rats act as reservoirs for the spirochete, 
while the intermediary, believed to be some stinging 
insect, has not yet been determined. 

In practically all the material the patients en- 
tered the hospital on the fourth or fifth day of the 
disease — hence we have no first-hand knowledge of 
the early symptoms. From the testimony of the 
patients it is evident that the inception is sudden, 
with headache and prostration. Myalgias are com- 
plained of in the posterior aspect of the thighs, the 
calves, flanks, loins, and nuchal region. The mus- 
cles are extremeh' sensitive to pressure. There is 
moderate fever, while the pulse seldom exceeds 100. 
The blood pressure is very low, with 120 as the 
maximum. Prostration is marked, and this, with 
induced muscle pains, makes even turning in bed a 
hardship. An experienced practitioner will make 
the diagnosis from this behavior alone. The con- 
junctiva and ciliary body are injected and the sub- 
ject complains of pains in the eyeballs whenever 
he looks upward or sidewise. A bronchitis is 
present with an harassing cough. The sputum, 
which is scanty, may be streaked with blood or at 
times there is hemoptysis without physical signs 
of bronchitis. The presence of blood in the sputum 
is the earliest hemorrhagic sjTTiptom as it is the 
most constant. Only when the subject is hemo- 
philic do we find purpuric and scorbutic types of 
hemorrhage. 



Tests of coagulation time show that this is some- 
what delayed, varj-ing directly with the degree of 
the hemorrhagic tendency. At the outset the stools 
are of normal color and consistence. Diarrhea was 
present in but 4 per cent. The liver is but slightly- 
enlarged. There are anorexia and vomiting, the 
former constantly and the latter commonly present. 
Quite a degree of meteorism is frequent. There 
are almost always albumin and urobilin in the urine 
in the first few days. There is habitually a leucocy- 
tosis with polynucleosis. 

The symptoms grow steadily worse from the 
first to the sixth day, at which period the conjunc- 
tiva is seen to be icteric. On the following day ic- 
terus becomes generalized. Bile is now present in 
the urine. The stools may or may not become 
blanched, depending on the degree of icterus. The 
latter appears to represent a stage of acme of 
the disease, and around the ninth or tenth day all 
of the sjTnptoms begin to improve notably. For 
some five days more the patient, although without 
fever, is very weak, though no longer prostrated. 
The cycle of the icterus is about eight days. 

Defer\-escence is followed by critical polyuria, 
which persists for perhaps a week, the patient 
voiding from three to five quarts daily for four 
days. But all is not over with these crises, for the 
malady is essentially remittent ; somewhere between 
the fifteenth and twentieth days the temperature 
rises and stays up for a week, reaching a higher 
mark at times than the initial fever. There is. 
however, no accompanying general reaction of se- 
vere subjective symptoms. The second deferves- 
cence occurs on the twentieth to the twenty-fifth 
day, but the patient may not regain his normal 
status until the end of about six weeks, and this 
takes no account of residual weakness, anemia, 
vertigo, shedding of hair, etc. 

The above description fits the typical case of 
moderate severitj- in which recovery occurs. In 
certain cases the subjective manifestations or the 
prostration are especially in evidence, but the au- 
thors do not mention any fatal cases such as have 
been described especially by the Japanese. 



THE ACRIDIXE DYES IN THE TREATMENT 

OF SEPTIC WOUNDS. 
Within the past year or so the bactericidal prop- 
erties of acridine dyes have been highly extolled, 
and attention has been drawn to the fact that 
contrarj- to most antiseptics their action is en- 
hanced in the presence of serum. In American 
Medicine for May, 1918, are two notable papers on 
this subject, one by Dr. R. Tanner Hewlett of 
London and the other by Dr. Douglas H. Stewart 
of New York. Hewlett deprecates the excessive 
praise that has been showered upon flavine re- 
cently by certain observers and he points out some 
of its drawbacks, especially its slow action as a 
bactericide. Hewlett quotes the conclusion of 
Drummond and McNee as regards the practical 
treatment of wounds with flavine, to the effect 



112 



MEDICAL RECORD. 



[July 20, 1918 



that flavine appears to have many advantages in 
the treatment of recent war wounds, such as (a) 
absence of all toxicity, (b) prevention of suppura- 
tion and spreading sepsis, (c) the primary dress- 
ing need not be changed for two or three days, (d) 
the wounds are not inflamed or painful. But 
fiavine cannot be classed as a success in the 
treatment of the later stages of war wounds. The 
wounds tend to assume a stagnant condition dur- 
ing which the processes of repair are almost in 
abeyance. After a few days when the dangers of 
gas gangrene and of spreading sepsis have, to a 
large e.xtent, passed off, flavine should be stopped 
and another treatment adopted. In the majority 
of cases, wounds are not rendered bacteriological- 
ly sterile even by the prolonged use of flavine. 

Hewlett, like so many others, who have had ex- 
perience in the treatment of war wounds, has been 
forced to the view that "good surgery" is the es- 
sential for success. That is, thorough cleansing 
and complete removal of all foreign bodies and 
material, and free drainage. He questions, more- 
over, after this has been done, whether hypo- 
chlorite solutions are better than some other anti- 
septics and would like to see some of the high 
coefficient phenoloid disinfectants, which have a 
comparatively low toxicity, and some formalin 
containing disinfectant applied by the Carrel- 
Dakin method and the results compared with 
those from Dakin's solution. 

Dr. Stewart points out that on account of the 
innocuousness of brilliant green and especially 
acriflavine, when applied to damaged animal tis- 
sues, contact with these dyes does not incommode 
parasites. In some instances, when conditions 
were favorable, maggots were observed by Stew- 
art to crawl over the green stains without being 
discolored or appearing to suffer the slightest in- 
convenience. Nevertheless Stewart states that 
the good results that have followed the applica- 
tion of the green solutions are all that have been 
claimed for them, save for one disadvantage. 
Stewart sums up the drawbacks of the greens 
when dissolved by stating that they are excellent 
germicides, but not parasiticides, and when 
gauze bandages are soaked with such solutions 
and placed upon wounds these adhere. 

It would seem that the value of the acridine 
dyes from the antiseptic standpoint have not been, 
by any means, accurately assessed as yet. It is 
likely as Hewlett suggests, from a consideration 
of the results gained from experiments and prac- 
tice by others that the use of flavine in the treat- 
ment of wounds may be as a primary agent extend- 
ing over a few days, other antiseptics being then 
substituted for it. 



for although such fractures have occasionally been 
reported, it is evident that the fact that the weight- 
bearing property of the maimed tibia and its power 
of resistance to lateral strain have been markedly 
interfered with, and are not regained for many 
weeks, needs to be emphasized. 

This is well shown by the experience of John A. 
Brooke, American Journal of Orthopedic Surgery, 
June, 1918, who reports three cases in which frac- 
ture occurred in patients who were allowed to walk 
without support to the weakened tibia, at the end of 
four or five weeks. In his first case, a man of 24 
was allowed to walk without support at the begin- 
ning of the fifth week. About a week later, upon 
rising from a chair, he made a misstep and slipped 
on the floor. There was immediate severe pain in 
the leg, and radiography showed a fracture begin- 
ning at the upper and inner angle of the cleft from 
which the graft had been removed, and extending 
abliquely upward nearly through the shaft. The 
second patient was a physician, 38 years of age, 
who was allowed to w'alk without support at the end 
of four weeks. A few days later, while going 
downstairs, he slipped, and brought sudden weight 
on the leg from which the graft had been removed. 
The a;-ray in this case showed a fracture beginning 
at the lower angle of the space from which the 
graft was removed and extending obliquely down- 
ward well across the shaft. The third case, that of 
a man 47 years of age, occurred in the service of 
Dr. James K. Young. This patient made a misstep 
while walking in the yard, during the fifth week 
after operation, turned his ankle, and fell. The 
.r-ray showed fracture of the tibia beginning at the 
upper angle of the area from which the graft was 
removed, and extending obliquely across the tibia. 
In all these cases the graft was removed by motor 
saw, hence it is reasonable to suppose that the mini- 
mum of trauma was inflicted. 

Very little evidence of regeneration at the site of 
removal of the graft is shown in a radiograph 
which accompanies one of the reports, and it is evi- 
dent that a tibia from whose crest a graft is taken 
should be supported for considerably more than the 
four or five weeks allowed in these cases. Adequate 
prophylaxis is so simple and easy, and the results 
from its neglect may be so disastrous, that accidents 
of this sort seem particularly regrettable as well 
as unnecessary. 



FRACTURES OF THE TIBIA FOLLOWING THE 

REMOVAL OF A BONE GRAFT. 
Apparently it has not been sufficiently realized 
that a tibia from which a bone graft has been re- 
moved needs protecting splints for a rather extended 
period, if one would avoid the danger of fracture: 



ETIOLOGY OF DYSENTERY. 

Aldo Castellani, the distinguished authority on 
tropical medicine, now connected with the Italian 
naval medical service, contributes an article on 
this subject in the Annali de medicina navale e 
coloniale for January-February. The distinction 
between diarrhea and dysentery was known to 
Hippocrates and etjually to Charaka and Susruta. 
In Sanskrit dysentery was denoted by a word 
meaning bloody-mucous-diarrhea, of which an 
acute and a chronic form were recognized. The con- 
ception of these troubles has come down to us 



Julv 20. 1918] 



MEDICAL RECORD. 



113 



undisturbed. The author recognizes dysentery 
proper and pseudodysentery or dysenteriform syn- 
dromes. The former is divided according to the 
e.\citing cause into four groups, bacterial, amebic, 
ciliate, and spirochetic, while dysenteric syn- 
dromes are due to malarial parasites, Leishmania. 
various worms, and certain arthropoda, and finally 
to mineral poisons. 

Passing by the well known amebic and bacterial 
types, we note that of the various ciliate parasites 
in the human intestine, only one — Balantidiinn 
coli, is known positively to cause a true dysentery, 
although seven other species may possibly set up 
the disease. Spirochetes have been accused on 
rather doubtful authority by a few -writers. The 
flagellates, such as Trichomonas and Lamblia — 
genera accused by Escomel and others as caus- 
ing dysentery — are exculpated by the present writer. 

In the diagnosis of dysenterj- it is necessary 
to e.xclude the pseudodysenteries. If a malaria! 
subject develops dysentery it is most often the 
case that a true double infection has occurred, but 
exceptionally the Plasmodium is able to set up a 
dysenteriform syndrome. In the latter case the 
symptoms subside promptly under quinine. The 
same may be said of kala-azar and dysentery, 
when antimony has a specific control of the bowel 
syndrome. Under pseudodysentery from worms 
the author relates a case due to one of the 
schistosomata. If there is a suspicion of mer- 
curial poisoning in a case with dysenteric stools, 
the urinarj' examination at once clears up the 
diagnosis. 



"Spanish Influenza." 

During the past six weeks or so, much has been 
said in dispatches from Europe of a mysterious mal- 
ady which appeared first in Spain and spread thence 
to other parts of the Continent. The German army 
is said to have suffered severely from its visitation, 
and it was even conjectured that the delay in the 
long-expected drive was due to its prevalence among 
the troops of the Crown Prince. At first, the dis- 
ease was unrecognized, and the public press and 
even some medical papers gravely discussed its 
symptoms, which, when analyzed, were seen to be 
those of ordinary influenza of rather mild type. As 
a matter of fact, it is nothing more than a wide- 
spread epidemic, almost a pandemic, of influenza. 
We learn from El Siglo Medico that it first attracted 
attention in Madrid during the celebration of the 
religious festivals in May, when the town was packed 
with visitors. The mysterious part of it was its 
sudden outbreak in that one locality, but inquiry 
showed that it had prevailed more or less for some 
time in other cities of Spain. A little earlier, Chauf- 
fard, in Paris, called attention, at a meeting of the 
Societe medicale des hopitau.x, to the epidemic inci- 
dence of a febrile affection recalling in its general 
features the influenza of 1889. Influenza prevailed 
in this country also to an unusual extent in the early 
spring. On March 30 it was stated in the news 
columns of the Medical Record that the Board of 
Health of this city had issued a warning regarding 



exposure to grippal infection, it being said that not 
since 1889-90 had the disease cut so heavily into the 
working forces of large employers of labor, both in 
oflfices and shops. A week before that one hundred 
cases were reported in Sing Sing prison, and two 
weeks later it was reported to be crippling the 
work of the Ford Motor Company in Detroit, 2,000 
of the employees having been attacked within a pe- 
riod of ten days. And so the mysterious "Spanish 
influenza," which the Germans call "Flanders grip," 
is merely epidemic influenza, which appears to have 
started on its travels from America, going eastward 
in a direction opposite to that usually taken by the 
great pandemics. 

Saliva as a Vulnerary. 

The fact that a dog heals its wounds aseptically by 
constantly licking them has been explained by the 
formation of antibodies generated by the swallowed 
disease germs or toxins ; the veterinaries indeed 
give the wound discharges to wounded animals by 
the mouth after and even in the absence of sterili- 
zation. The only other explanation of this fact, if 
it be a fact, is the bactericidal and vulnerary pow- 
ers of the saliva. In the Journal de Medecine de 
Bordeaux for May, 1918, Dr. Grevin deplores the 
fact that he has neither laboratory nor library to 
investigate this subject, but he believes that a study 
of the ingredients of saliva could throw much light 
on the preparation of an antiseptic solution to be 
used as a wound dressing. The belief in the vulner- 
ary properties of saliva per se, aside from any pos- 
sibility of conferring immunity by swallowing, is 
old and the simple admonition to spit on a recent 
insect bite as the utmost that is necessary is en- 
countered at times among practical members of 
the laity who come much in contact with these in- 
juries. Such advice used to be given by a veteran 
insect exterminator whose empirical knowledge must 
have stood for something. 



German Hospitals Change Name. — The German 
Hospital in Manhattan has changed its name to 
the Lenox Hill Hospital. The German Hospital 
in Brooklyn will take the name of the Wyckoff 
Heights Hospital. 

Infants Examined in Straus Milk Stations. — 
Nathan Straus has given instruction to Dr. 
Michael Schuman, physician in charge of the 
Straus milk activities and to his assistants to be- 
gin the examination of children who may be 
brought to the depots with a view to advising the 
mothers of these children as to the health needs 
of these infants. The work is part of the plan 
of the Federal Children's Bureau to save 4,700 
children's lives in New York City. 

Cholera in Russia. — According to a report com- 
ing through London, hundreds of persons in Petro- 
grad are daily fallings victims to cholera. Au- 
thorities state that it is impossible to do any- 
thing to combat the epidemic owing to the very 
serious shortage of food, it being impossible to 
furnish even a quarter of a pound of bread daily. 
The Russian Council of Commissioners had made 
a most urgent appeal to the councils in the corn 



114 



MEDICAL RECORD. 



[July 20, 1918 



provinces and to the railways to send food to 
Petrograd as rapidly as possible. 

To Fight Yellow Fever in Ecuador. — An Ameri- 
can sanitary commission, including four doctors 
and six nurses, headed by Dr. A. K. Kendall, has 
arrived in Guayaquil for the purpose of cooperat- 
ing in the endeavor to wipe out yellow fever in 
that locality. The commission was sent by the 
Rockefeller Foundation. 

Students in Maternity Hospitals. — It is reported 
that many mothers are being attended in child- 
birth by medical students at the Chicago Lying- 
in Hospital as a result of the shortage of regular 
surgeons. Publicity has been given to this inno- 
vation by an investigation of the State to deter- 
mine whether the procedure is legal. 

Call for Classification of Convicts.— The New 
York State Commission on Prisons, of which Dr. 
Walter B. James is chairman, met in the New 
York Academy of Medicine on July 12, to discuss 
problems in connection with mentally defective 
criminals. Resolutions were adopted calling for a 
classification of prisoners on a mental basis. The 
resolutions set forth that if a record were kept of 
each inmate's brain capacity prison authorities 
would be able to follow better methods in dealing 
with convicts. 

Medical Jurisprudence Society is Defunct. — 
The majority of the members of the American 
Association of Medical Jurisprudence have filed 
an application in the Supreme Court for the disso- 
lution of the corporation. The petition shows 
that the membership has decreased from 200 to 
23, and that there is a general lack of interest in 
the organization. An order has been signed di- 
recting all persons interested to show cause, on 
July 30. why the corporation should not be dis- 
solved. 

Floating Hospital Begins Season. — The Floating 
Hospital of St. John's Guild of New York made 
its first trip for the present season on July 12. 
The floating hospital makes trips between various 
points in New York and Brooklyn to the hospital 
of the Guild at New Dorp, S. I. This is the fifty- 
second year that the guild has given this service 
to sick children of the poor. 

Rally for New York Infirmarj-. — The auxiliary 
committee of the New York Infirmary for Women 
and Children, New York, recently held a patriotic 
rally at the Hotel McAlpin for the purpose of dis- 
cussing ways and means of raising the $200,000 
needed to continue the work of this hospital. 
This is the second rally held within a couple of 
weeks for this object. Dr. Angenette Parry is 
chairman of the committee. 

Act to Incorporate Medical Society. — The Se- 
nate, on June 30, passed an act to incorporate the 
Medical Society of the District of Columbia. This 
society was originally chartered by Congress in 
February, 1819, and the charter having fallen into 
disuse was revived in 1883. By the enactment, 
in 1896, of the medical practice act for the Dis- 
trict of Columbia, a large part of the charter which 
formerly had licensed practitioners of medicine 
was repealed. The society is planning to acquire 
a building of its own in which to transact its 
business and for this reason the revival of the 
charter has been requested. 



Feud in Birth Control League. — An official an- 
nouncement from the headquarters of the Birth 
Control League in New York City states that this 
organization has severed its connections with Mrs. 
Margaret Sanger, who served thirty days in the 
Queens County Jail for the dissemination of in- 
formation about birth control. The reason given 
for this action is that a disagreement has arisen 
between Dr. Frederick A. Blossom, one of the 
founders of the league and Mrs. Sanger as to the 
management of the league, and the league is sup- 
porting Dr. Blossom. 

Amend City Ordinance to Help Hospitals. — The 
New York Civil Service Commission announces 
that a serious situation arising in the city hos» 
pitals due to the ordinance passed in 1913 requir- 
ing that all city employees be citizens of the 
United States has been met by an amendment of 
the ordinance by the Board of Aldermen, permit- 
ting the employment in institutions for the sick 
and infirm, and in dispensaries, clinics, and labor- 
atories, of aliens of neutral or allied countries. Un- 
til this ordinance was amended the city faced the 
prospect of closing many of the hospitals because 
many employees in these institutions had been 
drafted or had enlisted and a large number were 
enemy aliens whose services were dispensed with 
as soon as war was declared. 

Blind to Use Braille Type. — The American Asso- 
ciation for the Blind, after ten years' discussion, 
has adopted the revised Braille type as best 
adapted for the use of blind readers. The other 
forms of type for the blind will be gradually 
discarded in future publications. 

Dr. Friedrich August Richard Strensch, a prac- 
tising physician of this city, a graduate of the 
Baltimore Medical College in 1898, has been ar- 
rested on a presidential warrant as a dangerous 
enemy alien. 

Dr. Maud Kinnaman, formerly of Washington. 
N. J., has been made head of the new medical 
college at Vellore, India. 

Dr. George T. O'Donnell has been appointed 
health officer for the Connecticut Valley district 
to replace Dr. W. S. Hitchcock, who has been 
made director of the division of communicable dis- 
eases. 

The Des iVIoines Valley Medical Association, 
at its annual convention in Des Moines, la., on 
June 27, elected the following officers: President, 
Dr. S. K. Davis of Libertyville; First Vice-Presi- 
dent, Dr. M. F. Moore of Ottumwa; Second Vice- 
Presideyit, Dr. T. P. Jackson of Albia. 

English Birth Rate Falling. — Sir Bernard Millet, 
the Register General, in a recent lecture, stated 
that in England and Wales the births registered 
in 1913 were 881,890; in 1915 they fell to 814,614. 
in 1916 there was a still further fall to 780,820; 
in 1917 they fell to 668,346, a decline from the 
1913 figures of 24 per cent. Vp to the present 
England and Wales are said to have lost in po- 
tential lives 650.000 on the standard of 1913. It 
is believed that without exaggeration it may be 
said that the war has thus far cost belligerent 
countries of Europe not less than 12,500,000 po- 
tential lives. At the present time every day of 
war is said to mean a loss of 7,000 potential lives 
among the Allies and the Central Powers. Race 



July 20, 1918] 



MEDICAL RECORD. 



115 



suicide on a colossal scale has been the outstand- 
ing result of German militarism. 

British Women Want Schools for Defectives. — 
A special subcommittee of the Joint Parliamen- 
tary Advisory Council, composed of women social 
workers and members of Parliament, has just 
issued a report upon existing permissive educa- 
tional provision made for defective children. The 
report calls attention to the need of making the 
acts of Parliament dealing with these children 
compulsory and not permissive. The report 
states that there are in the country to-day between 
37,000 and 40,000 children, who are cripples or 
otherwise defective, the greater number of whom 
are being deprived of educational advantages. 
There are in London thirty-seven schools for the 
physcially defective with an attendance of 3,700 
children. There are fifteen districts in England 
and Wales that possess these schools. The spe- 
cial committee is asking for compulsory powers 
under the education bill and for the establishment 
of special residential schools for defective chil- 
dren. 

Hospital Cornerstone Laid. — The cornerstone of 
the new People's Hospital was laid with appro- 
priate ceremonies on the afternoon of June SO. 
The building is located at 203 Second Avenue, 
New York City, and will be a ten-story structure 
with all modern facilities. 

Obituary Notes.^ — Dr. William Hunt Hall, a 
graduate of the New York University Medical 
School, in 1858, died at his home in New York, on 
July 8, aged 85 years. He was surgeon in charge 
of a Confederate base hospital near Petersburg 
durii:g the Civil War. 

Dr. N. Curtice Holt of New York, a graduate 
of Bellevue Hospital Medical College, in 1896, died 
suddenly in Webster, N. Y., on July 8, aged 65 years. 
He was a brother of Dr. L. Emmett Holt of New 
York. 

Dr. Aaron A. Mendel, a graduate of a medical 
college in Roumania, in 1896, died at his home in 
New York Citv on Julv 12. 



PART-TIME NURSING SERVICE. 

To THE Editor of the Medical Record : 

Sir: — The Red Cross demands the enrollment of 
25,000 nurses for the army and navy, for public 
health work connected with the encampments, and 
for reconstruction work at home and abroad. This 
will greatly deplete the number of trained nurses 
available for private duty. The Red Cross exempts 
those nurses who are indispensable to the Depart- 
ment of Health and to the visiting nurse services, 
and a chevron indicating this recognition of their 
patriotic service at home will be issued to these 
nurses. 

The needs of the country require a sacrifice on 
the part of the nurse-employing public and physi- 
cians to engage a private-duty nurse only when 
absolutely necessary. To meet the need of the pub- 
lic the Visiting Nurse Service of New York, admin- 
istered by the Henry Street Settlement, is ready to 
answer calls from all classes of society where the 
full time of a nurse is not essential. The staff con- 



sists of about 150 nurses, all graduates of recognized 
hospital training schools, and especially trained in 
the technique required in visiting nursing. They 
are qualified to carry out physicians' orders for 
special treatments as well as general care. Every 
precaution is taken to safeguard the patients, and a 
special group of the staff is assigned to the care of 
patients suffering from contagious diseases and an- 
other special group takes care of maternity cases 
only. The nurses caring for general medical and 
surgical cases also observe a very careful technique 
as they pass from case to case. 

This letter is addressed to those of your readers 
who may not be aware that the Visiting Nurse Serv- 
ice is meant for people of all classes. It is sincerely 
hoped that they, and their patients, who up to this 
time have used the full time of the nurse, will recog- 
nize the obligation to free such nurses whenever 
possible for war service. 

Lillian D. Wald, R.N. 

L. Emmett Holt, M.D. 

Xew Yokk. 



THE STATE NARCOTIC DRUG LAW. 
To the Editor of the Medical Record: 

Sir: — The representatives of the Medical Society 
of this city who failed before Governor Whitman 
in their opposition to the law for a State commis- 
sioner of drugs will restate the objections which 
they placed before him in regard to this measure 
before the informal convention of the Republican 
party of this State at the Saratoga convention this 
week. 

The result of drug laws in this State up to the 
present time has been to demoralize the practice of 
medicine so far as relates to the prescribing of 
opium. They have caused untold suffering and 
death to those having to use this drug, owing to 
drug laws harshly enforced by ignorant adminis- 
trators. They have developed a new criminal indus- 
try more profitable and less risky than robbery, 
crimes of violence, or ballot box stuffing, from all of 
which vocations many of its members have been re- 
cruited. This class the police are powerless to sup- 
press, for what reason is not known. The law for 
a commissioner of drugs has advantages of political 
patronage. It penalizes physician and patient and 
lets the drug peddler alone. Many physicians to- 
day are afraid to prescribe morphine in sufficient 
doses to patients dying of cancer. Of course, they 
are ignorant of their right to do so, as they have 
been terrorized by drug laws. Such a patient, using 
morphine in quantities, cannot be admitted to a 
public institution of mercy without having to be 
committed there like an incompetent, an inebriate, 
or a criminal. John P. Davin, M.D. 

New York. 



OUR LONDON LETTER. 

(From Our Own Correspondent.) 
THE MEDICAL SIDE OF RECRUITING — MURDER OF PRO- 
FESSOR FOZZI — SMALLPOX IN LONDON — HOSPITAL 
SUNDAY FUND— CARDIAC AFFECTIONS IN THE 

SOLDIER. 

London. June 19, 1918. 

Sir Auckland Geddes, the Minister of National 
Service, has had rather a difficult task of late in 
the House of Commons to explain to a body of lay- 



116 



MEDICAL RECORD. 



[July 20, 1918 



men the medical principles upon which the grad- 
ing of recruits are founded. In stating that there 
had been no change in the standards of medical 
fitness required for classification in Grades 1 and 
2 since the Ministry of National Service took over 
recruiting from the War Office, he pointed out 
that Grade 1 meant men who presented "a normal 
standard of health and strength and are capable 
of enduring the physical exertion suitable to their 
age," quoting the words from the Recruiting 
Code, and added that in the medical grading of 
recruits current statistics covering a large num- 
ber of e.xaminations showed no increase in the pro- 
portion of men placed in Grades 1 and 2 by his 
Ministry. Grade 2 was generally equivalent to 
Category Bl and Category CI in the old military 
classification, and included men passed for garri- 
son service at home and abroad. Sir Auckland 
Geddes stated further that the number of com- 
plaints by the recruits as to the methods or re- 
sults of examination by the civilian boards was 
not large, and that most of the cases, when in- 
quired into, were capable of satisfactory explana- 
tion. But while for medical reasons the simple 
classification into three grades, or at any rate into 
a small number of divisions has every merit, it is 
clear both from Parliamentary questions and com- 
munications to the lay press that the tribunals are 
now seeking a more detailed grading of the men 
in order to facilitate their work in allotting the 
men to military or civil positions. Such grading 
complicated with questions concerning any man's 
particular fitness for military or civil work is 
hardly the duty of civilian medical boards, who 
have to decide simply to which of certain grades 
of physical fitness a man belongs. When it be- 
came fairly certain that the military age would 
be raised by a new Military Service Act, the matter 
of grading was carefully considered by the Min- 
istry of National Service, the lines of possible pro- 
cedure being clearly two: (1) To institute a new 
system of grading for the men of the older years ; 
(2) to continue the system of grading already in 
use and apply it to the older men. The view taken 
by the Medical Department of the Ministry was 
that, to introduce any system of grading with a 
lower limit at such an advanced age as 43, though 
the idea would surely appeal to the lay mind, 
would have no firm foundation either on medical 
reasons or on reasons of efficiency for military or 
civilian work, while the innovation would inter- 
fere with the system of grading already in oper- 
ation. The Medical Department of the Ministry 
consulted high medical authorities and received 
the opinion clearly and firmly e.xpressed, that it 
would not be possible to establish diff'erent sys- 
tems of grading for men of different ages. As a 
result the existing orders to medical boards place 
upon these boards an entirely new responsibility 
for this country, though it is one with which the 
countries where military conscription holds are 
quite familiar. All the foreign military powers 
have an older army which is developed alongside 
their younger army. From these older men mili- 
tary work of a certain character and up to a cer- 
tain standard is expected. It is the hard case of 
this country that similar work is expected of our 
middle-aged men without the early training. 



A real tragedy was enacted in Paris on June 13 
when Professor Pozzi, certainly one of the most 
famous European authorities not only on gj'ne- 
cology but on abdominal surgery was murdered 
in his consulting room by a lunatic patient, who 
thereupon committed suicide. Samuel Pozzi, who 
was seventy-two years of age, though he presented 
a far younger appearance, was a native of Ber- 
gerac, was educated at the neighboring lycees of 
Bordeaux and Pau, and just fifty years ago went 
to Paris as a pupil of the great Broca. His gyne- 
cological work attracted public attention from 
the beginning, and at the age of thirty he was ap- 
pointed to the professorship in the subject founded 
by the municipality of Paris at the University. A 
man of wide learning outside professional sub- 
jects, no narrow specialist within these subjects, 
a fair linguist, a prolific writer, and a picturesque 
personage, Pozzi acquired a world-wide reputa- 
tion as a scientific ambassador. To him the French 
Government entrusted scientific missions on vari- 
ous occasions to all the European powers and to 
the United States, and he became a general in- 
terpreter at international congresses of the aims 
and accomplishments of different schools of medi- 
cal thought. He acted as Secretary-General of the 
French Congress of Surgery, was President of the 
Surgical Society of Paris, and Vice-President of 
the International Congress of Gynecology held in 
that city in 1900. He was a Senator, a member of 
the Academy of Medicine, and shared with (among 
others) W. W. Keen, G. W. Crile, Harvey Gushing, 
W. J. Mayo, and J. B. Murphy the rare distinction 
of the honorary Fellowship of the Royal College of 
Surgeons of England. Pozzi is not the first well- 
known doctor to be murdered by a patient, while 
attempts on the lives of doctors by disappointed 
invalids have been chronicled in every country. 
In England the threatened doctor is usually the 
alienist upon whose certificate detention in a luna- 
tic asylum has followed, but though the threats are 
quite common the attempts are rare. 

The epidemic of smallpox in London, to which 
attention was drawn in your issue of May 4 in one 
of these letters, has not quite died down. Only 
3 cases were notified during the month of May, 
and only 3 cases remained at the beginning of 
June in the Fever Hospitals of the Metropolitan 
Asylums Board, as against 13 at the beginning of 
May, and 30 at the beginning of April. 

June 23 will be Hospital Sunday, and on that day 
collections will be taken up for the Metropolitan Hos- 
pital Sunday Fund in many places of worship of 
all denominations within the metropolitan area, 
the money being devoted to the voluntary medical 
eharitites of London and the immediate environ- 
ment. King Edward's Hospital Fund for London, 
though a much more modern institution, is larger 
in capital and in scope than the Metropolitan Hos- 
pital Sunday Fund, and it was at one time feared 
that the public might consider that subscription 
to the Royal foundation removed any lien upon 
them to subscribe to the older charity. The appre- 
hension has been found incorrect. "The Metropoli- 
tan Hospital Sunday Fund receives every year 
from the charity of worshippers a sum of between 
£40,000 and £()0,000, and this is about the same 
sum that used to be received before the late King 



July 20, 1918] 



MEDICAL RECORD. 



117 



Edward VII (then Prince of Wales) started the 
noble movement with which his name will ever 
be associated. There is again this year, as there 
has been for the last three or four years, a very 
pertinent reason why the public should give un- 
grudingly to the support of the voluntary hospitals 
of the metropolis, and that reason is that so many 
beds in these hospitals, general and special, have 
been placed at the disposal of the War Office on 
extremely favorable money terms for the use of 
the sick and wounded of the war. For these pa- 
tients the War Office makes a capitation payment, 
but the prices of food, heating, lighting, and medi- 
v.al material have all increased so enormously that 
the capitation grant, though it has recently been 
increased, only slightly lightens the financial bur- 
den of the hospital authorities. The old capita- 
tion grant was 4s. per diem, but during this year 
the figure has been raised to 4s. 9d., and even at 
this rate a considerable debt is due to the hos- 
pitals. A recent report on the subject issued by 
the War Office and signed by Dr. E. N. Burnett 
and Mr. R. Orde, has been distributed by the 
British Hospitals Association, and throws inter- 
esting light on the manner in which civilian 
hospitals have assisted in the care of sick and 
wounded soldiers. It is clear that the additional 
burden placed by these patients upon voluntary 
hospitals during the war has been manfully met, 
but it is clear also that some of the hospitals 
are run in a vastly less economical manner than 
others. The cost to different hospitals for food, 
for fuel, and for laundry varies extraordinarily 
and in a way that cannot be accounted for either 
by any special character of the institution, by 
locality, or by the class of patients received. The 
range of prices for surgical dressings, the extent 
to which salaries have to be paid, the daily cost 
of surgery and dispensary, including the consump- 
ton of surgical dressings; all these things appa- 
rently are governed by no general law, some in- 
stitutions being quite extravagant, and others re- 
markably parsimonious. The War Office has no 
doubt distributed the report to show that it is not 
the Government that is parsimonious, but the 
charities which are profligate in the use of public 
money. This is not the general conclusion to be 
derived from a study of the evidence, but none the 
less the report forms a very pertinent reminder 
to hospital managements that good and wortny 
objects cannot be treated as a complete excuse for 
extravagance or for perfunctory supervision. The 
reminder is needed in a good many places. 

A memorandum forming one of the Special 
Report Series of the Medical Research Committee, 
and supplementary to previous reports, has been 
issued by the Committee, dealing with the position 
of soldiers who have been sent back from active 
service as cases either of disordered action of the 
heart (D. A. H.) or valvular disease of the heart 
(V. D. H.) The latest memorandum has been writ- 
ten by Dr. Thomas Lewis, a prominent member of 
the research staff of the Committee, and assistant 
physician to University College Hospital, London, 
and it forms a detailed comparison of the plight of 
patients falling under one or other of the cate- 
gories. The syndrome of effort, as displayed by 
soldiers returned to hospital, is found mostly 



among those offering no physical sign of struc- 
tural disease, though it is also displayed by those 
in whom clear signs of mitral or aortic regurgita- 
tion are present. Of those who displayed symp- 
toms on active service the non-valvular cases show 
a higher percentage, but this is because many 
valvular cases have been returned to hospital in 
the course of training. But naturally those in 
whom the valvular lesions have escaped detec- 
tion are those in whom those lesions are the least 
serious. When disordered action of the heart is 
associated with signs of structural disease the 
condition has generally occurred among men who 
have been recruited to the army from sedentary 
and light classes of work, but it must be remem- 
bered that recruits are taken generally from more 
arduous employments. A high percentage of cases 
occurs in the sedentary and light classes, and is 
largely due to the unfitness of the men before they 
join, though faulty or too rapid training plays a 
part. But even among the soldiers invalided for 
grave heart disease the larger percentage occurs 
among those employed formerly in light work. 
Among the non-valvular cases, previous infec- 
tions of various kinds play a great part, promoting 
a liability to cardiac failure in some 50 or 60 per 
cent, of cases where the effort syndrome is uncom- 
bined with clear signs of structural disease. This 
point has already been made in a previous memo 
randum of the Medical Research Committee, and 
Dr. Lewis now finds that the incidence as far as 
past histories of infectious disease are concerned 
is not dissimilar, whether in valvular or non- 
valvular cases, though in valvular disease the 
onset, when marked by any special event, dates 
most frequently from rheumatic fever. Gas pois- 
oning and shell shock both have an influence 
analogous to that of infection. The sobriety 
among the men of the new British armies both be- 
fore and after joining the service makes the ques- 
tion of the consumption of alcohol rather academic 
in the discussion of the etiology and development 
of cardiac disease. 



OUR LETTER FROM PARIS. 

(FYom Our Own Correspondent.) 
GOOD HEALTH CONDITIONS IN THE AMERICAN CAMPS 
— AN AMERICAN BASE HOSPITAL — WORK FOR CHIL- 
DREN AT TOUL — PROVIDING FOR THE TUBERCULOUS 
AT PARIS — AMERICAN FUND FOR FRENCH W^OUNDED. 
Pap.is. May 2?. 191S. 

Mothers of America have no cause to fear for the 
welfare and health of their sons in France. Sani- 
tary conditions are of the best in all the camps, and 
there is very little illness. Though the winter has 
been treacherous, and the men had to commence 
camp life at a bad time of the year, they have 
not suffered in the least, as particular attention 
has been paid to the supply of warm clothing 
and all of the buildings at the various camps 
are well heated. The field hospitals are in 
fine running order, and the men are as well taken 
care of as in any of the first-class hospitals of a 
city. It is most gratifying to see these boys who 
are so far away from home and mother being taken 
care of by good American nurses, and to find them 
so happy and contented with their surroundings. 



118 



MEDICAL RECORD. 



[July 20, 1918 



In visiting the American camps, I looked in at 
one of the base hospitals. It was the first base hos- 
pital to be established for the American troops, and 
came over with the first contingent last June. The 
staff is composed of the Johns Hopkins Unit from 
Baltimore, with Miss Bessie Baker as the general 
directress and chief of si.xty-two nurses, with a 
major as ranking officer. At present about 800 
patients can be cared for, and new buildings are 
being constructed to bring up the capacity to 5,000. 
The barracks are strongly built, with perfectly 
equipped operating rooms, and a most efficient medi- 
cal staff. The hospital is pretty well filled up for 
the moment with both surgical and medical cases. 
A number of the wounded have come from the 
trenches, but the majority of the patients have 
received their wounds accidentally in the camps or 
have had colds or appendicitis, but whatever their 
troubles are they are all as happy as possible under 
the circumstances. At first, there were more med- 
ical cases than surgical, but now there are about as 
many surgical cases. Although one hears a great 
deal about the soldiers having colds, and not being 
able to stand the French climate, there have been 
very few cases of pneumonia. Indeed, there has 
been much more pneumonia in the training camps 
in America than in France. 

The hospital has comfortable quarters for the 
nurses, with nice, bright living rooms and dining 
rooms, and the food is excellent and plentiful. 
Entertainments are given for the nurses once a 
week, and they seem contented and interested in 
their work. Both the Y. M. C. A. and the Y. W. C. A. 
have had a share in making the hospital comfortable. 
There is a Y. M. C. A. hut near, which affords great 
pleasure to both the staff and the convalescent pa- 
tients, and the Y. W. C. A. has contributed in many 
ways, such as giving a piano and gramophone for 
the recreation room, etc. The hospital was built 
and occupied by the French before America came 
into the war, and was turned over to the Americans 
in July. The staff is entirely American, with the 
exception of the lingerie staff. It is the French 
women of the village who do the laundry work and 
look after the linen. 

Toul has become the center of great war activities, 
particularly in relief work, since the American Red 
Cross has made it a center of the important work 
for the children. The accomplishments of the Red 
Cross in its affiliations with M. Mirman, the prefect 
of Meurthe-et-Moselle, whose name has become 
sacred through his wonderful devotion to his people 
of the department, are truly marvelous. From a 
meager beginning last July, when M. Mirman tele- 
graphed to the American Fund for the French 
Wounded that help was needed for 350 children who 
had suddenly been put in his care, has grown one 
of the most far-reaching organizations in a matter 
of real help to the French people that the Red 
Cross has yet undertaken to nourish. These same 
350 children to whom the Red Cross rushed a group 
of eight emergency workers, to find them herded 
together in an old barrack that was dirty and un- 
furnished, and had nothing in the way of sanitary 
appliances, etc., are now being cared for under the 
very best conditions. New buildings have been 
erected and installed with all modern improvements. 
The hospital, dispensary, and refugee home, where 



mothers as well as children are cared for, are all 
well organized and in perfect running order; and 
what counts for more than an\i;hing else, these 
same little children, now numbering about five hun- 
dred, who have been brought from the villages back 
of the lines, where asphyxiating gas bombs were be- 
ing dropped, are supremely happy. There are about 
35 or 40 American women, nurses, aides, playground 
instructors, and other trained workers, to look after 
the children, with Dr. MajTiard Ladd in charge of 
the medical department. 

Arrangements are being made to extend the work 
in many directions under Dr. Ladd's supervision. 
Toul is to have 700 beds in all, and other bases are 
being established at Nancy, Pont-a-Mousson, Lune- 
ville, and later there will be a base at Epinal; and 
sentiment has demanded that Einville be made a 
base for American work, as it is the village where 
the first American wounded were brought, and 
where the monument will be erected. Dr. Ladd 
has two points in mind in carrying out this work: 
First, the welfare of the children of France; and 
secondly, though equally important, the effect that 
such work will have on the morale of the French 
army. This may sound somewhat vague, but it 
is undoubtedly true that the French soldiers can 
remain in the trenches in a much better frame of 
mind when they know that their children are being 
given the best possible care. The workers are look- 
ing far into the future, and have in mind conditions 
after the war; and the fathers in the trenches realize 
this fact, and, with this vicinity being such a center 
for all the Allied soldiers, the news of the work is 
rapidly spreading, and it is bound to have its effect. 
The bad conditions that were supposed to be found 
here when the Red Cross came have been greatly 
overestimated. The French were doing a great 
work under the direction of M. Mirman, but after 
three years of war they had reached the point where 
they were overwhelmed with the burden and had 
to call for help, so the Red Cross came to the rescue. 
They came to help and not to teach, and have worked 
in the closest cooperation with M. Mirman, who is 
so beloved in this part of the country. 

There is no part of France where the French have 
shown such efficiency in relief work, and there is 
also no part of France where the need has been so 
great. The workers have taken children from the 
villages all along the line where gas bombs were 
being dropped. In some cases the mothers are with 
them, but on the whole the work is confined to 
children alone. It has not been necessary to remove 
the mothers from the villages, as the adults can wear 
gas masks; but the little children do not use them 
successfully, and therefore must be moved to places 
of safety. The military authorities try to remove 
all the children under eight years of age. Knowing 
that their children are in a safe place and are being 
well cared for, the peasant women are urged to 
remain and harvest the grain in that district. 

Dr. Ladd says that he is increasing the work by 
opening a new hospital of 200 beds. In fact, the 
recent raids on Nancy have already opened it. 
About forty beds are devoted to a maternity ward, 
which they expected to open ne.xt week, but M. 
Mirman notified them that a bomb had struck a 
maternity hospital in Nancy, and twelve women 
would have to be moved immediately, so they rushed 



July 20. 19181 



MEDICAL RECORD. 



119 



things up to meet that need, and within thirty hours 
after they received the notice the twelve women 
were comfortably installed in the hospital, and a 
baby was born. 

The Red Cross can be doing no better work in 
any place in France than at this base at Toul. The 
sanitary conditions have been made perfect, and 
nothing has been left undone that will make the 
children, who are to be the future of France, strong 
and ablebodied. It is plain that every department . 
has been looked after in the minutest detail by one 
who is intensely interested in the work. A special 
feature is being made of the recreation department, 
which is under Miss Cleveland of the University of 
California, where the children are made happy in 
J dozen different ways and taught to play. The 
dental department has been greatly developed re- 
cently under Dr. Stevens, a woman dentist. Par- 
ticular attention has been paid to the operating 
lOoms, and every branch of the medical department 
has been made as perfect as that of any hospital in 
the cities. 

Ground has already been laid out and cleared for a 
family colony and village community for 1,000 tuber- 
culous refugees just outside of Paris. The plans 
have just been approved of by the Finance Commit- 
tee of the American Red Cross. The houses will 
have three or five rooms. Each will have a porch, 
and will be of a type which can be dismounted 
and transported to the devastated districts when 
the war is over. Dr. William Charles White, chief 
of the Red Cross Tuberculosis Bureau, and author 
of the scheme, believes that the Red Cross is thus 
aiding in solving in France the problems and diffi- 
culties presented by the overcrowded cities of Amer- 
ica. It is a new opportunity in the history of the 
world, he declared. The daily entrance from be- 
hind the German lines of people useless to Germany, 
hundreds of homeless folks without any resources 
for resuming life, has created a problem similar 
to that of the misfit families which have troubled 
all big American cities. Many of them are tuber- 
culous. These repatriates without homes create the 
necessity to provide dwellings in cities where all 
houses are already overfull. This has opened an 
unprecedented opportunity to the Red Cross to do 
what has hitherto been impossible in America, to 
meet the menace of tuberculosis without breaking 
up the family group. Fifty acres of meadow and 
woodland at Malabry, near the American Red Cross 
Hospital at Plessis-Robinson, has been turned over 
for the period of the war by the Department of the 
Seine, and the French Government will pay more 
than half the cost of the maintenance of the refugee 
families who will be installed there, so that the 
total cost will only be about S265,000. All the ele- 
ments of a thriving French village will be developed. 
Schools and playgrounds, recreation facilities, a co- 
operative store, village laundry, community bath- 
house, and dispensary, will be established, all in 
demountable wooden houses capable of transfer to 
the liberated districts when the military situation 
makes that possible. Industrial education for those 
well enough to undertake it, and training in hygiene 
for all, are also a part of the project. Hitherto, 
hospital care has meant the breaking up of families. 
In this case refugee families without tie and con- 
nections in the city will be moved bodily to the 
country village. Dr. White firmly believes that the 



example of Malabry will be one invaluable contribu- 
tion to the solution of world-wide problems of urban 
congestion. 

The American Fund for the French Wounded 
has taken over new duties in its affiliation to the 
American Red Cross in searching for the American 
wounded in the French hospitals. Inasmuch as 
the fund is in communication with 4,000 French 
hospitals scattered all over France, and having de- 
pots in practically every department, it is more 
capable than any other organization of finding these 
men who have been picked up seriously wounded 
and taken to the nearest hospital, and whose where- 
abouts, for that reason, are often not heard of 
for a time. The president of the fund says that 
mothers of America need have no fear of their sons 
falling into the hands of foreigners who could not 
understand their language, and therefore be in- 
capable of seeing to all of their little needs, for 
the A. F. F. W. is everywhere in France, and it.s 
one great service is the personal attention that it 
gives the wounded. 

Mrs. Benjamin G. Lathrop, the president of the 
organization, has recently made a trip to America, 
where she had a talk with the mothers of fighting 
men, and she knows what they want. She made 
addresses in many of the States to the thousands 
of women who have been supporting the A. F. F. W. 
and making thousands of garments for the French 
wounded for the last three years. She gave some 
idea of the surroundings of the soldiers and the 
great good that had been rendered through these 
American gifts. She raised §90,000 without half 
trying, even though she had gone on another mis- 
sion altogether, and said that everywhere she went 
the women were saying "What shall we do? What 
shall we make? What is most needed?" and that 
no task was too great for them. 

The A. F. F. W., through its president, made it 
clear to the women of America that its theory as to 
its method of work was unity of action. "It is not 
one American boy that is to win the war, as any 
mother might be inclined to think of her own son," 
said Mrs. Lathrop, "but it is the big fighting force, 
and the relief workers are a part of that force just 
the same as the soldiers. The women at home realize 
that the unity of force is necessary, and they are all 
joining the Red Cross because it is our national or- 
ganization, and working as a body, and it is for 
the personal touch that they look to the American 
Fund for the French Wounded. In explaining the 
conditions in France the work should be divided 
into three duties : First, the duty of General Persh- 
ing; second, the duty of the Red Cross; and third, 
the duty of the women; and that is the basis on 
which the American women are working." 

146, AvEjrcE DES Champs Elysee? 



The Boston Medical and Surgical Journal. 

July 4. 191S. 

1. A Critical Discussion of Sugar in Its Relation to Infant 

Feeding. Lewis "Webb Hill. , 

2. Dental Diseases in Relation to Diseases of the Nose and 

Throat. Kurt H. Thoma. 

2. Dental Diseases in Relation to Diseases of the 
Xose and Throat. — Kurt H. Thoma refers to the fre- 
quent relation which exists between oral diseases and 
diseases of the nose and throat. The diagnosis of 



120 



MEDICAL RECORD. 



[July 20, 1918 



dental disease requires careful and painstaking in- 
vestigation and even though the Roentgen ray has 
facilitated it, the application of temperature and elec- 
trical tests as well as the diagnostic use of local 
anesthesia are often necessary to ascertain the exact 
location and nature of the difficulty. Thoma takes up 
certain typical lesions. He points out that the con- 
nection between malocclusion and nasal diseases was 
noticed by Hippocrates. Bottle feeding and thumb 
sucking are primary causes of compressed V-shaped 
arch and protruding maxillary bones; the lack of 
lateral development prevents expansion of the nasal 
passages and invites the formation of adenoids, which 
in turn causes mouth breathing. In such cases nasal 
respiration must first be established and the jaws given 
proper orthodontic treatment, which, of course, must 
be undertaken at an early age. Treatment should be 
supplemented by a diet which forces the child to 
masticate and by special exercises of the muscles of 
the face. Maxillary sinusitis, according to Brophy, in 
about 75 per cent of cases is due to diseases of the 
teeth. If large abscesses occur on the upper molars or 
bicuspids, sinus disease should be considered as a pos- 
sibility, and, on the other hand, the teeth should be 
roentgenographed in all cases of maxillary sinusitis. 
Chronic pharyngitis is frequently associated with pus 
discharge from sinuses of chronic tooth abscesses, 
from pus pockets due to ill fitting crowns and bridges, 
or from pyorrhea alveolaris. Pharyngeal abscesses 
also are sometimes of dental origin. The fact that 
pain originating from some dental or oral cause may 
be referred to distant parts of the face and head is 
explained by the extensive area of distribution of the 
trifacial nerve and its frequent communications with 
other cranial nerves and the sympathetic system. The 
pain quite often simulates symptoms of sinus disease 
or is referred to the ear (otalgia dentalis). The 
tympanic plexus is connected with the second division 
of the fifth nerve by means of the splenopalatine, or 
Meckel's ganglion, via the great superficial petrosal 
nerve, and the third division communicates through the 
small superficial petrosal nerve and otic ganglion, 
which also gives a branch to the tensor tympani. The 
most frequent causes of the condition are pulp-stones 
(calcareous nodular formations in the tissue of the 
dental pulp), chemical or thermal irritation of the 
pulp, pulp infection of chronic character, or abscesses 
between teeth. The pressure and pain are due to the 
mechanical force exerted against the obstruction in the 
effort to come to the surface, or to pressure absorption, 
affecting a neighboring tooth. The author has been 
able to collect data to prove that the pain is due not 
only to the pressure of the occlusial surface of the 
tooth against the obstructing tissue, but in many cases 
is caused by the development of the roots in the op- 
posite direction, where they may encroach upon the 
inferior dental nerve. Thoma reports a number of cases 
to illustrate his remarks and adds to the value and 
clarity of his article by the reproduction of .some excel- 
lent roentgenograms. 



New York Medical Journal. 

July 6. 1918 

1. Device for X-Ray I>ocation of Bullets and Other I'^orelgn 

Bodies in Wounds. Sinclair Tousey. 

2. Unusual Hyperpyrexia In Pneumonia. J P. Crozier 

Griffith. 

3. The Action of Radium on Cataract. Isaac Levin and 

Martin Cohen. 
4 A Case of Dyspituitarlsm. H. Climenko. 
5. A Plaster of Paris Bandage Roller, William H. Bennett 
8. Mechanical Comminution of Food in Therapeusis of Acute 

Alimentary Disturbances of Infancy and Childhood. 

Harrv Lowenburg. 

7. Analytic View of the Psychic Factor In Shock. George 

M. Parker. 

8. Dispen.«!arv Abuse. Ira S. Wile. 

9. A Briof TTililic.nl Evolution of Medicine. Joseph H. Marcus. 
10 The Epidemiology of Trench Warfare. Vincent Bardou 

3. The Action of Radium on Cataract, — Isaac Levin 
and Martin Cohen report three cases of different types 
of cataract which were subjected to radium treatment. 
In each of these cases improvement of vision was noted 
within a week of the commencement of treatment, ac- 
companied by an increased visibility of the fundus 



reflex which could only be due to a decrease in the 
lenticular opacity. The writers point out that a similar 
phenomenon has never been reported to have occurred 
spontaneously or to have been caused by any other 
agent. It is impossible as yet to say whether this 
improvement will be permanent or not. The writers, 
however, have undertaken a broad study of the subject 
on animals and on clinical material and a complete 
report will be presented at a future date. ^ detailed 
report of the technique employed will also be published 
later. They state in the present paper that the treat- 
ment was based on a case reported in 1911 by Fleming, 
in which a malignant tumor of the orbit was treated 
with comparatively small doses of radium. The tumor 
was diminished to such an extent that the cornea be- 
came visible and then a senile cataract was found 
which was not influenced by the radium nor was the 
perception of light impaired. They therefore decided 
that for the treatment of cataract as large quantities 
of radium should be employed as are now used in the 
modern treatment of cancer, but with strong filtration 
so as to avoid doing injury to the normal structures 
of the eye. 



The Journal of the American Medical Association. 

July 6, 1918. 

1. The Campaign Against Infantile Tuberculosis in France. 

and the Preservation of Childhood Against Its Ravages 
by the System of the "Oeuvre Grancher." Paul 
Armand-De Lille. 

2. Secondary Tuberculous Peritonitis: Its Cause and Cure. 

W. J. Mayo. 

3. The Sin of Treating Symptoms. H. S. Ward. 

4. Chronic Septicemic Endocarditis. With Splenomegaly 

Treatment by Splenectomy. David Riesman. 

5. A Clinical Study of Five Hundred Cases of Cholecystitis, 

With Special Reference to Diagnosis. W. H. Boden- 
stab 

fl. The Circulation of Arsenic in the Cerebrospinal Fluid 
John B. Rieger. 

7. The Nature of Nervousness in Soldiers. Foster Kennedy. 

8 Trench Fever ; A report of Clinical Observations and Re- 
search as to the Etiology. Pathology. Prophylaxis, and 
Treatment of Trench Fever Among Troops. Major W. 
Byam. Captain J H. Carroll, Lieutenant J. H. 
Churchill. Captain Lyn Diamond. Lieutenant L. Lloyd. 
Captain V. N. Sorapure, and Lieutenant R. M. Wilson 

3. The Sin of Treating Symptoms.— H. S. Ward 

points out the dangers arising from the observation 
of one leading symptom in diagnosis without con- 
sidering the patient's condition as a whole. Medicine 
is no longer the business of an individual; the time 
has come for team work, and diagnostic units are es- 
sential. The clinician must not allow the laboratory 
and the specialist to make his diagnoses, and the 
physician who waits for the laboratory to find tubercle 
bacilli in the sputum waits too long to be of real value 
to his patient. Many mistakes have been made in 
diagnosis; inoffensive appendixes have been taken out, 
normal tubes and ovaries have been sacrificed, and 
useful gallbladders drained; ptosed viscera have been 
stitched up or colons removed and healthy stomachs 
opened only for some painstaking surgeon later to 
diagnose a diseased kidney. In nervous diseases, the 
Wassermann test is not sufficient to diagnose syphilis; 
nor are prolonged rest and polypharmacy enough in 
chorea; and something more definite than "overwork" 
must be looked for as the cause of nervous breakdown. 
Finally, due importance must be attached to oral in- 
fection, pyorrhea, and abscessed and carious teeth. The 
writer reports cases to illustrate the various points 
raised. In regard to oral infection, he asks, in view 
of the frequency of diseased teeth in indigents, whether 
there may not be some connection between this and 
being "down and out"? As far as the future gen- 
erations are concerned, the teaching of oral hygiene 
will remedy matters to some extent. At the present 
time, however, should the treatment of this condition 
be radical or conservative? Many death? have oc- 
curred as a result of too radical treatment, and the 
best results have been obtained by the gradual clean- 
ing up of the pathological condition — by doing a little 
at each sitting, the patient resting in the meantime. 
Oral infection will find its proper place in medicine 
if the whole condition of the patient is considered as a 
diagnostic problem. 



July 20, 1918] 



MEDICAL RECORD. 



121 



The Lancet. 

June 15, 191S. 

1. The Conditions Under Which the Sterilization of Wounds 

by Physiological Agency Can Be Obtained. Colonel 
Sir Almroth E. Wright. Captain Alexander Fleming, 
and Captain Leonard Colebrook. 

2. Note on a Method of Dealing with the Divided Ureters 

when Implantation Into the Bladder Is Impossible or 
When That Viscus Is Absent. W. Blair Bell. 

3. Warfare Injuries of the Larynx. W. Douglas Harmer. 

4. Cecoplication? Surgeon-General Sir William Watson 

Cheyne and Surgeon-General Arthur Edmunds. 

1. The Conditions Under Which the Sterilization of 
Wounds by Physiological Agency Can Be Obtained. — 
Colonel Sir Almroth E. Wright, Captain Alexander 
Fleming, and Captain Leonard Colebrook discuss in 
some detail their observations on the treatment of 
bacterial infection of wounds, giving a careful descrip- 
tion of the technique adopted. They point out the 
fallacy of the assumption that the organism is unable 
to deal with the infecting microbes — in which case 
there would be bacterial infection from which nobody 
could recover. They add that in order to ascertain 
what the body is capable of achieving, we must find 
out how to bring its powers effectively to bear. They 
state, (1) Serum from normal blood and normal lymph 
constitutes for the vast majority of the microbes met 
with in foul wounds a very unfavorable culture medium; 
only the streptococcus, the staphylococcus and certain 
diphtheroid bacilli can grow in unaltered serum, and 
when a minimal implantation is made the streptococcus 
alone gives a growth. In other words the microbes 
of wounds fall into two catagories: serosaprophytes, 
which grow in corrupted, and serophytes, which grown 
in uncorrupted blood fluids. Hence, (a) a wound that 
contains serosaprophytic organisms contains corrupted 
discharges; (b) if the wound can be flooded with 
wholesome serum and that serum kept uncorrupted, 
the infection will be reduced to a purely serophytic, 
generally to a streptococcic and staphylococcic infec- 
tion. (2) Trypsinized serum provides an excellent 
culture medium for practically every species of microbe. 

(3) Neutralized or partially neutralized serum, such 
as obtains in every condition of collapse is a medium 
in which seroph>i;ic as well as all the microbes of the 
gas gangrene class flourish. These latter, however, 
are not genuine serophytes but serophytes only of 
acidosed blood fluids, which means that a gas gangrene 
infection in tissues in cases where the circulation is 
uninterrupted can be combated by drawing away the 
acidosed lymph and replacing it by alkaline lymph. 

(4) The whole blood constitutes a medium of essentially 
the same quality as the serum, in which only saprophy- 
tic microbes will grow. These observers then show by 
means of experiment that what is essential to the 
achievement of bactericidal effects is the employment 
of freshly emigrated leucocytes — which from a clean 
wound surface are precisely the same as from blood 
clots — the keeping of these alive and active, and the re- 
moval of the excess of serum which would carry the 
microbes out of reach. The solution of the problem of 
sterilizing the actual wound surface they believe will be 
found along these lines. They submit experimental 
data to show that it is possible to sterilize the super- 
ficies of a wound bj' the agency of antiseptics, provided 
that the surface has been washed perfectly clean from 
albuminous substances. Finally they conclude -nnth the 
following statement of facts proved to be true as 
against that which has been shown to be erroneous: 1 1 ) 
It has been erroneously inculcated that every wound 
should be sterilized before closure; and that, therefore. 
primary suture should be avoided and secondary suture 
undertaken only after a course of antiseptics. There 
is now no question, with respect to primary suture, 
that the wound taken after early surgical cleansing 
and resection is as good as sterile; and, with regard 
to secondary suture, undertaken with a wound in good 
condition and a purely serophytic infection, that such 
operative procedure, provided it leaves behind no in- 
fected dead spaces, directly contributes to sterilization. 
(2) It has been taught that we should judge of the 
fitness of the wound for closure by necro-pj'o-cultures 
and direct microscopic examination of the pus. We 
have learned that it would be infinitely more reasonable 



to base our judgments upon the results of bio-pyo- 
culture. (3) It has been taught that suture cannot 
be successful in a wound containing a haemolytic 
Streptococcus pyogenes. We have seen that leucocytes 
can, given proper conditions, successfully combat this, 
and of course all other streptococci ; and that these 
conditions can be realized in connection with the suture 
of wounds. (4) It has been taught that for the re- 
moval of sloughs from foul wounds chemical solvents 
are required. We have learned that sloughs can be 
removed by tryptic ferment set free from disintegrated 
leucocytes, and that the liberation of this ferment can 
be greatly accelerated by breaking down the leucocytes 
in the discharges with hypertonic saline solution. (5) 
Lastly, it has been taught in connection with antiseptics 
that sterilization is obtainable only by continuous or 
very frequently repeated application. We have learned 
that there is nothing to prevent any part of a wound 
surface which has been washed quite clear of albumi- 
nous matter being sterilized by a single application of 
antiseptics. 

British Medical Journal. 

June 15. 1915. 

1. A Lecture on Some Features of Gunshot Wounds of the 

Chest. Lt.-Col. J. F. Dobson. 

2. W^ar Sears and Their Pains ; With Special Reference to 

Painful Amputation Stumps. Major Edred .M Corner 
X The Emergency Treatment of Wounds. Lt.-Col. A. J 

Hull. 
4 Temporary Cecostomy in Resection of the Distal Portion 

of the Colon tor Xon-obstructive Conditions. Major 

Gordon Taylor. 
"■ The Local Application of Liquid Glucose in the Treatment 

of Certain Superficial Bacterial Infections. T. H. C 

Benians. 
(i. The Intravenous Injection of Eusol in Chronic Arthritis. 

Harold Fairclough. 

7. Deformity of Sternum and Malposition of Viscera. J. S. 

Manson. 

8. Treatment of Fractured Femur. Captain J. H. C. Fegan. 

2. War Scars and Their Pains: With Special Refer- 
ence to Painful Amputation Stumps. — Major Edred M. 
Corner points out that war scar tissue is an irritant, 
containing contracting fibrous tissue, inflammatory foci, 
and pathogenic organisms. The irritation ascends the 
stump and starts infective inflammation in the muscles, 
arteries, veins, bones, connective tissue, and ner%'es. 
The pain is of composite, not necessarily nervous, origin, 
from the osteomyelitis of bone or the arteritis of an 
artery, in which case it is folly to confine treatment to 
the nerve trunks. In one case, in which the arm had 
been shattered about the elbow and amputation made 
below the shoulder joint, Major Corner and Professor 
Marinesco discovered a piece of metal about the size 
of a pin's head in the nerve some months after the 
wound had healed. These observers also noticed the 
frequent occurrence of dark patches on their sections. 
These they concluded were shrapnel pulverized by the 
action of the body juices on masses embedded in the 
wounds and carried upwards by the lymph stream. 
They also found particles of fibers, probably silk, which 
also had been carried up into the structures including 
the nerve ends in these painful stumps. They consider 
these as probably relics of the fragmentation by the 
body fluids of silk ligatures, carried away by the lymph 
stream. From all this they conclude that silk is an 
irritant — a kind of internal seton — some of which is 
carried upwards by the lymph stream and some shed 
outward from abscesses, sinuses, and discharges of the 
wound, and that war time scar tissue is unable to 
encapsulate an unabsorbable suture; that, therefore, 
silk should never be used in war wounds, the great 
pathological characteristic of painful stumps being the 
presence in them of foreign bodies. Corner furthermore 
calls attention to the fact that a ner\-e divided always 
regenerates. In general it regenerates so as to re- 
innervate the deinnervated parts. But if the deinner- 
vated parts have been removed by amputation then 
the fibers of regeneration seem to innervate all struc- 
tures they meet, and sooner or later they must come 
across the inflammation infested scar tissue, when we 
have the simple algebraical equation : nerve + inflam- 
mation focus = pain. The particular function of the 
nerve affected does not seem to matter. War tissues 
must therefore be done away with before much regen- 



122 



MEDICAL RECORD. 



[July 20, 1918 



eration can take place, and this may be accomplished 
by heat, light, .r-ray, radium, vibration, electricity, and 
ionization. Should the regenerating fibers encounter 
an obstruction, they form a tumor — a regeneration 
neuroma. They then flow on. If this infective scar 
tissue is not removed, reamputation will become neces- 
sary and, of course, will have to be done much higher 
up. In the nerve end the irritation may cause arteritis, 
endarteritis, phlebitis, lymphangitis, and thrombosis in 
the intraneural vessels. The irritative process travels 
more freely and further along the vessels than along 
the nerves, and the vessels should therefore be cut 
short at every amputation. 



Berliner klinische Wochenschrift. 

April 29. 191!>. 

The Similunar Plica; a Prodromal Symptom of 
.Measles. — E. Meyer describes a sign which he consid- 
ers an even earlier one than Koplik's. It consists in a 
tumefaction of the .semilunar fold at the internal angle 
of the eye. The redness of this fold is in contrast 
to the normal vascularization of the surrounding con- 
juctiva. It may happen that the fold becomes covered 
with minute white spots making it analogous to Kop- 
lik's sign on the buccal mucosa. 

.\n Epidemic of Dysentery at Dresdin in the Sum- 
mer of 1917. — R. Lampe sifts the data collected from 
an epidemic whose primal cause was the food restric- 
tions of war and the indigestible quality of the food, 
particularly black bread and dried vegetables. In the 
resulting debility of the people, the dysenteric bacilli 
flourished with facility. The writer also admits the 
possibility of the transformation of already preexist- 
ing bacteria. The symptomatology of the epidemic 
did not appear to offer any particular characteristics, 
while of the various treatments resorted to with such 
drugs as bolus alba, bismuth, vegetable carbon, sima- 
ruba, rectal irrigations with tannin, antidysenteric 
sera, etc., bolus alba gave the best results, but could 
not be long continued on account of the absolute dis- 
gust which overcame the patients to its use. The 
writer at length employed Carlsbad salts and bismuth 
subnitrate. During the phase of frequent stools a 
coffeespoonful of bismuth was given in the morning 
and a dose of 30 centigrams was given six to eight 
times during the day. Lampe was not able to detect 
any difference in the clinical evolution of the affection 
in the cases in which the Shiga-Kruse bacillus was 
found from those in which the organism was absent 
and thinks that it is safe to admit that in the cases he 
observed both direct and indirect contagion were in 
play. 

Miinchjncr medizinische Wochenschrift. 

April 23. 1918. 

The Prophylaxis of Erysipelas with .Antistreptococcic 
S.Tum. — Rost having remarked the insuflSciency of the 
various treatments of erysipelas when once developed, 
as well as the present frequency of this nrocess follow- 
ing operative work on infected wounds, has injected 
antistreptococcic serum at the time of the operation 
ill cases where this complication was to be feared. 
Although the writer is unable to offer precise statistics, 
he believes that this practice has a sure effect. He 
thinks that the immunity thus obtained lasts for about 
ten days. Rost has observed reactions of the "serum 
disease" type following these prophylactic infections 
but the exhibition of calcium chloride will prevent these 
.seric reactions, which the writer regards as anaphy- 
lactic in nature. 

The Importance of Early Marriage for Repopulating 
.\fter the War. — A. Ploetz in the first place proves by 
his statistics that marriage among young people re- 
sults in greater fertility, not merely from the view- 
point of a longer duration of the child-bearing period 
but also for the annual percentage of births which 
result. Besides other factors related to late marriage 
(alcoholism, syphilis), late marriage appears to be one 
of the principal obstacles to the renewing and ex- 
pansion of the population. This reasoning applies to 
all classes of society but is more keenly felt among 
the more educated. A condition nine qua tion for re- 



juvenation of marriage among those belonging to the 
liberal professions consists in better salaries in the 
case of certain employees of the state (school masters, 
officers, assistant physicians, etc.) and above all short- 
ening the time now required in preparatory studies. 
The writer advises reducing the number of school and 
university years and winds up with considerations on 
measures of a moral order, consisting in opposition to 
individualism and rationalism, both of which are on a 
wide increase. 



Deutsche medizinische Wochenschrift. 

April -27,. IMl.v. 

Plastic Operation on the Face for an Exceptionally 
Extensive Loss of Tifesue. — J. Joseph offers two photo- 
graphs of the patient before and after the operation 
to be described, which unquestionably was a brilliant 
bit of plastic surgery. Both cheeks, the nose, and 
upper jaw of the patient had been blown away by a 
missile. Therefore it was a question of restoring the 
entire middle portion of the face and in order to ac- 
complish this, besides the prothesis of the jaw, Jo.-i ■ 
mobilized a flap of scalp extending from ear to • 
and containing both temporal arteries. At the I. 
seance, this flap was brought forward and turned ovt , . 
its raw surface being covered by Thiersch's skin graft.-^. 
At the end of a month the flap was again mobilized and 
again turned over, lowered and sutured on the anterioi' 
aspect of the face. The primarily under surface of 
the flap was thus made to form the bucconasal 
mucosa, covered as it was by the grafted epiderr 
The scalp consequently formed the skin of both chet 
nose and upper lip. "The vitality of the tissues has 
mained in such excellent condition that the writer docs 
not hesitate to say that it would be possible, if 
necessitated, to make a much larger scalp flap ut 
the reconstruction of the entire face from the eyebr 
to the chin. The cranial denudation was later on t 
in with skin grafts and flaps made from the - 
rounding areas, so that only a little depression > 
suited from the loss of tissue required for the pla-' 
operation. 

The Radiological Diagnosis of Gastric and Duodenal 
Ulcer. — G. Singer notes that the diagnosis of duodenal 
ulcer becomes more frequent and this has revealed the 
fact that this pathological process has, in the past, 
given rise to the mistaken diagnosis of gastric neuro- 
pathies in all functional disturbances of the stomach. 
Singer develops his thesis by experience acquired since 
the beginning of the war and discusses the indications, 
recently developed, for radiography in gastric dis- 
orders. 



Wiener medizinische Wochenschrift, 

May 11, 1918. 

Observations on the Etiology of Epilepsy, Particu- 
larly That of "War Epilepsy." — E. Re<llich, after hav- 
ing given some more examples of epilepsy occurring on 
account of the war, without any recognized causal 
factor, concludes by admitting an "exaggerated epilep- 
tic reactivity" in certain subjects. 'This peculiarity 
enters into the class of individual variation and is r 
of necessity in relation to an hereditary taint or • 
dent antecedents. It is this "reactivity" that is t( 
invoked in order to explain the frequency of epileps 
born from the influence of the moral or trauni: 
shock of war. In spite of all this, Redlich is • 
inclined to admit a true "war epilepsy." because si. 
a morbid entity cannot offer a sing'e character 
longing properly to it and which could assign it i. 
special place among the epilepsies in general. 

Disturbances of Micturition at the Front. — .1. To 
lak's choice in the subject of his contri*iution to scienof 
brings to mind a poetical contribution of the iate 
Eugene Field, "When Willie Wet the Bed," because 
he is quite unable to find in the diagnostic means at 
his disposal, likewise in modern physiological data, any 
explanation for the causation' of the manifold forms 
of incontinence of urine which is frequent among the 
Teuton soldiers at the front. He takes the practical 
standpoint and divides the cases into three classes, 
\Hz. : (11 Complete incontinence, the bladder emptying 



\y 20, 1918] 



MEDICAL RECORD. 



123 



it-elf drop by drop, without any sensation of the need. 
These suDJects are absolutely inapt for service. (2) 
IiiLomplete incontinence, the urine flowing only when 
there is a sensation of the need to empty the bladder. 
These subjects may be considered apt for service at the 
rear. (3) Pollakiuria, not a true incontinence, repre- 
sented by frequent and imperious desire to void urine. 
This class of cases is susceptible of cure by means 
ct' special treatment (urological and neurological) so 
that these subjects may be entered into the active 
formations. 



we see it everywhere. The relation of periosteum to 
bone is analogous to that of the epidermis to the 
derma. 



Wiener medizinisehe Wochenschrift. 

May 4, l'.n>. 

Traumatic Gastric Ulcer. — A. Edelmann reports four 
instances of this much discussed subject, showing the 
relation of cause to effect between abdominal trauma 
and the ultimate development of gastric ulcer, which 
appears to him unquestionable. All four of the pa- 
tients had developed ulcer of the stomach following 
■upon traumatism of the abdomen in warfare without 
offering an apparent surgical lesion. In all four cases 
the lesion resulted from an exploding shell at a little 
distance away. Edelmann underlines the fact that 
these patients in which he noted the lesion were vago- 
tonic subjects, their condition being characterized by a 
nervous state in which there was an excess of autono- 
mous nervous functions. 

Observations on the Etiology of Epilepsy, Particu- 
larly That of "War Epilepsy."-^E. Redlich studies the 
possible parts played in epilepsy by such factors as 
syphilis, helminths, burying by bursting shell, etc. The 
writer has met with other cases in which the epilepsy 
became manifest during service at the front, although 
he was unable to fix upon any etiological factor. Such 
instances may be related to a certain disturbance of 
the vaso-motor svstem. 



La Presse Medicate. 

March IS. 191S. 

Study of Globular Resistance in Various Isotonic 
Saline Solutions. — Chauffard and Huber after a study 
of many assembled data state that saline solutions have 
in common several properties — isotonic, isosmotic, equi- 
molecular. Does it also follow that they are isoactive 
chemically with reference to an anatomical element 
like the erythrocj-te? Osmosis alone cannot explain 
the generality of cellular exchange. Saline solutions 
formed of electrolytes appear to escape the principle 
of equimolecularity by the more or less complete dis- 
sociation of their constitutive elements. This dissocia- 
tion augments the number of molecules. In fact, the 
molecules in solution are dissociated into ions, water 
being the agent. This view of .-Vrrhenius shows how 
much more complex are these phenomena than one has 
suspected. In addition to a molecular phenomenon 
like osmosis we have electrochemical interreactions be- 
tween cellular elements and the media in which they 
live. -As Starling says, in addition to osmotic or vol- 
ume energy, each molecule in solution is endowed with 
chemical energy which does not depend alone on the 
number of molecules, but also on their nature. In the 
case of electrolytes or ionisable substances the chem- 
ical energy is measurable. Hence it would be an error 
to regard isotonic solutions as physiologically equiva- 
lent. Theories which are very simple are not always 
true. In regard to experimental hemolysis equality in 
osmotic tension is a protection to the living cell, but 
such protection is only relative and does not suppress 
the possibility of an injurious chemical action. 

Role of the Periosteum in the Formation of Bone. — 
Leriche and Policard conclude that the periosteum is 
a physiological rather than an anatomical element. It 
contains two antagonistic components which, acting 
together, secure harmony of osteogenesis. One is re- 
sponsible for growth of bone, while the other — the 
fibrous portion of the peritoneum — tends to limit the 
growth. Normally the two components are in a state 
of equilibrium. Surgical detachment of the periosteum 
ruptures the equilibrium and causes a series of phe- 
nomena of osteogenesis, whatever the subject's age. 
The surgeon is therefore able to create bone formation 
at will. This law is not peculiar to osseus tissue as 



II Policlinico. 

March 17. 191S. 

Adenoid Subjects with Pituitary Feminism. — Citelli 
and Caleceti refer to an earlier study of a psychic syn- 
drome associated with adenoid. The leading features 
are loss of memory, somnolence or insomnia, mental 
insufficiency, and inability to fix the attention. This 
mental picture may also be seen in nasopharyngeal tu- 
mors and sinus disease, and is believed to be associated 
in some way with the hypophysis. In the present article 
they report three cases in soldiers, one of which is as fol- 
lows: Soldier, aged 25, family history negative, save that 
a brother, aged 12, is a mouth breather and presents 
psychic disturbances. Has had nasal obstruction since 
childhood and an abscess in the right ear. He could 
make no progress in school, and at 14 began work in 
a sulphur mine. His outside life was solitary, and he 
slept poorly. At the age of 20 he began his military 
service, which was continued into the present war. 
He had always seemed preoccupied, and when he re- 
ceived a word of command would continue to repeat 
it lest he forget. He was rather indifferent to the 
opposite sex, and had had intercourse but a few times. 
Upon physical examination he presented hypotrichosis, 
his face being nearly smooth, with but a scanty growth 
in the axilla and on the pubes. The absence of hair 
about the anus and on the perineum suggested the 
other sex. The head hair was fine and not overabun- 
dant. The texture of the skin was feminine. There 
was a suggestion of gynecomasty and feminine pelvis 
and hips. However, the frame was that of a well- 
developed male, including the genitals. From a differ- 
ent angle the man was a typical adenoid subject, with 
ogival palate and crowded teeth. The temperature 
and pulse having been repeatedly determined, the pa- 
tient was tested for a reaction to pituitrin, an injection 
of which determined a slight increase of both along 
with sweating, restlessness, headache, palpitation, etc. 

Nederlandsch Tijdschrift voor Geneeskunde. 



Three Cases of Epidemic Parotitis with Iridocyclitis. 
— Weve refers to the description by Heerfordt in 1909 
of a uveo-parotid fever in which both the glandular and 
ocular processes pursued a chronic course. This author 
reported three cases of the malady which he concluded 
after the exclusion of lues, tubercle and pseudo-leuee- 
mia to be siii generis. Weve is now himself in posi- 
tion to report three further cases and is inclined to 
believe that the disease is essentially epidemic parotitis 
with secondary implication of the uveal tract. In 
other words, ordinary mumps with persistence of swell- 
ing and intraocular metastases. In the first case there 
was no history of exposure to mumps and no known 
case in the immediate vicinity, but the second case 
occurred after three cases had developed in the neigh- 
borhood and the third de%-eloped in a veritable epidemic 
of mumps. All the patients were children (under 16). 
If now we study the vagaries of mumps we find that 
sporadic cases occur and that the swelling instead 
of subsiding at a given date may persist for months 
(Osier). Various symptoms complained of by the 
different patients — such as pain in the joints — may 
occur in mumps. Of much interest are the known 
eye complications of mumps. These are rare and in- 
clude optic neuritis with secondary atrophy keratitis 
and catarrhal conjunctivitis. Iridocyclitis is not men- 
tioned, but could doubtless be masked under one of the 
other affections. Fuchs has seen double parotitis with 
lacryrnal gland infection and this leads to a suggestion 
of Mikulicz's disease in which the parotids and lacry- 
mal glands are synchronously involved. Now in this 
affection iridocyclitis has occasionally been seen, so 
that even if the syndromes of Heerfordt and Mikulicz 
are different affections there is apparently a bridge 
between them. We are also thrown back again on the 
hypothesis that Mikulicz's disease like many other 
rare affections is quite likely a result of lues, tubercle 
or other granulomatous process. 



124 



MEDICAL RECORD. 



[July 20, 1918 



?Bflnk l&evuma. 

A Diabetic Manual. For the Mutual Use of Doctor 
and Patient. By Elliott P. Joslin, M.D., Assistant 
Professor of Medicine, Harvard Medical School; Con- 
sulting Physician, Boston City Hospital; Collabora- 
tor to the Nutrition Laboratory of the Carnegie In- 
stitution of Washington, in Boston; Major, M. R. C. 
Illustrated. Price, $1.75. Philadelphia and New 
York: Lea & Febiger, 1918. 
In this little book the author gives, very briefly the 
modern ideas on diabetes and its treatment. The man- 
ual, which is quite elementary, is intended for the pa- 
tient as well as the practitioner, as it is presumed that 
the two will cooperate. The first part gives in simple 
language a rapid survey of the subject, noting the most 
important points and emphasizing certain details. The 
second part contains an outline of the treatment of the 
more severe cases. In the third part will be found the 
diet tables and recipes which the author has found 
valuable in his daily practice. The last part contains 
a description of the simplest reliable tests for the esti- 
mation of sugar and acid bodies in the urine, sugar in 
the blood, and carbon dioxide in the alveolar air. There 
is a certain amount of repetition, but this is a decided 
advantage. Those of our readers who are acquainted 
with the author's larger and more complete work on 
the subject will be glad to know of this little book; 
those who do not know the larger work should certainly 
look at this volume. 

A Manual of Clinical Diagnosis by Means of Lab- 
oratory Methods. For Students, Hospital Physi- 
cians, and Practitioners. By Charles E. Simon, 
B.A., M.D., Professor of Clinical Pathology and 
Physiological Chemistry in the University of Mary- 
land Medical School and the College of Physicians 
and Surgeons, Baltimore, Md. Ninth edition, en- 
larged and thoroughly revised. Illustrated with 207 
engravings and 28 plates. Price, $6.00. Philadel- 
phia and New York: Lea & Febiger, 1918. 
The new edition of this standard work has been thor- 
oughly prepared; many sections of the book have been 
rewritten, and new matter and new illustrations have 
been introduced. Important new matter will be found 
in the sections dealing with the intestinal animal para- 
sites, the diagnosis of acidosis, the e.xamination of blood 
for transfusion purposes, and the colloidal gold reaction 
of Lange. As in the two former editions, the work is 
divided into two parts, the first treating of the tech- 
nique of making the o^arious examinations and tests, 
and the second giving the various laboratory findings 
in the different diseases. The reader may obtain some 
idea of the completeness of the work when he learns 
that the chapter on the blood contains more than 170 
pages, that on the feces more than 60 pages, while 
that on the urine is nearly 200 pages in length. These 
chapters are almost encyclopedic in character. The 
second part of the book will prove most valuable to all 
practising physicians; it contains an account of the 
laboratory tests which may be of service in any given 
disease, and also shows how to interpret the various 
laboratory findings. The illustrations are numerous 
and excellent and add much to the value of a really 
useful book. 

A Text-Book of Obstetrics. By Barton Cooke Hirst 
A.B., M.D., I.L.D., F.A.C.S., Professor of Obstetrics 
in the University of Pennsylvania; Gynecologist to 
the Howard, the Orthopedic, and the Philadelphia 
General hospitals. Eighth edition, revised and reset. 
With 715 illustrations, 38 of them in colors. Pricej 
$5.00. Philadelphia and London: W. B. Saunders' 
Co., 1918. 
This new edition of Hirst's Obstetrics brings up to 
date one of the standard works on the subject. The 
volume, in spite of the revision, is a little smaller than 
some of its predecessors. As a text-book this work has 
few rivals, and in some respects it is superior to its 
competitors. The illustrations are numerous and well 
executed and have always been one of the distinguish- 
ing features of this book. Another characteristic is the 
inclusion of such gjTiecological operations and proced- 
ures as are necessitated by labor and its complications. 



There are few works on obstetrics which have reached 
an eighth edition and have held their own for a period 
of twenty years; a book which has accomplished this 
may be assumed to possess unusual merits, and to be 
well worth the attention of the general practitioner and 
the medical student. 

Progressive Medicine. A Quarterly Digest of Ad- 
vances, Discoveries and Improvements in the Medical 
and Surgical Sciences. Edited by Hobart Amory 
Hare, M.D., Professor of Therapeutics, Materia Med- 
ica, and Diagnosis in the Jefferson Medical College, 
Philadelphia; Assisted by Leighton F. Appleman, 
M.D., Instructor in Therapeutics, Jefferson Medical 
College, Philadelphia. June 1, 1918. Price, $6.00 per 
annum. Philadelphia and New York: Lea & Febiger. 
This issue of Progressive Medicine contains chapters 
on Hernia, by W. B. Coley; Surgery of the abdomen, 
exclusive of hernia, by A. O. Wilensky; Gyneeologj-, by 
J. G. Clark; Disorders of nutrition and metabolism, 
diseases of the glands of internal secretion, diseases of 
the blood and spleen, l>y O. H. P. Pepper; and Ophthal- 
mology, by E. Jackson. The present number is of more 
than ordinary value; it contains a number of timely 
and useful articles, such as: Hernia in relation to the 
war; the relation of trauma or industrial accident to 
hernia; the medicolegal aspects of hernia; military sur- 
gery; and Dr. Clark's always welcome discussion of the 
cancer problem. 

Evolution de la Plaie de la Guerre. Par A. Poli- 
CARD. Collection Horizon. Prix, 4 francs. Paris: 
Masson et Cie., 1918. 
This title naturally suggests the reaction of a wound 
and the process of repair without reference to infection 
or the results of treatment. As a matter of fact, how- 
ever, the latter are fully considered and it is not readily 
comprehended why the book was not termed "War 
Wounds and Their Treatment." The publishers' notice 
styles the volume a novel departure in applied physi- 
ology, but to the reviewer the chief element of novelty 
is perhaps the large number of microscopic sections, 
especially those of low powers (about 100 to 150 diam- 
eters), which may certainly serve to broaden the con- 
ception of wounds and their sequelae for the average 
reader. 

Manual of Vital Function Testing Methods and 
Their Interpretation. Second Revised and En- 
larged Edition. By Wilfrid M. Barton, M.D., 
Author of "Therapeutic Index and Prescription 
Writing Practice"; Associate Professor of Medicine, 
Medical Department, Georgetown University; At- 
tending Physician to Georgetown University Hos- 
pital, Columbia Hospital and Washington Asylum 
Hospital. Price $2. Boston : Richard G. Badger. 
The progressive physician has long been acquainted 
with some of the functional tests. Unfortunately, a 
description of these tests is generally to be found 
scattered in the periodical literature. The author of 
this little volume has performed a real service in 
collecting the most valuable of these tests into a handy 
volume. That the first edition was exhausted in less 
than a year proves that the book was appreciated. 
In this new edition a few additional articles are added, 
so that the volume now includes a description of the 
Van Slyke method of urea determination, Ambard's 
coefficient and McLean's index of urea excretion, test 
meal investigations of kidney function, and articles on 
sphygmobolometry, sphygmobolography and energom- 
etry. The volume contains all that" is of practical 
value on the functional tests of the liver, kidneys, 
pancreas, heart, and ductless glands. Clinicians and 
laboratory workers, alike, will find the book well worth 
their attention. 

Reagents and Reactions. By Edgardo Tognoli, M.D., 

Professor in the University of Modena. Translated 

from the Italian by C. Ainsworth Mitchell. B.A., 

F.I.C. Price, $2.00. Philadelphia: P. Blakiston's 

Son & Co., 1918. 

These are a list of reagents and reactions compiled by 

Dr. Tognoli. They provide a handy means to refer to 

the more important chemical reactions arranged in 

alphabetical form of the name of the chemist who first 

applied them. The book should be of great value to the 

medical man. 



July 20, 1918] 



MEDICAL RECORD. 



125- 



f^atiet^ S^pnrtH. 



AMERICAN ASSOCIATION OF PATHOLOGISTS 
AND BACTERIOLOGISTS. 

Eighteenth Annual Meeting Held in Philadelphia, 
March 29 and 30, 1918. 

Dr. Eugene L. Opie of St. Louis in the Chair. 

A Simple Method of Carrying Meningococcus Cultures. 

— Drs. J. Bronfenbrenner and M. J. Schlesinger of 
Boston presented this communication. Cerebrcspinal 
meningitis had achieved the reputation of being a "dis- 
ease of infants and children" on account of frequent 
epidemics among young individuals. With the idea of 
adding to the knowledge of this infection in prepara- 
tion for further possible outbreaks in the spring and 
summer, the present study was undertaken. Meningo- 
coccus strains had always shown great specificity, and 
for this reason curative sera were made polyvalent. 
This necessitated the carrying of many culture strains 
in each laboratory where this work was in progress, 
and it had become quite a problem to carry all the 
strains. On account of the difficulty of isolating the 
meningococcus and of cultivating it on prepared media 
a great deal of work had been done along this line. 
Numerous workers had advocated various media such 
as serum, ascetic fluid agar, Loeffler's serum, agar from 
placental extract, agar from beef heart, trypsin di- 
gested, etc. The best results, however, seem to have 
been gained by the use of liver agar medium, originally 
described by Dopter. This medium, however, had great 
variability in quality and with this in mind the authors 
had worked out a modification of the preparation of 
the medium, in order to render it more uniform. The 
method was as follows: (1) A liver infusion was 
made, using 1,000 grams of liver to 1,000 c.c. of water. 
The extract was collected through a single layer of 
cheese cloth, boiled, and stirred continuously. The re- 
action was not adjusted. The mixture was then 
strained through single cheese cloth and a thin layer 
of cotton. It was then sterilized at 10 lbs. pressure 
for 10 minutes. (2) A 3-per cent, agar solution in 
water was made and filtered through cotton, and to 
this was added 2 per cent, peptone and 1 per cent. 
NaCl. The reaction was not adjusted. It was steri- 
lized at 15 lbs. for 30 minutes. Equal parts of (1) and 
(2) were mixed while hot and tubed into sterile tubes. 
This gave a clear transparent medium with a great 
deal of water condensation. Meningococcus colonies 
grew very rapidly upon such medium, which was im- 
portant for detecting carriers. 

The Value of a Cooked Meat Medium for Routine 
and Special Bacteriology. — Dr. W. L. Holman of Pitts- 
burgh read this paper. The object of the study was to 
bring to notice the cooked meat medium now so widely 
used in the study of the anaerobic bacteria of war 
wounds and to show its usefulness in routine bacterio- 
logical study as well as in more special lines of re- 
search. Theobald Smith, Tarozzi, von Hibler, Robert- 
son, and Henry had shown the value of tissue media for 
cultivation of many anaerobic bacteria. The meat 
medium used since 1916 was made from beef muscle. 
The meat was freed from fat and gross fibers, finely 
minced, ground in a mortar and mixed with equal parts 
of water. It was then slowly heated to boiling with 
constant stirring to allow the soluble albumins to co- 
agulate about the meat particles. These coagulated 
albumins in themselves served as favorable medium 
for anaerobic growth. It was then neutralized to 
rosolic acid or phenolphthalein. tubed and autoclaved 
for one hour. Before use the tubes w-ere always heated 
to 100° C. for one half hour. The seeding was done by 
pipette or needle and the material thoroughly mixed 
with the meat particles. There were no further pre- 
cautions for anaerobic conditions necessary. The au- 
thor said he had grown all types of anaerobic bacteria 
from war wounds in such open tubes and all grew 
equally well. Thus it was found the best medium for 
mixed flora of wounds. One great advantage was that 
it was found that products of growth did not destroy 
the various forms, and the medium could therefore be 
utilized for reisolation of bacteria that had died out. 
or become overgrown into other media. The "buffer" 



action of the meat particles in preventing extremes of 
reaction, undoubtedly favored symbiosis. This medium 
was undoubtedly the best to be had at present for 
growth of anaerobic and also aerobic bacteria, for 
storing mixed cultures as well as pure cultures, and for 
the differentiation of the various types. 

Dr. H. T. Karsner of Cleveland asked Dr. Holman 
whether the meat was made neutral to litmus. They 
had used it a good deal and had always made it some- 
what alkaline to litmus. It was found a most remark- 
able medium for cultivating all of the flora out of 
wounds. He had never taken the trouble to heat it 
beforehand. So long as the meat was tender and the 
culture deeply implanted, growth was secured. He 
had been particularly impressed with the beauty of 
the chains of streptococci as the organism grew in the 
meat. 

Dr. W. L. HolM-\n said in closing that the meat was 
used with the reaction on the alkaline side of litmus, 
particularly for the anaerobes. It was useful in a 
great many ways. They had endeavored to bring out 
from the wound some of the stricter anaerobes, which 
are always more difficult to grow. Heating the meat 
one-half hour before seeding gave the best conditions 
for growth. 

The Influence of Oxidizing Substance on the Cata- 
lase Value of the Blood and Tissues. — Dr. A. Arkin of 
Morgantown, Pa., presented this subject. The work 
might be briefly summarized as follows: Sodium 
iodozybenzoate, an active oxidizing agent, which had 
been shown to have a stimulating effect on the pro- 
duction of. antibodies, inhibited the development of 
local allergic reactions, and had a stimulating effect 
on phagocytosis in vitro. It had no effect on the cata- 
lase value of the blood of normal rabbits. The tissues 
of rabbits injected with the drug showed no change 
in catalase value with the possible exception of the 
spleen in which it seemed to be increased. 

Experimental Trinitrotoluene Poisoning. — Dr. S. R. 
Haythorn of Pittsburgh presented this communica- 
tion. He said that all recorded attempts to produce 
T. N. T. poisoning, save in those in which the inunc- 
tion method had been employed, had failed thus far. 
Recent attempts to produce poisoning through the in^ 
halation of fumes and gases had also failed, but the 
conditions under which the employees of T. N. T. fac- 
tories are exposed to the inhalation of fumes and dusts 
from that substance had never been experimentally re- 
produced. The acute gasings (which was such a com- 
mon form in the nitrating places) was an incidental 
poisoning and was not due to the T. N. T. proper. By 
means of inunctions there had been successfully pro- 
duced dermatitis, discoloration of the subcutaneous tis- 
sues, early focal lesions, and fatty changes in the liver, 
and positive Webster's tests in the urine had been ob- 
tained. The best results had been obtained by feeding 
T. N. T. either as a powder or dissolved in milk. By 
this means discoloration of all of the fat tissues of 
the body, fatty changes in the liver and kidneys, and 
extensive necroses of the liver had been caused, while 
marked blood destruction accompanied by haemosidero- 
sis of the spleen and haemoglobinuria had been noted. 
T. N. T. was soluble in all of the body fluids. The au- 
thor stated that the more crude products were more 
poisonous than the chemically pure ones. It was also 
likely that the variations found in the percentages of 
those aflFected in the various factories were due quite 
as much to the relative amounts of impurities as to 
the unhygienic conditions. Further experiments were 
ad\Tsable, along the line of discovering whether cer- 
tain forms of T. N. T. were less toxic than others. If 
such products could be obtained, in which, at the same 
time, the detonating power would not be lessened, the 
work would have been worth while. 

Dr. Leo Loeb of St. Louis said he washed to point 
out that it was very easily possible to produce necrosis 
of the liver in guinea pigs. In some respects, there- 
fore, these animals were not favorable for experimenta- 
tion. He had no doubt, however, that in this case the 
lesions were entirely due to the substance employed. 
■ Dr. RoBEn?T A. L.ambert of Columbia University, New 
York, expressed his interest in Dr. Haji:horn's renort. 
He had worked in his laboratorv on the same problem 
for the past 6 months. His results agreed on the whole 
with those of Dr. Havthorn. He had produced a state 



126 



MEDICAL RECORD. 



[July 20, 1918 



of poisoning, sometimes fatal, with definite degenera- 
tive changes in the liver cells. So far, such changes in 
the liver cells, analogous to toxic jaundice of munition 
workers, had not been experimentally produced, that 
is, the changes practically identical with acute yellow 
atrophy. Dogs were selected, as being larger, and be- 
cause of the objection to rabbits and guinea pigs men- 
tioned by Dr. Loeb. The poison was administered 
in four different ways: (1) feeding T. N. T. dissolved 
in butter; (2) inunction (T. N. T. in lanolin) ; (3) 
subcutaneous injection of acetone solution; (4) intra- 
venous injection of an acetone solution. The last two 
methods were unsatisfactory inasmuch as they did not 
correspond to the mode of intake in man. Feeding pie- 
sented the difficulty that the dogs refused the food 
with T. N. T. and if they took it, they vomited after- 
wards. However, enough was ingested to produce 
symptoms in a week or two. These symptoms were 
lassitude, weakness, diarrhea, loss of weight. Some 
animals died in ten days or two weeks, one survived 
two months. Autopsy disclosed fatty and degenerative 
changes in the liver, particularly in the central part 
of the lobule. Blood pigment was encountered in the 
spleen and bone-marrow. The same results followed 
the inunction with T. N. T., when starvation and diar- 
rhea caused death. The urine obtained by catheteriza- 
tion gave an early and positive Webster's test, regard- 
less of the mode of administration. The test was evi- 
dently a very delicate one. The reason the animals 
did not show to.xic jaundice was most likely because 
they did not live long enough. In munition workers 
there was most likely a latent period between exposure 
and development of the symptoms. 

Dr. M. Abbott of Montreal said that a case seen in 
the hospital in Montreal would be of interest in con- 
nection with this subject. The patient, a medical stu- 
dent, who had been working for a short time in a dyna- 
mite factory, came into the hospital with quite a mild 
form of toxic type of poisoning. He was discharged 
after a short time with the direction that he should 
be careful through the summer and come back for his 
sessional work. He returned very ill with acute jaun- 
dice, was three days in the hospital, and then died. 
Autopsy showed an extreme form of jaundice with 
pronounced cirrhosis of the liver. 

Dr. S. R. Haythorn said in closing that he had ob- 
tained vomiting in the guinea pig fed with the tri- 
nitrotoluene in milk. Also there was diarrhea. There 
were not only lesions of the liver but the reaction of 
blood destruction, hemoglobinuria, and pigment in the 
spleen, showing that there was marked absorption. 

Autopsy Service in a Military Hospital. — Dr. How- 
ARn T. Karsner of Cleveland read this paper, which 
summarized the findings of a service of 8 months in a 
base hospital of 1,250 beds and included 87 autopsies. 
Only 6 of these were purely medical cases, including 
one case of diabetes, one of malignant endocarditis, and 
4 of mustard gas pneumonia. The remaining cases 
died of infections resulting from war wounds, most of 
them being multiple shell wounds. The involvement of 
serous cavities appeared to be important in determining 
the fatal issue. Gas gangrene was the cause of death 
in a few of the cases, being due particularly to the 
Bacillus welchi. Pyemia appeared fairly often, metas- 
tatic infection in important situations appeared also 
but the most common condition was septicemia as a 
result of infection with the Streptococcus pi/oncnes. 
Attention was called to the value of instituting every 
possible therapeutic measure to shorten the time dur- 
ing which a patient has suppuration going on in his 
wounds. It was suggested that very often amputation 
was much more desirable than the saving of a muti- 
lated member, the function of which would be impaired 
after recovery, for if suppuration were prolonged by 
such treatment there would always be the danger of 
permanent damage to parenchymatous organs such as 
the heart, liver, and kidneys. 

Dr. J. J. Mackenzie of Montreal said that Dr. Kars- 
ner's experience was in an area where he spent nine 
months at a time when there was very little fighting 
and few postmortems from war infections. He would 
emphasize the importance, in military hospitals, of the 
work of the pathologist and its influence upon the 
treatment of the cases. This was amply demonstrated 
in his experience in the treatment of dysentery among 
the soldiers. 



The Agglutination of Human Red Blood Corpuscles 
by Horse Serum. — Drs. Herbert W. Williams and 
Harold A. Patterson of the University of Buffalo 
made this communication. Nineteen specimens of nor- 
mal horse serum or antibacterial serum were tested and 
twelve of these produced some agglutination of human 
red corpuscles in the test-tubes in 1 to 20 dilutions: two 
sera agglutinated in 1 to 200 dilutions. Washed blood- 
corpuscies were used in dilute suspensions (1-100 in 
the final mixtures), and after incubation with the 
serum one hour at 36 , were allowed to stand at room 
temperature in a cool place, as these conditions seemed 
to favor the detection of small amounts of agglutinin. 
(In the case of three sera that gave positive agglutina- 
tion, two still gave agglutination but tKe third and 
strongest serum showed no agglutinati'm when the 
tubes were kept continuously at 37", uiing 1 to 20 
dilutions of the sera.) The last tests w( re only made 
with a single sample of blood. How fai test-tube ex- 
periments might be used as an indication of what hap- 
pened in the living body was uncertain, however. Ex- 
periments on laboratory animals with ilien sera had 
given results that were inconclusive. In view of the 
increasing use of normal horse seruni and curative 
sera for the infections in large doses, frequently in- 
travenously, the possibility that agglu' .nation of red 
corpuscles might sometimes occur in th> body seemed 
worthy of attention. 

Intestinal Flora in Scurvy of Guinea I igs and Infants. 
— Drs. Alfred F. Hess and J. C. ToRR^.y of New York 
gave this paper. A study was made 'if the intestinal 
flora of guinea pigs on a normal diet, on a diet which 
produced scurvy, and again on a diet which cured this 
disorder. A parallel study was carried out on the feces 
of two infants, the object of the investigation being to 
note whether a definite overgrowth of putrefactive bac- 
teria could be found under these conditions in the in- 
testinal tract. Putrefactive organisms were present 
only in small numbers, and were not found to increase 
as the scurvy progressed, or decrease as it subsided. 
Dr. Hess presented this study from a purely bacterio- 
logical point of view, and emphasized the fact that the 
amount of putrefaction, and its effect on the tissues, 
could be determined only by further investigation. 

Focal Degeneration of the Lumbar Cord in a Case 
of Infantile Scurvy. — Dr. Alfred F. Hess of New York 
presented lantern slides of a case of infantile scurvy 
in a baby 13 months of age, which showed an area 
of degeneration of the anterior horn cells of the lum- 
bar region. This case was the first where the spinal 
cord had been examined in this disorder. It was there- 
fore impossible to say whether this w-as a lesion due 
to the scorbutic condition, or merely associated with 
it. Further examinations of the central nervous sys- 
tem were called for in similar cases. 

Dr. E. T. Bell of Minneapolis asked Dr. Hess what 
muscular changes were associated with the lesion. The 
picture appeared much like the Hoffman type of pro- 
gressive muscular atrophy, except that the lesion was 
focal, which made a marked diflference. If there were 
progressive muscular lesions of long standing the con- 
dition might have some relation to that disease. 

Dr. Oscar Klotz of Pittsburgh said that the picture 
shown hardly suggested bacterial invasion. Investiga- 
tions upon degenerative lesions of the cord, and the 
central nervous system showed the focal picking out 
of certain areas; this was very interesting. They had 
come to recognize that there were regions in the nerv- 
ous system which might be affected in a peculiar man- 
ner by various agents. The peculiarity to lead was an 
instance. 

Dr. A. F. Hess in conclusion said that there were 
no lesions of the muscles, as in progressive atrophy. 
The lesions found were quite typical of infantile scurvy, 
and the diagnosis was clear. He was much interested 
in what Dr. Klotz had said, particularly since he had 
recently read the work of an English investigator de- 
scribing his experimental study showing similar focal 
necroses due to various bacterial toxins. Personally 
he felt that the condition was not due to bacteria, but 
that it was toxic in origin. 

Method of Isolation and Identification of Bacteria of 
the Colon Typhoid Group.— Dr. J. Bronfenbrenner of 
Boston made this renort. The question of infection of 
food, by being handled by "carriers" was considered. 
It was necessary to isolate all the varieties of patho- 



July 20, 1918J 



MEDICAL RECORD. 



127 



genie bacteria which might happen to be present in a 
sample of stools. It was sought to find a medium which 
could be prepared in large quantities for rapid work 
on a large scale. Difficulties in preparing such media 
on account of the instability of its color were encoun- 
tered. After much experimentation with media it was 
found that a lactose agar medium with proper mix- 
ture of rosalic acid and China blue was the most suit- 
able. This indicator left the lactose agar (if properly 
prepared) without change in color. The slightest 
amount of acid produced by bacteria stained the colony 
intense blue, while bacteria not fermenting lactose left 
the media colorless, or slightly pink. Further prob- 
lems arose with regard to the identification of bacteria 
which did not ferment lactose. To meet this problem 
it was arranged in preparing the medium, that the 
"buffer" was adjusted so as to permit the reading of 
the change in reaction as early as possible. If, how- 
ever, the carbohydrate medium was made with the 
view of keeping the cultures for a long time then a 
suitable increase of "buffer" would prevent the ac- 
cumulation of acid. 

Certain Structural Changes in Subacute and Chronic 
Arthritis in Horses and Cattle. — Dr. S. A. Goldberg of 
Ithaca, N. Y.. stated that nonspecific forms of arthritis 
■were apparently more common in the larger domestic 
animals than they were in man. The structural 
changes in these inflammations were in many respects 
similar to defortiiing arthritis in man but they had not 
been found in the combination that characterized de- 
forming arthritis. Etiological factors for these in- 
flammations were stated to be : pressure on articular 
ends, faulty conformation, heavy loads, strains and 
stretching of ligaments and tendons. Infection evi- 
dently played a part in many cases. Umbilical infec- 
tion was a frequent cause in the lower animals, and 
the fact that this was rare in man was due to better 
postnatal care. The dog and the cat were found to be 
more resistant to ordinary infections. Pathological 
changes were found to be thickening of capsular liga- 
ments and connective tissue changes. Hyperemia and 
exudation were found in the synovial membranes, and 
proliferation was also observed. Changes of the articu- 
lar cartilage, on the other hand, were mostly degenera- 
tive. A diffuse superficial necrosis of the articular 
cartilage appeared. In the majority of cases no ap- 
parent change in the periosteum was observed. Aside 
from the fact that various microorganisms were found 
in many of the cases studied, the pathological changes 
in the early stages were similar to those caused by in- 
fection. 

The Relationship of the Leucocyte Count and Bone- 
Marrow Changes in Acute Lobar Pneumonia. — Drs. 
R. A. I-jVMBERT and S. S. Samuels of New York City 
presented this paper. Dr. Lambert pointed out that 
the leucocyte count in lobar pneumonia might vary 
wathin wide limits. Fatally ending cases showed either 
very high, or relatively low counts, while those ter- 
minating favorably usually showed a count between the 
two extremes. Two theories had been put forth to ex- 
plain the low leucocyte count: (1) the bone marrow 
failed to react, either as the result of some previous 
injury (as chronic alcoholism) or from paralysis of 
blood forming elements from over stimulation by the 
pneumococcus infection; (2) the rapid spread of the 
pneumonic process took the leucocytes out of the blood 
faster than they were introduced into the circulation 
from the bone-marrow; therefore, the number of cir- 
culating leucocji;es might be normal or slightly in- 
creased, even though the output from the bone marrow 
might be exceedingly high. There was still a third 
theory which might account for the phenomena, namely, 
that the leucocytes might be forming in some other or- 
gan; for instance, the spleen. Dr. F. A. Evans had 
pointed out that the gray, acute, splenic tumor of lobar 
pneumonia contained numerous myeloid cells, as indi- 
cated by the oxydase reaction, thus indicating a prob- 
able source of some cells of the pneumonic exudate. In 
a study of cases of lobar pneumonia which had come 
to autopsy, the authors made records of the leucocyte 
counts and the bone-marrow changes correlated. Speci- 
mens of bone-marrow were stained and studied. The 
summary of results was : Parallelism of leucocyte 
count and degree of hyperplasia of the marrow found 
in only half the cases; few showed inactive marrow 



and leucocyte counts above normal; on the other hand 
there were cases where the leucocyte count was low 
during life, but a hyperplastic marrow was found post 
mortem. One explanation of this might be the forma- 
tion of leucocytes in the spleen or some other organ; 
a second, a hyperplasia of the marrow of the flat bones. 
The cases of hyperplasia of marrow with low leucocyte 
count were not easily explained. One could not prove 
that there was a rapid drainage of leucocytes out of the 
circulation. 

Studies on Bacteriemia in the Agonal Period. — Dr. 
DEV.^ G. RiCHEY of Pittsburgh reported observations 
on blood cultures taken at the time of death from the 
peripheral circulation of consecutive cases. In all, 206 
cultures were examined. Seventy-six (36.8 per cent.) 
were positive and 130 (63.2 per cent.) were sterile. 
The pneumococcus was found on 32 occasions, or in 50 
per cent, of the cases clinically diagnosed as acute lobar 
pneumonia. Pneumococcus inucosus was isolated five 
times. Streptococcus heiuolyticKS. as a class, was ob- 
tained in 27 instances. S. riridans in 3. Staphylococ- 
cus pyogenes aureus in 7, while the gonococcus. Micro- 
coccus pharyngis siccus, B. coli coinmunior, and B. 
typhosus were each found once. Streptococcus pyogenes 
comprised two-thirds of the hemolj'tic streptococci, 
while S. anginosus and S. subacidus hcnwlyticus were 
next in order of frequency. Out of twenty-five cases 
of periotonitis, only four yielded a positive culture. 
The acute traumatic (non-infectious) deaths gave posi- 
tive findings in less than 3 per cent., whereas 36.3 per 
cent, of the chronic wasting diseases showed a bac- 
teriemia. Sterile cultures were encountered in all cases 
of diabetes mellitus. In twenty-four instances, both 
ante mortem and immediate post mortem, blood cultures 
were taken. Eighty-three per cent, of these showed 
identical findings and 17 per cent, yielded organisms 
which were absent during life. Comparisons were also 
made between immediate post mortem blood cultures 
and cultures taken from the heart's blood at autopsy. 
Sixty per cent, showed the same results, and in 40 per 
cent, an altered bacterial invasion occurred. Cocci 
played the leading role at all times. Bacilli were pro- 
portionately increased in the autopsy cultures. The 
technique for cultivation did not include anaerobic 
methods. 

Transplantation of Tissues into Nearly Related Mem- 
bers of the Same Family. — Dr. Leo Loeb of St. Louis 
presented this study. It was desired to know whether 
in transplanting tissues from parents to children, the 
tissues would behave in certain offsnring like auto and 
in others like homeotransplants. Two sets of experi- 
ments were made. In one various organs were trans- 
planted, either from parents to children, from one mem- 
ber of a fraternity to another, or from offspring to 
parent. Homeotransplants were also made. The re- 
sults of both sets of experiments agreed. In the large 
majority of cases intermediate results were obtained, 
ranging between effects obtained between auto trans- 
plants on the one hand and homeotransplants on the 
other. In regard to the character of tissue planted, a 
few interesting facts were observed. Liver tissue was 
found to survive and even moderately proliferate after 
transplantation. Spleen remained alive in many cases. 
The uterus and ovary of the rat were readily trans- 
plantable. Lutein tissue might form anew in the 
ovary, and some eggs were found to withstand the ef- 
fects of transplantation. The ovary of the guinea pig 
was not so easily transplantable as that of the rat. 
The homeotransnlant gave results much more fre- 
quently than other varieties. Transplantation into 
relatives gave intermediate results. 

Immunity and Tissue Transplantation. — Dr. Leo Loeb 
of St. Louis also made this presentation. Previous 
studies by the author showed that after homeotrans- 
plantation of certain normal tissue a lymphocyte re- 
action occurred. This was also present in homeotrans- 
plantation of tumor tissue in cases in which the com- 
patability between transplant and host was not com- 
nlete. Following a second transplantation of the tumor 
into the same host the lymphocyte reaction apneared 
earlier. In other cases, it was stated, a lymphocyte 
reaction might be absent after a first transplantation, 
but appeared after preliminary inoculation with modi- 
fied tumor material. This would indicate that the re- 
action of the host towards a transplant is altogether a 



128 



MEDICAL RECORD. 



[July 20, 1918 



response to the development of immunity, the lym- 
phocytes being attracted by immunohomeotoxins and 
not by homeotoxins that form as a result of disturbed 
cell metabolism through incompatibility between host 
and transplant. A study was therefore undertaken to 
determine whether after g-rafting of tissue, or second 
inoculation of the same tissue, the lymphocytic reac- 
tion would be noticeably accelerated. A series of ex- 
periments were made in which thyroid of the guinea 
pig was homeotransplanted successively into the same 
host. The first transplant showed lymphocytic reac- 
tion, but at this time the second transplant was almost 
free from lymphocytic infiltration. In some cases, how- 
ever, it would seem that the first transplantation might 
increase the lymphocytic infiltration in the second piece. 
Transplanted thyroids tended to disappear at an early 
date, but whether this was due to an immune reaction 
on the part of the host could not be determined. It 
was considered probable that the lymphocytic reaction 
was a response to the primary homeotoxins, and not 
merely to the effect of immunohomeotoxins, although 
the latter might cause an additional reaction. 



PHILADELPHIA COUNTY MEDICAL SOCIETY. 

Stated Meeting, Wednesday, March 27, 1918. 

The President, Dr. Frank C. Hammond, in the 
Chair. 

Symposium on Xephritis: Symptoms and Diagnosis. — 

Dr. David Riesman under this caption designated hys- 
teria and uremia as two diseases manifesting them- 
selves in protean ways. The greater frequency of 
uremia than of true hysteria emphasized the impor- 
tance of a knowledge of its peculiar habits. He ob- 
served that while the cause of uremic poisoning was 
not known the fact of its exerting itself largely upon 
the central nervous system was well known; also that 
every one with hospital experience was familiar with 
the difficulty in a case of coma in determining the cause. 
No definite earmarks attended the comas of the various 
infections. A recent case was cited in which this diffi- 
■culty was encountered in deciding between uremic coma 
and coma of acute cerebrospinal meningitis. Alcoholic 
coma and the coma of brain injuries frequently pre- 
sented difficulty in differentiation from uremic coma. 
Catheterization and examination of the urine in such 
a case were regarded as of foremost importance. En- 
largement of the heart and hypertension were said to 
point toward uremia ; the eyeground changes were also 
mentioned as of valuable differential import. Mention 
■was also made of the difficulty of differential diagnosis 
of uremic hemiplegia and of uremia aphasia. Those 
trained in the Philadelphia Hospital would remember 
the frequency with which a case diagnosed as apoplexy 
would at autopsy show no hemorrhage in the brain. 
Uremic hemiplegia was transitory in character with a 
tendency to recover. There was nearly always hyper- 
tension with cardiovascular changes of chronic Bright's 
disease and while the problem presented was that of a 
poisoning of the nerve cells, or of vascular crises in 
the brain, the transitory character of the picture might 
be compatible with either condition. The nervous con- 
dition of uremic headache might be the only condition 
of which the patient complained, and this so inton,se as 
to suggest brain tumor. Severe neuralgias referable 
to uremic intoxication were also mentioned. Uremic 
narcolepsy also was referred to as presenting difficul- 
ties in diagnosis. In a case brought into one of the 
hospitals sleep had been exactly like that produced by 
drugs. Autopsy showed the kidneys to be not much 
larger than a silver dollar; the only symptom, however, 
had been the narcolepsy lasting throughout six days. 
Uremic dysentery, though of rare occurrence, had been 
observed. Another manifestation of uremia was the 
so-called hemorrhagic diathesis, in which a patient 
would suddenly bleed from the mouth and nose and 
perhaps from the bowel, with patches of hemorrhage 
showing in the skin. In all such cases under Dr. Ries- 
man's observation there had been the contracted kidney 
with high blood pressure and injured heart. In one 
case of uremic pericarditis there had been shortness 
of breath with symptoms of mediastinal tumor; tapping 
showed hemorrhagic fluid in the pericardium; at au- 



topsy chronic interstitial nephritis only was shown to 
have been present. The diagnosis of uremia and of 
Bright's disease in general was to be made not upon 
one element but by the consideration of many. Urinary 
analysis might be misleading; the author had seen 
cases of Bright's disease with no albumen; greatly con- 
tracted kidney might be present with low blood pres- 
sure. A most valuable point observed was, that with 
the albuminuria of heart disease the urine was nearly 
always highly colored and contained a large amount of 
urates; the albumen was small in amount and casts 
few. It would, however, often test the skill of the best 
men to determine whether a given case was one of 
Bright's disease with cardiac failure, or purely a heart 
condition. 

Functional Tests of the Kidney iD Diagnosis and 
Prognosis. — Dr. O. H. Perry F>epper pointed out the 
following three difficulties in the study of kidney by 
functional tests: (1) The complexity of the kidney 
function; (2) the present lack of knowledge regarding 
the mechanism of urinary secretion; (3) the impor- 
tance of extrarenal factors. Not only should the quan- 
titative appearance of the ingested substance be meas- 
ured but consideration be given the time relation, since 
even a markedly diseased kidney would always elim- 
inate the increased amount of water, salt or urea if 
given time. It was not necessary, he observed, at this 
day again to kill the dead by referring to the entire 
uselessness of estimations of urinary urea if unac- 
companied by exact control of the intake of all protein 
food and of the nitrogen loss in the feces. The extra- 
renal factors were too many for any reliance to be 
placed upon the test, except under extremely favorable 
conditions. The separate tests of the ability of the kid- 
neys to dispose of known amounts of water, protein and 
salts might be combined and the patient placed on a 
diet containing known quantities of these substances 
and the results observed. This, however, was usually 
to be done in conjunction with studies on the blood. The 
determination of the freezing point and the estimation 
of urinary toxicity were other tests mentioned, not, 
however, widely employed. The blood sooner or later 
showed the results of any depreciation of renal activity. 
Attempts had been made to express the relationship of 
the urinary urea and the blood urea in a formula which 
would give the functional efficiency of the kidney in 
mathematical terms as an index. None, however, had 
proved wholly satisfactory and the plan was scarcely 
one for general clinical use. Another group of tests 
mentioned was that based upon the introduction into 
the body of some substance foreign to the organism but 
which is eliminated by the kidneys and of which it is 
possible to determine the rate and quantity of excretion. 
Of the various tests the three of special usefulness were 
said to be (1) The testing of the ability of the kidneys 
to eliminate water and to dilute or concentrate the 
urine; (2) The estimation of salt test; (3) The esti- 
mation of blood urea nitrogen; (4) The phthalein. 
Diagnosis by functional test might be considered from 
(1) The ability of the kidney to perform a given func- 
tion; (2) an estimate of the degree of renal impair- 
ment by nephritis by one or more tests; (3) an esti- 
mate of the patient's condition at the time; (4) con- 
clusions concerning the anatomical lesions in the kid- 
neys. This, however, could not be successfully done 
with the present knowledge of the subject. The test 
of provoked polyuria was said to be of chief value in 
the recognition of acute nephritis, simple degenerative 
nephritis and of passive congestion of the kidneys. The 
test of chloride elimination often gave the earliest evi- 
dence of impaired renal function. The phthalein test 
Dr. Pepper regarded as the best all-round test of renal 
function and said there were few renal diseases in 
which it did not give a fairly true estimate of the renal 
function. Its especial value obtained in chronic 
glomerulonepiiritis. The tests mentioned were re- 
garded as aids in prognosis only as they led to a correct 
diagnosis; a zero phthalein might occur in an acute 
nephritis and recovery ensue. It might also appear as 
a warning of imminent fatal uremia. In prognosis and 
for the control of treatment the author said that the 
functional tests must be repeated at intervals to obtain 
the best results. Emphasis was placed upon the im- 
portance of carefully excluding extrarenal factors and 
of always interpreting the tests in conjunction with 



July 20, 1918] 



MEDICAL RECORD. 



129 



routine study of the urine, the blood pressure, and the 
patient. 

Treatment of Nephritis. — Dr. William E. Hughes 
outlined the picture of Bright's disease as a condition 
due to retention of poisons, deterioration of the blood, 
interference with function of various organs and 
changes in the circulatory apparatus. To be remem- 
bered was the fact that the crippled condition of the 
kidney is aggravated by attempts to secrete even a nor- 
mal amount of excrematous matarial. Treatment 
should include the attempt to prevent ingestion of 
further poisons, to take as much work off the kidneys 
as possible, to stimulate faulty function of other or- 
gans, to restore the blood condition, to minimize the 
injurious effects of circulation, and possibly to stimu- 
late the faulty kidney to renewed activity. In the ques- 
tion of treatment food was regarded as the most im- 
portant. Milk was probably the least injurious food. 
This might be taken as sweet milk, buttermilk, whole 
milk, or skimmed milk, and in some cases of Bright's 
disease such a diet was to be reverted to as the ideal. 
Meat was regarded as the most injurious form of diet 
because of its high nitrogen content. The nitrogenous 
foods apparently poisoned the most seriously and 
permanently. A certain amount of nitrogenous intake, 
except for a short period of time, was of course neces- 
sary, and for this eggs, rather than meat, might be 
adopted. Dr. Hughes' practical experience had been 
that a moderate amount of salt in the diet was not 
harmful. In the use of water he thought the tendency 
was to be extreme; by increase of the watery content 
of the blood a secondary danger to the kidney function 
was produced by the consequent rise in blood pressure. 
Effervescent beverages were said to hold a certain 
element of danger in their stimulative character. The 
state of the digestion w-as regarded as of exceeding im- 
portance in Bright's disease and to it treatment should 
be directed with the closest attention since through ab- 
sorption of toxins in the intestinal tract additional irri- 
tation in the kidneys is brought about. Intestinal anti- 
septics Dr. Hughes had found to be of slight value; of 
these calomel was probably the best. Colonic irriga- 
tion was worthy of consideration. The poison produced 
by fatigue was mentioned among those operative in the 
production of Bright's disease or in its aggravation. In 
no other class of disease was the character of the wear- 
ing apparel believed to be of so much importance: 
woolen, of proper weight, worn the year around he be- 
lieved served an exceedingly useful purpose. In climate 
California preferably and secondly Florida probably 
offered the best conditions for the patient. While fresh 
air and plenty of it were of great value, not infre- 
quently an exacerbation of Bright's disease might be 
traced to too light bedclothing and too much fresh air 
at night. Emphasis was placed upon the importance 
of the skin circulation which w-as to be favorably in- 
fluenced by baths and massage to a moderate degree. 
Anemia as one of the ill effects of nephritis should al- 
ways be borne in mind. The drug of greatest value 
was iron ; pylocarpin in small doses was also employed. 
The dropsy of Bright's disease was said to be in no way 
different from the dropsy in other affections; there 
were present the diseased vessels, poor heart power, 
and wrongly mixed blood. Of cardiac stimulants digi- 
talis was regarded as the best. It was to be remem- 
bered that many cases of apparent apoplectic "stroke" 
were really cases of uremia, and that in such instances 
vigorous treatment must be directed to the kidneys. 
Work, so far as possible, should be taken off of the kid- 
neys, and the intestinal tract should be cleaned. In the 
presence of much hypertension, if the patient were 
fairly well nourished and not particularly anemic he 
should be frequently bled. 

Dr. M. How.ARD FussELL believed with Dr. Pepper 
that the use of the term "nephritis" as a substitute for 
Bright's disease, which was applied to many cases of 
nephritis, would be advisable. To the layman the name, 
Bright's disease, carried the idea of an absolutely fatal 
condition. It was well known that many cases of 
nephritis, if not curable, did not bring death in any 
short length of time. Although, as Dr. Riesman had 
said, in the vast majority of the arteriosclerotic types 
uremia might be easily recognized by the cardiovascular 
changes, in acute nephritis these changes were not pres- 
ent. Hemiplegia it had been observed sometimes per- 



sisted until death ensued. One case cited was that of 
a woman in the Episcopal Hospital with typical inter- 
stitial nephritis. She did not seem to be very ill but 
developed a leftsided hemiplegia. Death followed, due 
in Dr. Fussell's opinion, to apoplexy, but autopsy re- 
vealed no sign of thrombus, simply the presence of the 
sclerotic arteries. Reference was also made to a case 
in the University Hospital which in Dr. Fussell's 
opinion had a bearing upon Dr. Riesman's statement 
that in treatment it made little difference whether the 
arteriosclerotic condition be recognized as the basis of 
certain cases of nephritis. The case presented an ex- 
cellent example of nephritis due to a general arterio- 
sclerosis. There had been dyspnea with recurring at- 
tacks of edema of the legs. The arteries had the ap- 
pearance of pipe stems. The man was (35 years of age, 
had polyuria with low phthalein output. From the re- 
sults of treatment by rest and elimination the case was 
in all probability one of arteriosclerosis; it was not 
Bright's disease. He believed it a great mistake from 
the standpoint of treatment to regard such a case as 
nephritis. Such a patient with the rest he would have 
if placed in an old man's home would live for many 
years. He emphasized the fact that albuminuria did 
not always mean nephritis. It was also true, un- 
fortunately, that a great many physicians did believe 
that albumin in the urine proved the presence of 
nephritis. Notwithstanding the disappointments from 
the removal of teeth and tonsils for the elimination of 
foci of poisons causing nephritis, search should be 
continued for such foci, but there should be increase of 
knowledge of the proper method of dealing with teeth. 
Dr. Fussell believed that in the treatment of nephritis 
each case was a law unto itself. With some patients, 
meat, however slight in amount, seemed to act as an 
actual poison. In acute nephritis diuretics were re- 
garded as absolutely harmful. Absolute rest should be 
enjoined and the use of digitalis in the failing heart. 

Dr. WiLLiA.M DuFFlELD RoBlNSON emphasized the 
necessity of study by every method of research to de- 
termine the cause of nephritis. Much could be accom- 
plished he believed by a proper dietary. One day of 
starvation a week was advocated, with the intake, how- 
ever, of the usual amount of fluids. Great reliance was 
placed upon pylocarpin in the treatment of nephritis. 
The essential point was to seek the cause of the ab- 
normal content in the blood of nephritis. 

Dr. Moses Behrend said that any disrepute into 
which the operative treatment of nephritis might have 
fallen was probably due to the fact that most cases 
were brought to the surgeon too late and that the cases 
were not properly selected. Cases of chronic inter- 
stitial nephritis did very badly as did those of inter- 
stitial nephritis in the aged on account of the arterial 
changes and the changes in the kidneys themselves. 
The most favorable cases for operation were those of 
acute parenchjTiiatous nephritis. The best results had 
been obtained by Edebohls and Lloyd. The former 
had operated on about 110 cases and the latter, 25 or 
30. They give a mortality of 10 per cent and claimed 
a cure in .33 per cent of their cases with improvement 
in 43 per cent. This was an extremely good record ; 
most of the cases were well selected. His own experi- 
ence had not been at all satisfactory. He had operated 
on six cases; three were of the chronic parenchymatous 
type. The last case was that of a child of six years; 
death followed in from 24 to 36 hours. The case was an 
extreme one and operation was the last resort. He had 
operated for bichloride poisoning, stripping the kid- 
neys, but the patients died as they usually did in 
severe bichloride poisoning. About 1912 the Editors of 
the Medicale Clinique had sent a letter to the various 
surgeons. Favorable reports had been received from 
Thiersch. Other operators reported no results. In 
operation for eclampsia the best results had occurred 
after labor. Before the puerperium the results were 
for the most part fatal. Litchfield's mortality was 
1.73 per cent in 53 cases. Many writers, especially 
Lloyd, had said that a fibrous capsule redeveloped after 
decapsulation of the kidney and that this fibrous cap- 
sule was just as bad as the original capsule. This was 
denied by another writer. Opportunity for reoperat- 
ing on these cases was naturally not very good. E. H. 
Goodman had noticed a rapid fall of blood pressure 
after decapsulation. 



130 



MEDICAL RECORD. 



[July 20, 1918 



Stated Meeting, Wednesday, April 10, 1918. 

The President, Dr. Frank C. Hammond, in the 

Chair. 

symposium: the modern treatment of burns and 
leg ulcers. 

Treatment of Burns by Exposure to the Air and the 
Application of Dichloramine Through Paraffined .Mos- 
quito Netting. — Dr. Walter Estel Lee and William 
F. FuRNESS presented this paper. They quoted .Stew- 
art's definition of an ideal dressing for severe burns, 
one "that would be (1) aseptic or (i) mildly antiseptic, 
(3) that would provide free drainage, (4) that would 
not macerate or (5) stick to the tissues, and (6) would 
not necessitate frequent changing." Still another pro- 
vision which Dr. Lee thought might be added was one 
which should minimize the abnormal radiation of body 
heat from surfaces devoid of the protection of the skin 
and subcutaneous tissues. There was not at the pres- 
ent, the author said, any one treatment of burns meet- 
ing all these conditions, although ambrine and many 
forms of paraffin films at present in use did fulfill some 
of these requirements. The recent interest in paraffin 
film treatment had induced many surgeons to abandon 
a method which for some time had given e.xcellent re- 
sults, i.e. the exposure of the burnt surfaces to the air. 
The open-air treatment of burns, in Dr. Lee's opinion, 
more nearly met the theoretical requirements of an ideal 
dressing than any other which had been proposed. Of 
this method the author suggested the following modifi- 
cations: The covering of the entire burnt area and a 
generous portion of the surrounding skin with a single 
layer of mosquito netting previously impregnated with 
paraffin wax, the netting being held in place by single 
layers of a circular turn of gauze bandage or by adhe- 
sive strips applied over the netting and the uninjured 
skin (never over the burnt area). Such a dressing was 
aseptic, and the large open meshes provided perfect 
drainage for the wound secretions to the outer surface 
of the netting. When the scab formation on the outer 
surface of the netting interfered in the slightest way 
with the drainage of the wound secretions it could be 
completely and painlessly removed by lifting the non- 
sticking paraffin net from the surface of the wound, 
usually once in twenty-four hours. The paraffin net- 
ting, it was said, rarely adhered to the wound surface, 
but a generous spraying with sterile paraffin oil would 
always loosen it. The only remaining condition to be 
met to have the air treatment fulfill all the require- 
ments of the ideal dressing was the use of an antiseptic. 
In this connection Dr. Lee said that a 1 or 2 per cent, 
solution of dichloramine-T dissolved in chlorinated par- 
affin wax (after tlie method of preparation proposed by 
Dakin and Dunham) could be used on burnt surfaces 
without causing any objectionable subjective or objec- 
tive irritative phenomena. This oil solution could be 
readily applied in the form of a spray (at the room 
temperature no heating was required as with the paraf- 
fin films) to the entire burnt surface before the paraf- 
fin net dressing was applied, and subsequently through 
the meshes of the net onto the surface of the wound, if 
for any of the above mentioned reasons it was unnec- 
essary to remove the dressings each day. This modified 
air treatment of burns had been employed upon eighty- 
six cases at the Pennsylvania and Germantown hospi- 
tals during the past seventeen months. Dr. Lee ob- 
served that with this they had felt that because of the 
surprisingly small degree of infection occurring in the 
wounds these had healed more promptly and with more 
satisfactory scars than with any othei" method hereto- 
fore used. An outline was given of the preparation of 
the paraffin mosquito netting used to minimize the stick- 
ing of the dressings to and permit the drainage of the 
discharges from the surfaces of the wounds and exten- 
sive burns. 

The Treatment of Burns. — Dr. Robert Perry Cum- 
mins said that in the steel industry almost every type 
of burn was seen, the niosi common being those caused 
by molten metal splashes coming in contact with the 
tissues, those setting fire to clothing, and those due to 
back drafts from furnaces. As regarded treatment, 
burns should be regarded as infected wounds. To be' 
considered also were shock, the question of primary 



dressing, the postinflammatory stage, and the sequelas. 
For the treatment of shock Dr. Cummins placed more 
reliance upon the use of adrenalin and ergot than upon 
strychnine and digitalis. Caution against overstimula- 
tion, however, was given. For the cleansing of the 
wounds he had found high-grade benzine his best agent. 
He used warm sterile dressing or boric or physiological 
salt solution, changed once or twice every twenty-four 
hours, continued for three or four days. In the healing 
period the treatment with ambrine or one of its sub.sti- 
tutes, or the open-air method, had given the best results 
in his hands. In the case of the ambrine treatment he 
would suspend its use for a few days that the wound 
might be freed of pus by the application of an antisep- 
tic such as dichloramine-T. Dr. Cummins was decided. y 
opposed to the exclusive use of the ambrine method in 
burns of large area ; also he would not employ it in a 
sloughing area. Exuberant granulations he believed 
should not be cauterized since these were soon strangled 
by the elements of regeneration of the skin. The ab- 
sence of hard, poorly nourished scar tissue was men- 
tioned as a striking characteristic of the ambrine treat- 
ment. The open-air treatment he had found more sat- 
isfactory in hospital than in ambulatoi-y cases. Refer- 
ence was made to the important role of splints, pos- 
tures, and passive motion in scars and contractures 
likely to cause physical deformities, and in the treat- 
ment of the usually complicating toxic nephritis en^- 
phasis was laid upon the importance of an abundan 
of concentrated liquid food and water, stimulation, a; 
elimination by every possible avenue. The progno> - 
was regarded as difficult and uncertain until recover;, 
was well advanced. With alcoholics the chance of u- 
covery in extensive burns was slight. The value u: 
careful surgery and technique equaled that of the dress- 
ings. 

Iodine Fumes in the Treatment of Ulcers. — Dr. John 
J. Gilbride said that about a year and a half ago, hav- 
ing read in the Journal of the American Medical A^i-o- 
ciation of the satisfactory results in treatment of ulcers 
with iodine fumes, he had employed this method in a 
severe burn of the leg from a hot water bottle in a 
patient who had had an appendectomy. The burn had 
resisted the ordinary treatment given for a month or 
two. At the time of the first application of the iodine 
fumes the ulcer was about three-quarters of its original 
size. One subsequent treatment was given and in a 
week following the ulcer had completely healed. He 
had since used the fumes in four other cases of burn 
with most satisfactory results. 

Treatment of Leg Ulcers. — Dr. Penn-Gaskill Skil- 
LERN, Jr., in this communication, stated that the prin- 
ciples of the treatment of ulcer included sterilization 
of the ulcer and support of the part. Since congestion 
was the first stage of inflammation, the patient should 
be put to bed and the limb elevated to an angle of 20'. 
Sterilization of the wound should then be effected, which 
was best accomplished by the use of dichloramine-T. 
Following the application of a 20 per cent, solution of 
dichloramine-T, the paraffined wide-mesh mosquito net- 
ting described by Dr. Lee was to be placed over the 
area and secured at the edges with adhesive plaster. 
The ne.xt dressing was made in from twenty-four to 
forty-eight hours and consisted of a 5 per cent, solution 
of dichloramine-T. If the ulcer was large, skin graft- 
ing might be needed, the best method of which was car- 
ried out by Steele in 1870 and which utilized a greater 
thickness of skin giving a graft from the size of a pea to 
that of a finger nail. These grafts took hold and made 
a more pliable scar. The treatment subsequent to the 
skin grafting was the same almost as before, that by 
the open method. A basket of wire gauze was placed 
over the open wound and the graft allowed to heal un- 
derneath. The best treatment for a small ulcer, prac- 
tically sterile with healthy granulations, when the 
patient was able to be up and about, was said to be that 
proposed as far back as 177(i by an English surgeon and 
revived recently, consisting of the application of imbri- 
cated adhesive plaster strips two-thirds around the limb 
from below upward in the direction of the venous cur- 
rent. These strips supported the edge of the ulcer, com- 
pi-essed it. and kept the blood out of the edge, thus pre- 
venting the granulations from becoming edematous. 
Discharge was thus reduced to a minimum by means of 
the compression, and calomel powder dusted on kept the 



July 20, 1918] 



MEDICAL RECORD. 



131 



wound dry. If there happened to be a concavity be- 
tween the floor of the ulcer and the surface of the leg 
the compression by the adhesive plaster strips could be 
transferred to the base. In certain cases of simple 
ulcer in which this method was not effective others 
might be used, the simplest of which was the Nusbaum 
operation. In addition to local treatment there must 
sometimes be exposure of the nerves supplying the 
ulcer area. Dr. Skillern emphasized that in the treat- 
ment of leg ulcer it was essential to remember the 
underlying congestion and the other fundamental etio- 
logical factors involved. 

Dr. Edward J. Klopp stated that he had had oppor- 
tunity to see Dr. Lee's method for the treatment of 
burns and believed it to be the best in vogue. His 
experience with the ambrine treatment had been lim- 
ited, but disappointing. For the removal of the car- 
bonized tissue in the third degree burn he believed 
that the dichloramine-T was probably not necessary. 
The method formerly employed had been the use of 
salt solution. Most of the textbooks gave as one of 
the best methods that of immersing the patient in a 
tub of warm salt solution at a temperature of 100° to 
105^ F. Unfortunately, in the majority of instances 
the water was not maintained at this temperature and 
the already shocked patient was further depressed. To 
facilitate the removal of carbonized tissue when the 
patient was anesthetized and to remove the tissue with 
the forceps, the surface was covered with narrow strips 
of sterilized gauze separated about ^ inch. The sur- 
face was then covered with gauze saturated with warm 
sterile salt solution. The dressing could be changed 
and warm salt solution added without interfering with 
the wound. Dr. Klopp said he had nothing to offer that 
would take the place of the dichloramine-T. Concern- 
ing the end results he observed that it was sometimes 
several years before the maximum contraction of a 
scar was known. He was of the opinion that in the 
presence of a large burnt area with healthy surface, 
skin grafting should probably be attempted because 
it expedited matters. Here, of course, the method of 
choice was the Thiersch procedure. 

Dr. William L. Clark said that the ulcers which 
he saw were usually advanced cases in which ordinary 
methods had failed and w-hich were sent with the idea 
that electricity might be helpful. He had had much 
success, also some dismal failures. The diagnosis of 
the ulcer was of first importance. Syphilitic ulcer had 
been referred for epithelioma; epithelioma, for simple 
sluggish ulcer. For the different types different treat- 
ment was required. He had found that various phy- 
sical measures often did good. The principle on which 
electricity was used was first, destruction of the gran- 
ulations; second, sterilization; third, relief of passive 
congestion. 

Dr. Kate W. Baldwin had found nothing to be more 
soothing in burns and giving more rapid healing than 
the application of the violet ray of moderate strength. 
The value of the treatment had been beautifully demon- 
strated in a child brought to the hospital in whom one- 
third of the surface of the body had been burned. The 
patient had been treated outside until it was in a septic 
condition. The child was placed on the table and with- 
out an anesthetic the moderate current was applied. 
Care had been observed to put the electrode in contact 
before turning on the current. The child went to sleep 
and remained asleep while the application was made 
over the entire surface involved. 

Dr. Moses Behrend observed that the treatment of 
burns with ambrine had given good results in his hands. 
The scarring he had found to be as soft following the 
use of ambrine as that following dichloramine-T. He 
believed, however, that the dichloramine-T was the bet- 
ter method because of its antiseptic quality and because 
of the fact that the ambrine retained the discharges 
for quite a long time. 



Krbnig's Latest Results from Cancer Operations. — 

According to one of Kronig's assistants many cases of 
cancer treated by the knife at the Freiburg Gynecologi- 
cal Clinic have been followed up for 10 years with the 
discovery that only .5.2 per cent, of the women had 
survived that period. Hence Kronig is henceforth 
for .T-ray therapy. — Correspondenz-Btatf fiir Schu-eizer 
Aerzte. 



#tate Mihxtai ICtrettamg Snarlia. 

STATE BOARD EXAMINATION QUESTIONS. 

Board of Medical Examiners of Maryland. 

December, 1917. 

ANATOMY. 

1. Define marrow, periosteum, compact and cancellous 
bone, epiphysis, diaphysis. 

2. Bound the superior carotid triangle, and name the 
contents of same. 

3. Name the organs of generation in the male and 
female, and describe the ovary. 

4. Define hernia, and name and locate all hernias 
which occur in the abdomen (not traumatic). 

5. State what muscles enter into the formation of (a) 
anterior wall and (6) floor of pelvis. 

6. State definitely the result of cutting in living sub- 
jects the following nerves : Radial, peroneal, pudic, 
anterior femoral (below Poupart's ligament). 

7. What anatomical structures pass through the sphe- 
noidal fissure (foramen lacerum anterius) ? 

8. Name the salivary glands, and locate the orifices of 
their ducts. 

9. Through what vessels does blood pass in going 
from the spleen to the under surface of the middle toe. 

10. Name bones and ligaments entering into forma- 
tion of the ankle joint. 

PHYSIOLOGY. 

1. State causes of pressure in the arteries, capillaries, 
and veins. 

2. Name some of the bodily states which lessen the 
alkalinity of the blood. 

3. Describe the process of osmosis and give examples 
in the human economy. 

4. (a) Name the secretions of the alimentary canal, 
their reactions and functions, (b) Name the active 
principles of the digestive secretions. 

5. (a) Describe bile and its uses; where first found; 
trace its course. (6) Name the bile salts. 

6. State the general classes into which foods are 
divided, and give examples of each. 

7. (a) What are the functions of the skin and its 
appendages? (6) What matters are excreted by the 
skin? ((■) How may the function be affected as to the 
amount of excretions? 

8. (o) Describe the functions of the kidneys. (6) Do 
both kidneys constantly act? (c) How does the impair- 
ment of the functions of the kidneys affect that of the 
skin and lungs? (rf) Give the variations within limits 
of health in the specific gravity of urine. 

9. Describe nerve-cells and fibers. 

10. (a) Define reflex action, and give example. (6) 
Give illustrations of morbid reflex action. 

chemistry. 

1. Describe phosphorus, and name and give formula 
of three of its compounds. 

2. Why should solutions of silver nitrate not be em- 
ployed after irrigations with salt solution? Illustrate 
by formula. 

3. How is chlorine made, and what are its chemical 
properties? 

4. What are simple and what are compound proteins? 

5. What is glucose? Why is it sometimes employed 
in solution intravenously? 

6. Name three hydrocarbons, and give formula. Name 
three carbohydrates, and give formula. 

7. What is Fisher's solution? What is its chemical 
effect when administered by the vein? 

8. Describe two important chemical tests used in ex- 
amining the stomach contents. 

9. Describe two important chemical tests used in ex- 
amining urine. 

10. What chemicals are used in purifying water for 
drinking purposes, and how are they employed? 



ANSWERS. 
anatomy. 



1. Marrov: is a substance found in the marrow canals 
of long bones and the medullary spaces of cancellated 



132 



MEDICAL RECORD. 



[July 20, 191c 



bone, and in the Haversian canals. It is composed of a 
fibrous matrix with blood vessels and myelocytes. 

Periosteum is a fibrous, vascular structure covering 
bone (except where there is articular cartilage). 

Ccmipact bone is bone in which the constituents are 
so closely packed together that the bone appears 
(macroscopically) dense and like ivory. 

Ca>iccllute(l bone has an open or porous appearance. 

Epiphysis is a process of bone which has a secondary 
center of ossification, and which is temporarily attached 
by cartilage to the principal part of the bone. 

Diiijiliysis is the shaft of a long bone. 

2. The superior carotid triangle is bounded, behind 
by the sternomastoid; below by the anterior belly of the 
omohyoid; and above by the posterior belly of the di- 
gastric. 

The superior carotid triangle contains: Termination 
of common carotid, external and internal carotid ar- 
teries; superior thyroid, lingual, facial arteries and 
veins; internal jugular vein; vagus, superior laryngeal, 
hypoglossal and sympathetic nerves; upper part of 
larynx, and lower part of pharynx. 

3. Organs of generation in the male: Testes, penis, 
prostate, Cowper's glands, seminal vesicles, vasa defer- 
entia. 

Organs of generation in the female: Ovaries, Fal- 
lopian tubes, uterus, vagina, mons Veneris, labia 
majora and minora, clitoris. 

The ovaries are two in number, and correspond to the 
testes in the male; they are of a flattened ovoid form, 
vertically placed in the posterior part of the broad liga- 
ment. By its anterior border the ovary is connected to 
the broad ligament, and by its lower pole to the uterus 
by a proper ligament, extending to the superior angle 
of the uterus, and called the ligatnent of the ovary. 
The lateral surfaces and posterior border are free. 
The superior pole and posterior border are embraced 
by the Fallopian tube; on its inner surface it is in 
relation with small intestine in Douglas' pouch, and 
externally lies in a peritoneal fossa between the ex- 
ternal and internal iliac vessels as they diverge. The 
vessels enter the hilum at the attached anterior border. 
— {Aids to Anatomy.) 

4. A hernia is a protrusion of part of the parietal 
peritoneum, through some weak point in the abdominal 
wall, in the form of a sac ; in this sac may be a portion 
of the omentum, small intestine, or occasionally some 
other abdominal organ. 

Varieties of abdominal hernia (not traumatic) : 
Oblique fAcquired 

\ Congenital 

(infantile or encysted 

f Exiiernal 

( Internal 

flntraparietal 

< Interparietal 
Interstitial ( Extraparietal 

[Incomplete, or Bubonocele.] 

2. Femoral 

("Congenital 

3. Umbilical < Of infants 

(.Of adults 

4. Ventral. 

The inguinal occurs in the inguinal region, above 
Poupart's ligament; the femoral in the femoral region, 
below Poupart's ligament; the umbilical in the region 
of the umbilicus; the ventral (generally) in one or more 
of the muscles of the anterior abdominal wall. 

5. Muscles entering into foivnation of anterior wall 
of pelvis: Rectus abdominis, pyriformis, transversalis, 
external oblique and internal oblique. 

Muscles entering into formation of floor of pelvis: 
Transversus perinei, compressor urethrse, accelerator 
urinffi (or sphincter vaginje), erector penis (or clitori- 
dis) , levator ani, and coccygeus. 

6. Section of the radial nerve (B. N. A. term for 
the musculospiral nerve) causes: (n) Anesthesia. If 
the nerve is divided in the upper third of the arm — 
i.e., above the origin of its external cutaneous branch — 
there is loss of both epicritic and protopathic sensation 
over the radial half of the dorsum of the hand, of the 
epicritic a little more than of the protopathic. Sec- 
tion of the radial nerve in the upper third of the 



1. Inguinal 



Direct 



forearm causes no loss of sensation; but section of the 
lower third causes a limited loss of epicritic sense over 
the back of the thumb. (6) Paralysis of (1) the ex- 
tensor of the forearm (triceps), hence the forearm can 
only be extended by its own weight; (2) the long and 
short supinators, hence the hand is pronated; (Zj the 
radial and ulnar extensors of the wrist, hence wTist- 
drop; (4) the extensors of the fingers and thumb, which 
either hang limp and motionless or may be bent up 
into the palm from the unopposed action of the flexor 
muscles. 

Section of the peroneal nerve (B. N. A. term for 
the external popliteal nerve) causes anesthesia of the 
dorsum of the foot and a varying portion of the front 
and outer side of the leg, together with paralysis of 
the extensor and peroneal groups of muscles; and from 
the contraction of the unbalanced opposing groups, the 
paralytic form of talipes equino-varus results. 

Section of the pudic nerve causes pain in perineum, 
penis, scrotum, buttocks, dowTi the thigh; priapism, in- 
continence of urine; and interference with the action 
of the levator ani, compressor urethrse, ischicavernosus, 
bulbocavernosus, and transversus perinei muscles. 

Section of the anterior fetnoral nerve below Poupart's 
ligament (B. N. A. term for anterior crural nerve) 
causes paralysis of the quadriceps extensor, pectineus 
and sartorius, and the most marked effect will be sec- 
ondary flexion of the knee joint from the unopposed 
action of the hamstrings; anesthesia extends over the 
front of the thigh and along the inner side of the leg 
and foot as far as the ball of the great toe. (From 
Rose and Carless' Surgery.) 

7. The sphenoidal fissure trans^nits : The motor oculi, 
patheticus, the three branches of the ophthalmic divi- 
sion of the trigeminus, and the abducens nerves, and 
some filaments from the cavernous plexus of the sjin- 
pathetic; the orbital branch of the middle meningeal 
artery, a recurrent branch from the lacrimal artery, 
and the ophthalmic vein. 

8. The salivary glands are the two parotid, two sub- 
lingual, and two submaxillary glands. 

Stens07i's duct (from the parotid) opens in the mouth 
opposite the second upper molar tooth. 

Wliarton's duct (from the submaxillary) opens on 
the floor of the mouth at the side of the frenum of the 
tongue. 

The ducts of Rivinus (from the sublingual) open on 
the floor of the mouth near the frenum of the tongue. 

9. In passing from the spleen to the under surface 
of the middle toe, blood passes through: The splenic 
vein, portal vein, hepatic vein, inferior vena cava, right 
side of heart, pulmonary artery, pulmonary veins, left 
side of heart, aorta, common iliac, external iliac, fe- 
moral, popliteal, posterior tibial, external plantar, and 
third and fourth digital arteries. 

10. Ankle joint. Bones — Tibia, fibula, astragalus. 
Ligannents — Anterior tibiotarsal, posterior tibiotarsal, 
external lateral, internal lateral. 

PHYSIOLOGY. 

1. Arterial pressure is produced and maintained by: 
The force and contraction of the left ventricle; the 
volume of blood pumped by the heart into the already 
full arteries; the action of the aortic semilunar valves 
in preventing regurgitiition of the blood into the left 
ventricle when it goes into diastole; the elastic resil- 
iency of the middle coats of the large arteries; the 
peripheral resistance exerted by the muscular wall of 
the arterioles, which are especially controlled by the 
vasomotor nerves; the increased surface over which the 
blood flows through the capillaries; and the tension of 
the extravascular tissues. The capillary pressure de- 
pends upon the condition of the arterioles. If the 
arterioles to a part dilate, the capillary pressure rises; 
if they constrict the capillary pressure falls. If, how- 
ever, the venous pressure is raised, the capillary pres- 
sure must consequently rise too. Gravity very ma- 
terially influences the capillary pressure. 

The venous pressure is influenced by: The presence 
of valves, which prevent a backward flow; and respira- 
tory movements. (From Lyle's Physiology.) 

2. The alkalinity of the blood may be decreased dur- 
ing health by (1) great muscular exertion, and (2) by 
exposure of the blood to conditions of coagulation. Path- 



hily 20, 1918] 



MEDICAL RECORD. 



133. 



olugically, the alkalinity of the blood may be decreased 
\>y (1) anemia, (2) uremia, (3) rheumatism, (4) high 
fuver, (5) diabetes, (6) cholera. (Hall's Textbook of 
Physiology.) 

3. Osmosis: "If two different liquids are separated 
from each other by a porous partition, a current sets in 
from each liquid to the other. The strength of these 
currents depends on the facility with which the liquids 
are imbibed by the partition and the tendency the two 
fluids have to mix with each other; the fluid which 
soaks most rapidly into the partition — i.e., that which 
wets it most readily — passes through it most rapidly. 
If a bladder be filled with syrup and immersed in water, 
the water will pass into the bladder more rapidly than 
the syrup passes out, and may so far raise the pres- 
sure in the interior of the bladder as to burst it. The 
water is said to pass into the bladder by endosmosis, 
and the syrup to pass out by e.xosmosis. Dialysis dif- 
fers from osmosis in this: In dialysis a crystalloid 
in solution passes into a fluid, which contains a smaller 
quantity of the crystalloid; osmosis occurs at the same 
time, but the phenomena are quite distinct. The law of 
osmosis deals only with the currents of liquid. The 
blood-vessels of the alimentary canal absorb fluids by 
osmosis. The plasma has only a very slight tendency 
to pass out of the vessels, while the liquids contained 
in the alimentary canal pass into the blood with great 
readiness. The taws of osmosis are: (1) The liquids 
must be of different densities. (2) They must be cap- 
able of mixing with each other. (3) The membrane 
must be permeable to at least one of the liquids. (4) 
The current produced is greater the greater the tend- 
ency of the liquid to permeate the membrane — the 
greater current is spoken of as endosmosis, the lesser as 
exosmosis. AU these conditions exist between the blood 
and the fluids with which the blood-vessels are sur- 
rounded, and the fluids outside the vessels pass into 
them more readily than the blood plasma escapes. En- 
dosmosis usually occurs from a lower to a higher pres- 
sure." — (Aids to Physiology.) 

Examples of osTtiosis in the human economy: "In 
the body we have aqueous solutions of various sub- 
stances separated from one another by membranes. 
Thus we have the endothelial walls of the capillaries 
separating the blood from the lymph; we have the 
epithelial walls of the kidney tubules separating the 
blood and lymph from the urine; we have similar epi- 
thelium in all secreting glands; and we have the wall 
of the alimentary canal separating the digested food 
from the blood vessels and lacteals." — (Halliburton's 
Physiology.) 

4. The secretions of the alimentary canal are: Saliva, 
gastric juice, pancreatic juice, bile, and succus enteri- 
cus. Of these the gastric juice has an acid reaction; 
the others, alkaline. 

The functions of the saliva are: (1) To moisten the 
mouth, (2) to assist in the solution of the soluble por- 
tions of the food, and thus (3) to administer to the 
sense of taste, (4) to lubricate the bolus of food, and 
thus (5) to facilitate the acts of mastication and de- 
glutition, and (6) to change starches into dextrin and 
sugar. 

The functions of the gastric juice are: (1) To change 
proteids into proteoses and peptones, and (2) to curdle 
the casein of milk. 

The functioiis of the pancreatic juice are: (1) To 
change proteids into proteoses and peptones, and after- 
wards decompose them into leuein and tyrosin; (2) 
to convert starch into maltose; (3) to emulsify and 
saponify fats; and (4) to cause milk to curdle. 

The functions of the bile are: (1) To assist in the 
emulsification and saponification of fats; (2) to aid 
in the absorption of fats; (3) to stimulate the cells of 
the intestine to increased secretory activity, and so 
promote peristalsis, and at the same time tend to keep 
the feces moist; (4) to eliminate waste products of 
metabolism, such as lecithin and cholesterin; (5) it has 
a slight action in converting starch into sugar; (6) it 
neutralizes the acid chyme from the stomach and thus 
inhibits peptic digestion; (7) it has a very feeble anti- 
septic action. 

The functions of the succus entericus are: The secre- 
tion of enterokinase, secretin, and erepsin, which assist 
the pancreatic juice in digestion. 





ACTIVE 




SECRETIONS. 


PRINCIPLES. 


FUNCTIONS. 


Salivary 


Ptyalin. 


changes starches into 
dextrin and sugar. 




(-Pepsin. 


Changes proteids into 
proteoses and pep- 


Gastric 




tones in an acid me- 




< 


dium. 




A curdling 


Curdles the casein of 




ferment. 


milk. 




^Trypsin. 


Changes proteids into 
proteoses and pep- 
tones and afterwards 
decomposes them into 
leuein and tyrosin; 
in an alkaline me- 


Pancreatic 




dium. 




Amylopsin. 


Converts starches into 
maltose. 




Steapsin. 


Emulsifies and saponi- 
fies fats. 




A curdling 


Curdles the casein of 




ferment. 


milk. 


Intestinal 


Invertin. 


Converts maltose into 
glucose. 



5. Bile is a secretion of the liver; it contains water 
and solids. The latter are bile salts (sodium taurocho- 
late and sodium glycocholate), mucin, bile pigments 
(bilirubin and biliverdin), cholesterin, lecithin, neutral 
fats, and inorganic salts (NaCl, KCl, and phosphates). 

The functions of the bile are: (1) To assist in the 
emulsification and saponification of fats; (2) to aid in 
the absorption of fats; (3) to stimulate the cells of the 
intestine to increased secretory activity, and so promote 
peristalsis, and at the same time tend to keep the feces 
moist; (4) to eliminate waste products of metabolism, 
such as lecithin and cholesterin; (5) it has a slight 
action in converting starch into sugar; (6) it neutral- 
izes the acid chyme from the stomach and thus inhibits 
peptic digestion; (7) it has a very feeble antiseptic 
action. 

The bile is secreted in the liver; it passes by the 
hepatic duct and cystic duct to the gall-bladder, where 
it is stored ; it then passes down the cystic duct, through 
the common bile duct, and into the duodenum. 

6. Foods are classified: 
( Water. 
1 Salts. 

f f Carbohydrates. 

1 J.T 1. 



I. Inorganic. 



II. Organic. 



Non-nitrogenous, -j p„+g 
(. Nitrogenous — Proteids. 



Examples of each: Carbohydrate, sugar and starches; 
Fat, fat of meat, and butter; Proteid, flesh of animals, 
and white of eggs; Salt, sodium chloride, and calcium 
phosphate. 

7. The functions of the skin are: (1) Protection, 
(2) excretion, (3) secretion, (4) regulation of body 
temperature, (5) absorption, (6) general sensation, 
(7) special sense of touch, and (8) respiration. 

Matters excreted by the skin: Water, salts, urea. 

Certain drugs (as pilocarpine) increase the amount 
of perspiration; others (as atropine) diminish it. The 
ingestion of much water increases the amount of per- 
spiration. The excretion of much urine causes a dim- 
inution in the secretion of sweat; in uremia there is 
more urea than normal in the perspiration. 

8. The functions of the kidney are: (1) To secrete 
(or excrete) urine; (2) to regulate the reaction of the 
urine; (3) the formation of hippuric acid; (4) regu- 
lation of the composition of the blood plasma by ex- 
cretion of abnormal or toxic substances; and (5) the 
production of an internal secretion. The mechanism of 
the secretion of urine by the kidneys is twofold: (1) By 
filtration, most, if not all, of the fluid is eliminated, 
and also inorganic salts; this depends upon blood pres- 
sure, and takes place in the glomeruli. (2) By cell 
activity and selection, in the cells of the convoluted 
tubules, the urea, and principal solids are eliminated. 

"The urine is secreted continuously by the kidneys." 
Impairment of the function of the kidneys throws 



134 



MEDICAL RECORD. 



[July 20, 1918 



more work on the skin, which it can only partially 
perform; some of the work must also be performed by 
the lungs. 

The specific gravity of the urine, in health, may vary 
from about 1015 to about 1025. 

9. Nerie fibers and nerve cells. Nerve cells are of 
different sizes and varying shape; some are ovoid, some 
irregular in outline. Each cell has a large, distinct, 
spheroidal nucleus with a single nucleolus and fibril- 
lated protoplasm. Nissl's granules are sometimes found 
in the protoplasm. From the cells are given off a.xis 
cylinder processes or neura.ces, and protoplasmic proc- 
esses or dendrites. These are the principal elements in 
nerve fibers. Every nerve cell has an axis cylinder 
process, which in the medullated nerve fiber becomes 
the axis cylinder, and in the non-medullated is the nerve 
fiber itself. The function of the nerve cell is to re- 
ceive, or to send out, or to modify, nerve impulses; the 
function of the nerve fiber is to carry nerve impulses. 
Nerve Fibers. — 1. Medullated Fibers. — "Medullated 
nerve fibers usually consist of three parts: (a) axis 
cylinder, (6) medullary sheath, (c) neurilemma. An 
n.vis cylinder is a cell process that carries an impulse 
away from the nerve cell. It is a slender cytoplasmic 
process and may be very long, as is the case with the 
motor fibers that come from nerve cells in the anterior 
horn of the spinal cord and extend, without interrup- 
tion, to muscles in the distal parts of the limbs. The 
axis cylinder presents a longitudinal striation, a fibril- 
lar structure, that is supposed to be continuous with 
the cytoplasmic striation of the cell body. The fibrils 
are imbedded in a fluid protoplasmic substance, the 
neuroplasm, and the whole surrounded by a delicate 
membrane, the exolemma. Implantation cone is an ele- 
vation that is sometimes present at the junction of the 
axis cylinder and cell body. The medullary sheath 
(white sheath of Schwann) is a covering to the axis 
cylinder. This sheath never extends to the nerve cell, 
but begins a little distance from it. Nodes of Ranvier 
are constrictions of this sheath at regular intervals. 
The smaller the fiber the greater the distance between 
these nodes. Long fibers are slender, with long distance 
between the nodes; short fibers are coarse, with short 
distance between nodes. The neurilemma is a thin 
structureless membrane that surrounds the medullary 
sheath. An oval nucleus is present in this sheath, mid- 
way between the nodes of Ranvier. At each node the 
neurilemma is constricted and touches the axis cylinder, 
which in turn may be slightly thickened at this point 
and may give off a collateral. Medullated nerve fibers 
with a neurilemma are found in the cranial and spinal 
nerves. Medullated fibers without a neurilemma are 
found in the brain and spinal cord. The neurilemma 
gives great strength to the fibers. Its absence in the 
brain and cord accounts for the pulpy soft nature of 
this tissue." 

"Non-medullafcd nerre fibers with a neurilemma, but 
without a medullary sheath, mingle with the medullated 
fibers. The sympathetic system consists largely of non- 
medullated fibers. Terminal branched endings of an 
axis cylinder, called neuropodia, have neither medul- 
lary sheath nor neurilemma. The axis cylinder, just 
as it leaves its nerve cell, is likewise uncovered." — 
(Hill's Histology.) 

10. Reflex actions are involuntary or unconscious 
movements due to suitable stimuli. They depend upon 
the integrity of the reflex arc, which is a complex made 
up of: (1) A surface capable of receiving an impres- 
sion; (2) an afferent nerve; (3) a nerve cell capable 
of receiving and also of sending out impulses; (4) an 
efferent nerve, and (5) a surface capable of responding 
in some way to the impulse conveyed by the efferent 
nerve. Example: The patellar reflex consists of a con- 
traction of the extensor muscles of the leg and a move- 
ment of the foot forward when the ligamentum patellae 
is struck; the quadriceps extensor must first be slightly 
stretched by putting one knee over the other. Its in- 
tegrity depends upon a healthy condition of the entire 
reflex arc, consisting of tendon, afferent or sensory 
nerve, posterior roots, and anterior horn of the spinal 
cord, the efferent or motor nerve, and the muscle itself. 
Illustrations of morbid reflex action can be seen in 
tetanus, when a slight touch, or even a breath of air, 
on the skin may cause convulsions of the whole body; 
also in the vomiting of pregnancy. 



CHEMISTRY. 

1. Phosphorus exists in four forms. The two most 
common are: Yellow phosphorus, a translucent solid 
which becomes opaque when exposed to light; it is 
poisonous, of waxy consistency, and when exposed to 
air it gives off white fumes and an odor of garlic. It 
ignites readily, is insoluble in water, but soluble in oils, 
alcohol, ether, and carbon disulphide. Red phosphorus 
has no odor and no taste, is insoluble, not luminous, and 
not poisonous. 

Three compounds of phosphorus. — Phosphoric acid, 
H,PO,. Hj'drogen phosphide, PHj. Phosphorus penta- 
chloride, PCI,. 

2. Silver nitrate solution and salt solution enter into 
double decomposition, producing sodium nitrate and 
silver chloride : AgNO^ -f NaCl = NaNO, — AgCl. 

3. Chlorine may be made by heating together hydro- 
chloric acid and manganese dioxide: 

MnO, - 4HC1 = MnCU + 2H,0 + CU. 
Chlorine has a tendency to unite with other elements 
sometimes violently, with evolution of light and heat. A 
candle burns in cnlorine with a faint flame and thick 
smoke. In the presence of water chlorine is an active 
bleaching and disinfecting agent. 

4. Simple proteins are naturally occurring proteins 
which on being treated with enzymes or acids break up 
only into alpha-amino acids or their derivatives. They 
differ from the (compound or) conjugate proteins in 
that the latter break up not only into amino-acids, but 
also into other non-protein substances. 

Compound proteins are compounds of simple proteins 
with some other non-protein group. 

5. Glucose is a monosaccharide carbohydrate, with 
the formula CsHi.Oo- It is sometimes employed in solu- 
tion intravenously, because of its nutritive properties. 

6. Three hydrocarbons: Methane, CH,; ethane, CjH,; 
propane, C;H,. Three carbohydrates: Glucose, CsH^Oj; 
saccharose, C.jH^Oi,; starch, CjHj.Oj. 

7. Fischer's solution is composed of sodium carbonate, 
sodium chloride and water. It has been administered 
intravenously in order to make the urine alkaline. 

8. Test for free hydrochloric atid in gastric contents. 
— Gunzburg's reagent (phloroglucin, 2 grams; vanillin, 
1 gram; dissolved in 100 cc. of alcohol) freshly pre- 
pared, and a few drops of filtered gastric contents 
(equal parts of each) are mixed in a porcelain dish, 
and then evaporated in a water bath ; in the presence 
of free mineral acids a bright scarlet color is produced, 
beginning at the upper border. 

The presence of lactic acid is detected by Uffelmann's 
reagent, which consists of a solution of ferric chloride 
and phenol, diluted to an amethyst-blue color, which is 
changed to yellow by lactic acid. In order to avoid 
error by the action of other substances which have a 
like action upon the reagent, 10 cc. of the filtered gas- 
tric contents are agitated with ether, and the ethereal 
extract separated and agitated with the reagent; or it 
may be evaporated, the residue dissolved in water, and 
the solution added to the reagent. 

9. First of all, test for albumin, as follows: The urine 
must be perfectly clear. If not so, it is to be filtered, 
and, if this does not render it transparent, it is to be 
treated with a few drops of magnesia mi.xture, and 
again filtered. The reaction is then observed. If it be 
acid the urine is simply heated to near the boiling point. 
If the urine be neutral or alkaline it is rendered faintly 
acid by the addition of dilute acetic acid, and heated. 
If albumin be present a coagulum is formed, varying 
in quantity from a faint cloudiness to entire solidifica- 
tion, according to the quantity of albumin present. The 
coagulum is not redissolved upon the addition of HX(^ 

If albumin is present it should be removed. Ta- 
urine is then tested for sugar as follows: Render tiiv 
urine strongly alkaline by addition of Na.COj. Divide- 
about 6 cc. of the alkaline liquid in two test tubes. To 
one test tube add a very minute quantity of powdered 
subnitrate of bismuth, to the other as much powderr-^ 
litharge. Boil the contents of both tubes. The presenn 
of glucose is indicated by a dark or black color of tl ■ 
bismuth powder, the litharge retaining its natural colo' 

10. Chemicals used in purifying water for drinki}' 
purposes: Ozone, chlorinated lime, chlorine, potassiuir, 
permanganate, alum, sulphate of iron and lime, metal- 
lic iron, copper sulphate. For details as to their meth- 
ods of employment, see Rosenau's Prccentiic Mcdicin, . 



Medical Record 



A Weekly Journal of Medicine and Surgery 



Vol. 94, No. 4. 
Whole No. 2490. 



New York, July 27, 1918. 



$5.00 Per Annum. 
Single Copies, I5c. 



©rigmal Artul^fi. 

MEDICAL WOMEN, YESTERDAY AND 
TO-DAY.* 

By SARAH J. McNUTT, M.D., 

NEW TORK. 

Early last year the general public seemed to have 
suddenly awakened to the fact that the woman 
doctor was receiving marked attention, and her 
work was enthusiastically commented upon by press 
and populace. The clubs, curious to know more in 
detail, requested information regarding the woman 
doctor's preparation and experiences. 

The very busy life of a woman physician and 
the ethics of the profession have limited personal 
reports. After considering the subject and consult- 
ing with a number of the leading workers, it was 
decided that the times required that some concession 
be made to these requests. 

This paper is the outgrowth of my efforts to reply. 
Your Chairman of Program has asked me to repeat 
it here. 

Sorosis Chairman of Education asked me to tell 
them if I regretted that I had not a better founda- 
tion in medicine. In reply I said I have never for 
one moment regretted that I was a graduate of the 
New York Infinia'-y for Women and Children. Nor 
do I bi'lie\e that any other College in the land could 
have buiided lor women a better foundation than 
was there laid for medical work. 

It was in 184L that a plan of studying medicine 
became a settled resolution with Elizabeth Black- 
well. She was the real originator of the idea and 
movement in America. She was graduated in 1849 
and was the first English-speaking woman in the 
world to take a medical degree. 

Her sister, Emily Blackwell, was graduated in 
medicine three years later, in 1852, and they having 
realized the needs of a hospital where women and 
children could receive medical care from women, set 
about founding the Infirmary or Hospital. 

The New York Infirmary for Women and Children 
was incorporated in 1853 as a center for the 'prac- 
tical medical education of women. At first it took 
the form of a hospital and dispensary, and not a 
college, because there was then no hospital or dis- 
pensary open to women students in this countn.-. 
Many students were from time to time admitted to 
the infirmarj^ and dispensary for private instruc- 
tion, and as their number increased it was deemed 
expedient to establish a woman's medical college in 
connection with the New York Infirmary and Dis- 
pensary. 

*Read at a meeting of the Women's New York State 
Medical Society, Albany, May 20, 1918. 



Through the earnest and well-directed efforts of 
Doctors Elizabeth and Emily Blackwell, a charter 
was obtained from the State Legislature in 1868 
for the establishment of the college, fifteen years 
after the infirmary and dispensary had been 
founded. 

On Nov. 2. 1868, Dr. Elizabeth Blackwell, in her 
opening address, said at its close: "The college 
must be an honest and earnest attempt to give to 
women the very highest education that modem 
science will afford." These ideals of Dr. Blackwell 
in the years that followed were never lost sight of 
as long as the college lived. It was resolved at the 
first to make the quality of the instruction and the 
requirements for graduation equal to the best 
schools for men in this country. Soon after this 
college was founded, Dr. Elizabeth Blackwell went 
to England to live and assisted in founding there 
the London School of Medicine and the hospital 
connected with it, developing a great work for med- 
ical women ; many of its graduates have done most 
commendable work throughout Great Britain and 
most wonderful war relief work since 1914 in Eng- 
land, France, and Serbia. 

Dr. Marie Zakzrrewska obtained her degree iff 
medicine some years after the New York Infirmary 
was founded and she was associated for a time with 
the Drs. Blackwell when she went to Boston, where 
she founded, in 1862. the second hospital in this 
country to be staffed by medical women — the New 
England Hospital for Women and Children in 
Boston. 

These two great centers. Boston and London, were 
outgrowths of the New York Infirmary. 

After Dr. Elizabeth and Dr. Zakzrrewska went to 
their own fields of medical work, Dr. Emily Black- 
well remained alone at the head of the medical work 
of the New York Infirmarj' and College for Women. 
The name of Dr. Emily Blackwell means much to 
those who have known her personally. 

I can never forget the first time that I saw her. 
WTien I came to apply for entrance to the college, 
there came into the reception room a stately woman 
with white hair, clear complexion, pink cheeks — and, 
though reserved in manner, yet there was a some- 
thing about her that made one feel at once that it 
would be a privilege to be under her teaching and 
that one must really come up to the standards she 
set. 

I was very fortunate in coming in close relation to 
her. I lived in the hospital my first student year, 
and for a year as interne after my graduation. I 
was her assistant for over twenty years, and also 
attending physician to the hospital and instructor 
in the college in her department, diseases of women. 



136 



MEDICAL RECORD. 



[July 27, 1918 



for over twenty years, performing minor and major 
operations. 

While life was simple and an interne's duties 
varied and laborious, it was fully counterbalanced 
by the intimate cooperation between internes at- 
tending and consulting physicians and trustees. 

It fell to an interne to do what is now considered 
her legitimate work, and also that which is now 
detailed to hospital druggist and operation-room 
nurse. 

Before the days of isolating wards, equally with 
other maternity hospitals of the land we sometimes 
had cases that were then called "childbed fever," 
and once, with the proverbial Blackwell thorough- 
ness, we decided to fumigate the whole hospital. 
Patients and workers were transferred to other 
quarters, windows and doors were sealed, and large 
quantities of sulphur ignited. Soon the fumes 
began to extend to the outer air. 

It had not been thought sufficiently important to 
notify the trustees, but it chanced that this special 
time was selected by Robert Haydock, our beloved 
president of the hospital board, and Hannah, his 
wife, whose very presence was always a benediction, 
to make a friendly evening visit, coming as usual 
in their quaint Quaker garb. What was their horror 
in finding fumes of sulphur escaping and no re- 
sponse to their persistent knocking! Greatly 
alarmed for the inmates, the neighbors were aroused 
and the fire company called out. 

After it was all over, Dr. Blackwell, who always 
saw the amusing side, naively suggested that "the 
next time perhaps it would be well to leave the 
janitor in the building," but a compromise was 
made by having him act as watchman on the out- 
side. 

No one could fill the place Dr. Blackwell occupied 
in one's heart. Truly, she was a woman whom 
it was a privilege to have known and loved. In all 
the years that I was so closely associated with her, 
I never knew her to be ill but once. She was out 
of town at her country place in Orange. I was 
notified that she was having a very acute gastroin- 
testinal attack, with alarming symptoms. I went 
at once, and fearing I might need assistance, left 
word for a younger worker (Dr. Kilham) to follow. 

I found Dr. Blackwell alone in her house, uncon- 
scious — no pulse at her wrist, heart sounds very 
weak, with cold extremities and clammy skin. I 
was busy using restoratives, when the maid re- 
turned — she had been at the neighbors reporting 
Dr. Blackwell's great improvement, because the 
doctor was so quiet. Dr. Kilham soon arrived and 
we worked unceasingly during the entire night be- 
fore we could feel that there was an encouraging 
response to treatment, and it was well into the 
morning before she was able to recognize us. 

The time was August, the weather specially hot 
and depressing — she longed for sea air, and as soon 
as I could do so safely I took her to Nantasket 
Beach, where we spent our time idling about in 
most delightful air. 

I never shall forget the night on the Sound boat, 
we could not sleep and sat up in the moonlight and 
talked, or rather she did. one needs must feel that it 
was best to listen when she talked — that night is 
among one of my most precious remembrances. 

Dr. Emily Blackwell was a great teacher, and no 



one could come under her wonderful influence with- 
out feeling that a great privilege had been her's. 
A broad-minded woman, guided by high ideals and 
lofty purposes, her personality made a strong im- 
press upon the life and work of her students — their 
lives were fuller from having known her. 

The college closed, but it did not die, it never can 
in the minds of its alumnae. Its growth was so 
strong it blossomed and bore fruit, with good seed 
that has been scattered so far about there must 
ever be the individual or the group that see the 
vision, and be ever ready to give themselves to the 
great service. 

This woman's college was the first college to 
require a three years' course of eight months each 
year, and among the first to increase the three 
years to four yeai's. 

It was among the first to establish entrance ex- 
aminations, ten years before such examinations 
were made compulsory by the State. 

When the New York Infirmary issued its first 
prospectus no college in the United States required 
so thorough a course or such severe examinations. 

The first chair of hygiene was established here, 
and Dr. Blackwell said "The prevention of disease is 
quite as important as the cure." She also estab- 
lished the first chair of pathology in this country. 

A special board of examiners was selected from 
among the faculties of the several men's medical 
schools of the city. WTien one realizes that this 
board which examined the candidates, passed by the 
faculty, and which could refuse them their diplo- 
mas, were composed of the leading men in the pro- 
fession — such men as Stephen Smith, Fordyce Bar- 
ker, Austin Flint, Alfred Loomis, Gaillard Thomas, 
William Polk, and Robert F. Weir— the ability of 
the graduates is unquestioned. 

The record of the college was one of steady prog- 
ress. The well-equipped laboratories allowed the 
desired extension of the scientific courses, under a 
corps of thoroughly trained enthusiastic instructors 
from among our own graduates. 

The most distinctive feature of the four years' 
course was the clinical instruction — it was the key- 
stone of the entire curriculum, toward which e%'ery- 
thing else was made to converge. The clinical 
opportunities of a New York medical school for 
individual instruction in the study of diseases are 
unequalled by any in the land. 

Each senior assisted at twelve maternity cases, 
under direction of the physician in charge, and 
made written reports of these cases. This was at 
the time when men's colleges made no arrangements 
for their student* to see even one maternity case 
before graduation. 

Dr. Blackwell insisted that the student be taught 
to study the patient as well as the disease, since no 
two persons having the same disease would show 
the same symptoms; in each the symptoms would 
be modified by individual idiosyncrasies. 

In our own dispensary at this time — 1880 — about 
8,000 new patients were treated annually; they made 
from one to many visits — in all there were 40.000 
to 50,000 calls yearly. 

Not only our own clinics, but the numerous posi- 
tions held by the faculty of this school in other 
institutions, were utilized for the benefit of our 
students. Dr. Blackwell selected the members of 



July 27, 1918] 



MEDICAL RECORD. 



137 



her faculty wisely and well, from the several best 
male colleges of the city. I give a few names 
• typical of the rest, and indicative of the valuable 
I teaching powers of the school — the two Jacobis — 
j Abraham and Mary Putnam, known and honored 
I on two continents — Abbe, Fox, Dana, Adler, Stim- 
son, Bulkley, Judson, Willy Meyer, Tuttle, Cragin, 
Chapin, the two Lamberts, Samuel and Alexander. 
All of these need no introduction or commendation 
from me. 

The alumnaa may well be proud of the fact that 
their Alma Mater kept up with the times, won the 
cordial respect of the medical profession and re- 
ceived warm and repeated testimony from the State 
Board Examiners as to the thorough preparation 
of the students. It was these superior clinical 
advantages which brought many students to our 
senior classes, who had taken their earlier instruc- 
tion in colleges with less clinical opportunities. 

The New York Infirmary College, with its high 
standards for education, its eminent teachers, could 
give its student body vastly greater individual op- 
portunities and advantages than could be obtained 
in a large coeducational institution with many hun- 
dred students. Dr. Blackwell believed if women 
were to study medicine, and expected to be recog- 
nized by men physicians, they must be prepared not 
only as well as men, but even better. However, it 
had always been Dr. Blackwell's idea that when 
the best colleges for men opened their doors to 
women, it was better for women medical students 
to study at a coeducational medical college, that 
the world at large would know that they were equally 
prepared with men. 

Cornell Medical College in 1899 received an en- 
dowment of §1,500,000, with the proviso that 
women should be admitted on equal terms with men. 
The infirmary college was closed, its building trans- 
formed into a hospital annex, and its pupils trans- 
ferred to Cornell. To the general public the broader 
field seemed a great step in advance for the woman 
medical student. To the medical woman who knew 
the wonderful individual teaching and the great 
amount of practical work to supplement the college 
lectures, it seemed a tragedy. 

I am glad to have been graduated earlier. I had 
four college years. The first one I lived in the 
hospital, acting as assistant in the wards, also at- 
tended the college lectures, made daily visits in the 
wards as assistant, recorded patients and their 
symptoms, carried out directions given for their 
comfort and treatment. The various wards were, 
maternity, general medical, genera! surgery, dis- 
eases of children, and diseases of women. Many 
minor and major operations were performed in 
which I could assist and do all the dressings neces- 
sary during convalescence. I had entire charge of 
the delivery and made records of 54 maternity cases 
during my college course, and in addition was 
present at the delivery of more than double that 
number, while serving as interne. 

Every other morning I worked in the dispensary 
drug room, making pills and powders and mixtures, 
even our own tinctures and ointments and supposi- 
tories, and filled out the prescriptions given by the 
dispensary physicians, these prescriptions averaging 
100 to 200 daily. The work in the drug room has 
changed greatly since those days when simpler 



medicines were used. In place of compressed tab- 
lets, bought by the thousand from the wholesale 
druggist, we had to weigh out and put up bulky 
packages of "simple bitters," composed of boneset 
leaves, chamomile flowers, columbo roots and quas- 
sia chips. These packages were much prized by 
our old ladies, who joyfully added the quart of cold 
water, kept it in the ice box as directed, and cheer- 
fully drank their cupful three times a day, confi- 
dent that it removed all ills. Loath to part with 
their beloved remedy until all its virtues were ex- 
hausted, they renewed the quart of cold water until 
there was no longer a bitter taste to the infusion. 

When my year of internship was over I was 
appointed to the out-practice for one year, and 
visited over 1,500 patients in their homes. Our pro- 
fessors were always ready to help with advice or 
assistance when needed. I went from sub-cellars 
to attics, sometimes up seven flights of stairs. I 
never thought of the stairs, but what they were 
taking me to, and what I could do when I got 
there. 

Early in the out-practice I realized the great 
value of the practical work we had had in com- 
bination with our college lectures, and how well 
thej- had helped to prepare for the emergencies 
that would arise in active practice. 

One of the first calls I received has been ever 
memorable. I had gone to the dispensary for the 
addresses for that day's calls. Suddenly a lo-3'ear- 
old boy rushed in with, "I want a doctor quick — me 
brother's choking to death — he'll die if you don't 
hurrj-." This to me as I'd been pointed out to 
him as the one he wanted. As he explained, I knew 
what I was up against, and suddenly in a panic, 
turning to our anatomy professor, Dr. Wattles 
Founce, who stood near, with, "Oh, do go ! I'll surely 
cut the carotid arterj\" She exclaimed indignantly, 
"If you do, it will be murder, and you will be hung, 
and you'll deserve it. You know what to do. Get 
your knife and strip of adhesive plaster, and wind 
it while you run, don't let him die while you linger 
in going." She was born in Kansas, but was an 
ideal New England Priscilla. I knew better than 
to urge, and did not care to — my panic was gone. 
The boy ran, I after him, winding the knife. We 
ran from Eighth Street up Second Avenue to 
Eleventh Street, east on Eleventh Street three long 
blocks. If for a moment I lagged he'd call back over 
his shoulder, "Me brother is a-choking, you know," 
and on again I'd go. I was at his elbow as we 
arrived at the house. The door entered directly 
level with the sidewalk, and the room door was 
right by the entrance. As the boy threw both 
open, I saw at once a man on a straw pallet on 
the floor, sitting up in the corner pressing both arms 
as high as he could firmly against the wall on 
each side, to get all air possible into his lungs. 
His face was black, eyes bulging, and expression 
agonized. I had not stopped running, and was im- 
mediately on my knees at his side, depressed the 
tongue, saw a great black mass — which was both 
tonsils greatly distended — filling the passage and 
obstructing the entrance of air. Passing in the 
knife, I introduced the point into the black wall 
and drew it well down on one side. There was an 
immediate evacuation of contents, with some blood, 
and he fell forward on his bed, and for an instant 



138 



MEDICAL RECORD. 



[July 27, 1918 



I saw that rope dangling for me, was sure the 
artery was cut — but only an instant, for my finger 
was on his pulse and I recognized that the beat 
was regular and forceful, that his black face was 
becoming red, as air rushed into his lungs, and his 
agonized expression was gone — in a few moments 
he could sit back in the comer while I lanced the 
other tonsil. The quick change in his appearance 
was wonderful, and I was glad to have helped to 
make it so. 

During one of these years I received a hurry call 
from a clinical patient. She feared her child was 
dying. I found an 18 months old boy gasping for 
breath with diphtheritic croup. He was lying in 
bed with his mother, who had been confined a few 
hours before. The new baby was on the other side 
of the bed. The locality was in one of the most 
crowded tenement sections of the city. The door of 
the living room opened directly upon the street and 
was even with the sidewalk. Both inside and out 
it was one of the most unhygienic places I had ever 
been in — truly not one to select for an operation, 
but there was no choice, the child could not live 
more than a few moments if not relieved. Quick 
tracheotomy made breathing easy. I was giving 
instructions to physicians, post-graduate students, 
at this time, at the Morgue upon the operations of 
children, and the technique of this one was very 
familiar to me. 

On my arrival, and on seeing the existing condi- 
tions, I had sent at once for two of the senior stu- 
dents, whom I knew I could rely upon. It was a 
wonderful opportunity to demonstrate what perfect 
care could do. These students arrived quickly and 
were installed. To their untiring vigilance, skill- 
ful manipulations, tact, and gentleness in managing 
the little patient was due its rapid and complete 
convalescence. 

This two-roomed tenement was a comparatively 
quiet home by day, a well-filled lodging house by 
night. The lodgers began to arrive by late evening, 
the door opened noiselessly, by ones or twos they 
glided in like specters, silently arranged themselves 
on the floor, seemed to be trying to efface them- 
selves, and the students let them feel that they did. 
At early dawn they began to glide out as they had 
come, and soon only the mother and two children 
were left. 

When I arrived early the next morning with 
two other students to relieve them I found quite 
normal respiration, and the bright appearance and 
evident well-being of the patient, made certain his 
recovery, and their work had made this possible. 
One Dr. Kilham. after many years of hospital ex- 
perience here, went "over sea," and for three years 
has been "somewhere in France," making herself 
necessary to the people in the devastated sections. 
The other is my sister. Dr. Julia G. McNutt — most 
of you know her so well, do I need to add more? 
While my calls were for medical or surgical attend- 
ance, I sometimes encountered on my way to them 
those that demanded immediate "social service." 
There was an especially large old dilapidated tene- 
ment, recorded as "housing 1,000 souls," that fur- 
nished me a large experience, by reason of its very 
bad sewage and its poor ventilation. It had many 
inner dark rooms that were only provided by win- 
dows and doors opening upon the halls. These halls 



were lighted by the outer door below, and the closed 
skylight seven stories above. Sometimes these dark 
rooms furnished homes for whole families, de- 
pendent upon light from kerosene lamps. 

Once I was called to a patient on the top floor of 
this building and I was part way up these stairs, 
when I saw through an open door a man and woman 
unconscious on the floor — intoxicated. Strange to 
say, everything about the room and the individuals 
was neat, comfortable, and home-like — it seemed a 
sudden giving up of hope, and an effort to gain 
oblivion. On the table in the center of the room 
was a large kerosene lamp burning. The woman 
had caught the tablecloth as she fell, it was partly 
wound about her, and was stretched taut. The 
lamp had been drawTi to the verj- edge of the table. 
The slightest movement of her body would have 
instantly tipped it over upon her head and shoulders. 

I quickly stepped around and over her, turned 
out the light, set it back on the mantel out of danger, 
and continued my way up to the top floor, to my 
patient, comforted by the thought that I had just 
prevented a great panic. How many, think you, of 
those 1,000 souls would have lost their lives in their 
frantic race down those rickety stairs, struggling 
with fire and smoke and fear. 

When I first entered the medical college I heard 
a student who had been considering the amount of 
work that the college required from its students, 
anxiously ask Dr. Blackwell, "When we have done 
all this, will patients trust us, and come to us for 
treatment?" Dr. Blackwell replied, "There are a 
great many women and children needing good med- 
ical and surgical care — if you prepare yourself so 
well that no one else could do better work, you will 
soon have so much to do that you will not have time 
to wonder if some one else does not approve of 
women physicians." Dr. Blackwell's students found 
by experience she was right. 

For six years I assisted the professor in children's 
diseases, at the end of that time was asked to take 
a position on the faculty of the Post-Graduate Col- 
lege, to give clinical lectures in diseases of children 
three times a week to men and women physicians. 
One year later, 1883, I founded there the Babies' 
Wards for Children under 2 years, the first place 
where such children could be admitted to a hospital 
without their mothers. I gave bedside instruction 
and gave instruction in child surgerj- and autopsies 
twice a week in the Morgue to these doctors. 

There came a time in 1888 when there was the 
need of withdrawing from some of my hospital 
and college work. Though greatly interested in my 
children's work I could not give time to children 
in my oflice or s«e them at their homes — this work 
had to devolve entirely upon my assistants. My 
office work was wholly devoted to general and special 
diseases of women, and the Infirmary work was in 
that line of practice. Therefore, in 1888 I resigned 
from the Post-Graduate College and Babies' Ward. 

Some of the members of my Auxiliary Board 
urged that we found a Babies' Hospital. It was 
thought that I would be able to take the medical 
care with my sister. Dr. Julia G. McNutt's help, 
since there would be no college duties that required 
so much of my time as the work at the Post-Grad- 
uate College and Babies' Ward had done. 

A charter was obtained from the State Legisla- 



July 27, 1918] 



MEDICAL RECORD. 



139 



ture in 1888 for the establishment of the Babies' 
Hospital of the City of New York, for children under 
2 years. The charter members were: Mrs. An- 
drew H. Smith, Mrs. Thomas E. Satterthwaite, Mrs. 
J. Lenox Banks, Dr. Julia G. McNutt, Dr. Sarah 
J. McXutt. The consulting medical board was se- 
lected from among the most eminent specialists of 
the city. They gave hearty co-operation and sup- 
port to our work. They were: Dr. Andrew H. 
Smith, president of the Academy of ]\Iedicine, pro- 
fessor of General Medicine at the Post-Graduate 
College and Hospital; Dr. Thomas E. Satterthwaite, 
Professor of Heart Diseases, Post-Graduate Hos- 
pital and College; Dr. Edward B. Bronson, Profes- 
sor of Diseases of the Skin, New York Infirmary; 
Dr. Francis Kinnicutt, Professor of Diseases of Chil- 
dren, Columbia University. 

The Babies' Hospital of the City of New Y'ork 
obtained a temporary home, and was opened at 161 
East Thirty-sixth Street, June 16, 1888, with 24 
beds for patients. At the end of the first six months 
I made a report of the work, which was read before 
the Alumnas Association of the New Y'ork Infirmary. 
February 18, 1889, and was published in the ISIedi- 
CAL Record, March 2, 1889, under the title -'The 
Babies' Hospital — A Summer's Work." 

This medical work, however, grew so rapidly, and 
encroached so much upon our private work, that we 
felt obliged to withdraw from the Babies' Hospital 
a year after assisting in founding it. The hospital 
found a permanent home at Fifty-fifth Street and 
Lexington Avenue, where it now remains. 

Medical Woinen of To-day. — A definite place in 
the field of medicine has been won by women. Over 
40 coeducational medical colleges in the United 
States admit women on the same terms as men — 
Columbia University in 1916, and Harvard, 1917. 
and Y'ale has announced that she will admit women 
this fall, 1918. 

The opportunities for women in medicine were 
never so numerous or so remuuerative as at the 
present time, both here and abroad. No occupation 
open to women is so signally attractive from every 
point of view. It offers practically an unlimited field 
for usefulness and financial success. The influence 
of the woman physician increases, rather than di- 
minishes, as she grows older, an advantage peculiar 
to medical practice. The demand for women physi- 
cians exceeds the supply. Of what other profession 
or occupation open to women can that be said? The 
woman physician is sought, not only as a private 
practitioner, but also as a salaried officer in insti- 
tutions, medical and otherwise, as an expert in 
sanitation, care of the feebleminded, and treatment 
of the insane. 

New needs for the women physicians are spring- 
ing up every day, and not enough women are enter- 
ing the profession to profit by the constantly increas- 
ing opportunities. 

War Relief. — Of the more than 6,000 women phy- 
sicians in the United States, over 2,200 have regis- 
tered to be ready "at call" for war relief — over 30 
per cent, of all the medical women graduates of the 
United States. 

A goodly number have already braved the subma- 
rine peril and landed "somewhere in France," giv- 
ing up home and practice, willing to face hardship 
and peril, without the help of military glory, to 



bring comfort and succor to the stricken people of 
that devastated land. 

Truly they are worthy followers of our great 
pioneer and teacher, Dr. Emily Blackwell. 

265 Lexjn'gtox Aa-ente. 



PROTEIN TREATMENT OF ARTHRITIS. 

By S. p. BEEBE, Ph.D.. M.D.. 

NEW TORK. 

Many physicians have made the casual observation 
that a case of chronic arthritis is at times bene- 
fited by severe constitutional disturbances that ac- 
company an acute infection, such as typhoid fever 
for example, and without a satisfactory basis for 
the deduction other than the observed beneficial 
effects that have been known to follow such proced- 
ures, a variety of therapeutic agents have been 
given to these chronic sufferers, such as bacterial 
vaccines of various sorts, including Shaefer's vac- 
cine. A variety of different types of ductless gland 
preparations have been administered in the form of 
tablets by mouth as well as extracts given hypo- 
dermically. Meanwhile studies on the pathology 
of these conditions have led us to look for the 
source of infection in some other part of the body 
than the joint itself, the toxins from which give 
origin to the joint reactions. The teeth, tonsils, 
nasal sinuses, gall-bladder, and appendix very fre- 
quently indeed are subject to chronic infections, the 
toxins from which may give rise to the joint con- 
dition. Abnormal conditions within the digestive 
tract giving rise to absorption of toxic products, and 
putrefaction therein may likewise prove to be the 
point of origin of the joint inflammation. It seems 
unnecessary to state that any plan of treatment 
designed to relieve the joint condition must take 
into account these chronic infections, and insofar 
as it is possible to do so adequate relief must be 
accorded by medical or surgical means from these 
disturbances to the general health. 

Within the last two years attention* has again 
been called to the beneficial effects in joint condi- 
tions that often follow the administration of the 
bacterial vaccines of a non-specific type. The gen- 
eral disturbance which follows their administration 
is accompanied not infrequently by relief in the 
inflammatory condition in the joint itself. Such 
a plan of treatment has been in use, as a matter 
of fact, for many years and it seems probable that 
the vaccines that may have been recovered from 
infected teeth or tonsils act quite as much as non- 
specific agents as they act in a specific manner by 
combating the infection supposed to give rise to 
the toxic inflammation in the joint. However, as 
a matter of practical therapeutics, the attention of 
physicians has been called very sharply to the meth- 
od by the work of Jobling, Miller, Thomas, and as- 
sociates, who have for the most part used intra- 
venous injections of typhoid vaccine as a thera- 
peutic agent. A vast majority of bacterial vaccines, 
given intravenously, produce a reaction which in 
severity depends upon the dosage and personal idio- 
syncrasy of the patient but is accompanied by chill, 

*Nearly all the literature on the recent phases of 
this subject is summarized in Miller's article on the 
Nonspecific Character of Vaccine Therapy. — Journal 
.A.M. A., Sept. 8, 1917. 



140 



MEDICAL RECORD. 



[July 27, 1918 



fever, leucocytosis, depressed blood pressure, and an 
occasional collapse. This is the kind of reaction 
that has been depended upon for many years by 
some physician.s to afford relief from a variety of 
conditions after the administration of Shaefer vac- 
cines, know'n by the name of phylacogen, and by 
Coley's to.xins. 

Other forms of foreign protein stimulate reaction 
quite as well as the bacterial toxins, but in most 
cases a larger amount of the foreign protein must 
be administered, as bacterial vaccines are quite 
toxic to a subject by this method of administration. 
Non-bacterial proteins do indeed vary somewhat in 
their toxicity, and some may be administered with 
very little or no reaction, and yet be followed by 
clinical relief in the joint conditions. The non- 
specific character of vaccine therapy, and the recog- 
nition of the fact that other proteins than bacterial 
proteins may be suitable for therapeutic uses were 
the basis for the publication by Jobling, and were 
the subject of his lecture before the Harvey Society, 
and while it is possible to measure temperature, 
blood pressure, make blood counts, and in this way 
arrive at some conclusion as to the disturbances 
produced when foreign proteins are administered, 
Jobling frankly recognizes that all these measurable 
factors do not adequately explain the therapeutic 
benefit observed to follow their administration, "but 
here as in so many other biological problems which 
have to do with that most complex of tissues, the 
blood, it seems probable that no single factor can 
be identified as responsible for all the changes which 
occur, but that a whole train of events is inaugu- 
rated, when the equilibrium of some of the delicate 
serum balances is disturbed, all of which tend to- 
ward a condition favorable for recovery from in- 
fection." 

The writer has watched the growing sentiment 
toward protein therapy with unusual interest be- 
cause during the last three and a half years he has 
given much time and effort in this direction, and has 
treated quite a variety of conditions with injections 
of foreign protein with a i-esulting therapeutic bene- 
fit that has not been observed to follow other lines 
of treatment. Quite a variety of different proteins 
have been used in this line of work, prepared by 
somewhat different methods, practically all having 
their origin in plants or seeds, but in the Mp:dical 
Record for July 21. 1917. he de.scribed a method 
for preparing proteins from alfalfa and millet seeds 
which for purpose of non-specific protein therapy 
have none of the disadvantages which earlier prepa- 
rations showed and which are simple of administra- 
tion from every standpoint. A considerable num- 
ber of patients suffering from rheumatoid arthritis 
have been treated by the injection of these pro- 
teins and the relief experienced by the patients 
and the constitutional benefits which followed the 
administration of protein were so decided that in 
his opinion these seed proteins present all the thera- 
peutic advantages found in the non-specific bacterial 
vaccines without the admitted disadvantages which 
the latter show. 

Bacterial proteins for the most part are highly 
toxic when given intravenouslv in the human sub- 
ject, and it is a question indeed whether the pro- 
found reaction which they occasion is altogether 
of benefit to an individual already below ]iar from 



long continued depressing illness such as rheumatoid 
arthritis often proves itself to be. Miller recog- 
nizes these dangers but states that he has treated 
200 cases without any grave consequences except 
one case, an alcoholic, where delirium tremens de- 
veloped and death supervened 52 hours after the 
injection. The severe chill, with nausea and head- 
ache, high fever, herpes, with a marked fall in 
blood pressure following the chill, is not an ex- 
perience to which a chronic invalid should be re- 
peatedly exposed and unless it can be shown, as 
Miller believes, that the severe reaction is essential 
to relief, there is no reasonable justification for 
producing it. Scully, who has been working with 
Miller, describes in detail the type of reaction ob- 
served and notes that the average dose in some in- 
stances, especially in those cases in which the pa- 
tients were bedridden for some time, proved to be 
excessive and in these cases there was occasioned 
a severe rigor lasting for one to two hours, accom- 
panied by marked cyanosis, rapid, weak pulse, and 
following the chill the patient was very weak and 
showed signs of collapse. He observes "Intravenous 
injection of vaccine are contraindicated in those 
cases in which the vasomotor system is weakened 
and when the nervous .system is unstable. In these 
cases collapse may occur, with the possibility of 
death resulting. In serious organic heart lesions 
the injection is seriously contraindicated as the 
heart becomes dilated and overworked so that car- 
diac failure may result." While Scully's paper is 
devoted to the reaction which occurs after the in- 
travenous injection of foreign protein, it should be 
noted that the foreign protein in all these cases was 
typhoid vaccine administered intravenously. 

Unless it can be demonstrated that these severe 
reactions are a necessary part of the process by 
which relief is afforded, there is every reason to 
avoid producing it. Miller frankly believes that 
the reaction is essential. In closing the discussion 
on his paper he states that he has used pollen pro- 
tein on some of his cases but had some difficulty 
in getting the right dosage to bring about a chill 
but when the chill was obtained he got the same 
results as in the other proteins although he admits 
that certain German investigators have reported 
benefit from the intramuscular injection of milk 
which produced a very mild reaction. 

Any foreign protein introduced parenterally 
stimulates a response on the part of the organism 
but this response need not be accompanied in all 
cases by chill and fever, unless the dose introduced 
is of considerable magnitude. Proteins are not 
equally toxic by this method of administration. The 
common method for measuring protein content is 
the nitrogen determination and if equal quantities 
of nitrogen are used, certain proteins, such as those 
found in bacteria, are more toxic to the human or- 
ganism and will produce severe reactionary re- 
sponses of a toxic character which are not at all 
produced when equal quantities of nitrogen ex- 
pressed in certain seed proteins are given in the 
same manner. The therapeutic application of ty- 
phoid vaccine to this purpose seems hardly better 
suited than the use of Coley's fluid or phylacogen. 
The repeated administration of the bacterial pro- 
teins with the accompanying chill or fever is not a 
proceeding which can be repeated with impunity 



July 27, 1918] 



MEDICAL RECORD. 



141 



" many times in any patient, and while following the 
chill and fever there has been noted relief from 
pain, this admittedly has been of a somewhat tem- 
porary character in many instances. The patient 
must be in a hospital with facilities to afford the 
necessary care during- the reactionary period. 
Moreover, it has not been shown that the general 
constitutional condition of the patient is much bene- 
fited by the severe disturbances to which he is sub- 
jected if bacterial proteins are given in sufficient 
dose. 

The therapeutic agents employed by the writer, 
as has been stated previously, are the proteins pre- 
pared from millet and alfalfa seeds by the process 
fully described in the article referred to, but the 
method is essentially one of partial hydrolysis, 
resulting in the formation of proteins readily steri- 
lized by head without coagulation. The proteins 
which have been used are in a 2 per cent, solution. 
They have been given subcutaneously. It is quite 
possible to produce a reaction of the general char- 
acter shown by the bacterial proteins if too large 
a dose is given as a first injection. In the writer's 
experience it has not been necessary to produce such 
reactions to get relief. Patients vary somewhat in 
their susceptibility to these proteins as they do to 
all proteins. A beginning dose of 10 to 12 minims 
practically never produces a reaction of the type de- 
scribed. It may be and often is followed by quite 
as much relief from pain as is the case when the 
more to.xic proteins are administered. 

Miller has for the most part been dealing with 
conditions of acute arthritis which in its pathology 
is somewhat different from the chronic conditions 
which may follow the acute infections and which 
for the most part have been found more difficult to 
control. 

The writer's experience has been almost entirely 
with chronic arthritis. In the cases, however, there 
have been three patients with acute arthritis whose 
joint pain was not controlled promptly by salicy- 
lates. In two of these cases the protein injection 
was accompanied by a mild increase of temperature 
but without chill and with complete relief from 
pain. The injections in these two cases were con- 
tinued for a period of two weeks. There was, how- 
ever, no return of the pain and the patients made 
a prompt recovery. In the third case a larger 
dose, 15 minims, was given for the first injection 
and in this patient there was a distinct chill with 
fever following. No further injections were given 
and none was necessary. As stated, the majority of 
the patients had chronic arthitis. In some instances 
it had continued over a period of years. They had 
been treated by a variety of means including the 
administration of bacterial vaccines prepared from 
teeth, tonsils, etc. They were suffering from the 
depressed physical condition which goes with a 
long period of toxemia. Many indeed were crip- 
ples and bedridden. The injections have been con- 
tinued over a period of months and the results 
which have been obtained have been so gratifying 
as to make it seem probable that this therapeutic 
method is one of considerable importance in this 

k group of patients. It must be obvious that only 
in exceptional cases would a patient submit to the 
administration of vaccine injections of sufficient 



day over a period of some months, and it is in every 
way probable that such treatment of a chronic 
arthritic patient would seriously injure rather than 
improve him. On the other hand these seed pro- 
teins have been injected three times v.eekly in gradu- 
ally increasing doses over a period covering 4 to 10 
months, with the result that the general health 
has been much improved, painful joints entirely re- 
lieved, and the patient restored from a condition of 
invalidism to one of useful activity. The seed pro- 
teins stimulate the blood-forming organs and the 
patients who have been treated have shown marked 
improvement in blood conditions. They cause no 
disturbance to the patient. It is not necessary to 
be in a hospital or under the constant observation 
of a nurse, nor do the injections in any way in- 
convenience the patient or prevent him from activity 
which he could readily indulge in if no treatment 
were given. 

The writer's experience with acute arthritis is not 
sufficiently extensive as yet to permit a decision as 
to what percentage of cases can respond as favor- 
ably as the three quoted. In the chronic cases of 
arthritis approximately 60 per cent, have responded 
so favorably as to be practically entirely relieved. 
Chronic arthritis is a more difficult problem to solve 
than acute arthritis, and a 60 per cent, relief is no 
insignificant result, particularly when it is obtained 
by a process that does not inconvenience the patient 
nor cause any discomfort. 

417 P.\RK A\'ENUE. 



HAYFEVER POLLEN EXTRACTS AND THEIR 
STANDARDIZATION. 

By WILLIAM SCHEPPEGRELL. A.M.. MP.. 



PRESIDENT. .AMEKICA.N- HAYFEVER PREVENTION .\SSOCI.iTION ; EX- 

PRE.SinE.NT. AMERICAN .\CADBMY OF OPHTHALMOLOGY AND 

OTOLAETNGOLOGT : CHIEF. HAYFEVER CLINIC. 

OHAEITY HOSPITAL. 

As the .scientific application of pollen therapy is ef- 
fective in the treating of hayfever,' we have made a 
careful investigation of the various pollen extracts 
on the market, with a view of facilitating their ap- 
plication in the treatment and diagnosis of hay- 
fever. As a result of this, we have made certain 
rules for the standardization of the pollen extracts, 
which we believe will be advanta.trfous to both the 
practitioner and the pharmaceutical houses. 

The strength of the pollen extracts should be 
stated in units to the cubic centimeter, the standard 
unit in pollen therapy being O.OOI mg. of pollen 
protein. The most convenient strength is 100 units 
to the c.c, this being the most practical for both 
the diagnostic tests and the treatment. For the 
former, we inject into (not under) the skin 0.05 
c.c. of this strength, containing 5 units, which is 
sufficient to produce a well-defined reaction in sensi- 
tive subjects, and without danger of developing 
anaphylactic disturbances. 

The usual doses of pollen extracts range from 5 
to 50 units, which is represented by 0.05 to 0.50 
c.c. of this extract. The pollen extract of 100 units 
to the c.c. therefore simplifies the application of 
pollen therapy and diagnosis. 

Diluents have been recommended when less than 
1.00 c.c. is injected, but we have not found this 



142 



MEDICAL RECORD. 



July 27, 1918 



necessary or advisable, and, as it unnecessarily com- 
plicates the technique, it should be omitted. 

The pollen used for preparing a special extract 
should belong to a single variety or class. Com- 
binations, except as far as they belong to the same 
class of pollens, should not be used. Our investiga- 
tions have shown that there are certain pollens in 
which the biological reactions (hayfever; are simi- 
lar and which can therefore be combined in one 
preparation." 

In the grasses, for instance, there are about 5000 
varieties, and if it were necessary to prepare a 
special extract for each, this form of pollen therapy 
would evidently be hopeless. Fortunately, however, 
the biological reactions for these, while differing 
somewhat in degree, are otherwise identical. 

It is therefore permissible to use any convenient 
variety of grass pollen, or a combination of several, 
for the grass pollens. This group is preferably 
called (1) "Graminese," as it includes rye, w-heat 
and other varieties which are not popularly recog- 
nized as belonging to the grass family. 

In the same manner we have segregated three 
other groups for their biological reactions, viz., 

2. "Ambrosiaceie." These are the principal 
-causes of autumnal hayfever east of Kansas, and 
include the common, giant, and other ragweeds 

(Ambrosias), the "false ragweeds" {Gaertnerias) , 
the marsh-elders (Ivas), and the cockle burrs 

( Xanthhim ) . 

3. "Artemisia." This group is an important 
cause of hayfever in the Rocky Mountain and Pa- 
cific States.' It contains numerous varieties, the 
most common being the following: Mugwort 
(Artemisia heterophylla) , wormwoods sage f.4. 
frigida), sagebrush (A. tridentata), absinth worm- 
wood (A. absinthium), dark-leaved mugwort u4. 
ludoviciana) , biennial wormwood (A. biennis), 
California old man (A. calif ornica), Indian hair 
tonic (A. dracunculoides) , and bud-brush (A. 
spinescens). 

4. "Chenopodiacex." In this group we include 
the amaranths, chenopods, Russian thistle (Sal- 
sola), and docks (Rumex), which, while not botan- 
ically as closely allied as the other groups, give a 
similar biological (hayfever) reaction. 

These four groups are responsible for most of 
the hayfever in the United States. There are some 
forms of hayfever, such as are due to the cedars, 
black walnut, and other trees and plants, which are 
not included in these groups. Most of these cases, 
however, have a limited distribution, and their pol- 
len extracts, when required, should be prepared 
especially. 

The terms "spring pollen" and "autumn pollen" 
extracts should be omitted from the manufactured 
preparations. The autumn hayfever, for instance, 
in the East, is due principally to the ragweeds 
(Ambrosias), but in the Pacific and Rocky ^loun- 
tain States to the wormwoods ( Artemisias). 

We have a "spring" hayfever in the Gulf States 
also, which is due to the oaks and cottonwoods, and 
one in Texas due to the cedars.' The extracts 
should, therefore, be named simply from the con- 
tained pollen. 

Combined extracts of so-called "spring" and 
"fall" pollens are not advisable. While our experi- 
ence of the past two years has shown that susoepti- 



bility to both forms is much larger than is gen- 
erally supposed (42 per cent of cases in Series C), 
the degree of susceptibility to both varies greatly. 
Exposure to the grass pollen is usual in the spring, 
and to the ragweeds (Eastern and Southern States) 
in the fall, so that both extracts are not indicated 
at the same time. The principal reason for such a 
combination being used is to avoid the necessity of 
making a diagnostic test, which, however, is an es- 
sential factor in the success of this method. 

The date of manufacture of pollen extracts should 
be stated. In spite of the utmost care in their 
preparation, the activity of some of the pollen ex- 
tracts dimini.'^hes materially after the first season. 
This is observed not only in the diagnostic tests but 
also in the effects of the treatment. 

The use of these rules not only simplifies the ap- 
plication of pollen therapy, but also enables the re- 
sults to be analyzed with a view of perfecting this 
method. The manufacturers generally have shown 
a disposition to cooperate in this standardization 
of pollen extracts, which will simplify the treat- 
ment of hayfever and hayfever asthma. 

REFERENCES. 

1. Scheppegrell, W.: The Treatment of Hayfever 
and Hayfever Asthma by Pollen Extracts and Bacterial 
Vaccines. New York Medical Journal, June 1, 1918. 

2. Scheppegrell, W.: The Clas.sification of Hayfever 
Pollens from a Biological Standpoint. Boston Medical 
and Surgical Journal. July 12, 1917. 

3. Scheppegrell, W.: Hayfever; Its Cause and Pre- 
vention in the Rocky Mountain and Pacific States, 
United States Public Health Reports, July 20, 1917. 

4. Scheppegrell, W.: Hayfever and Its Relation to 
100 of the Most Common Plants. Trees, and Grasses, 
Medical Record, August 11, 1917. 

AtTDUBON Building. 



A CONSIDERATION OF SOME OF THE PROB- 
LEMS OF HEREDITARY SYPHILIS.* 

Bt WALTER S. RETX<1LP.<;. M.D . 

NEW YORK. 

Questions relating to the transmissibility of syphilis 
by inheritance are of the utmost importance, involv- 
ing as they do the life, health, and happiness of 
countless individuals. The physician who is more 
actively engaged in the treatment of syphilis and 
has the opportunity of seeing day after day a large 
number of these unfortunates is perhaps more im- 
pressed with the truth of this statement than physi- 
cians engaged in other lines of medical work. But 
in whatever branch of medicine the physician may 
be interested he is undoubtedly frequently con- 
fronted with hereditary syphilis as having a pos- 
sible influence or being a direct cause of the trouble 
for which he may be consulted. In our asylums and 
public institutions many of the inmates bear testi- 
mony to the havoc it has wrought in the lives of 
these pitiable individuals. 

While some progress has undoubtedly been made 
in our knowledge regarding hereditary syphilis, 
there are still many problems which remain to be 
solved in this very complex question. Based on 
clinical evidence alone, as they were, some of our 
former theories relating to the question have not 
been found to hold good and it has been found neces- 

♦Read at the meeting of The West End Medical 
Society, New York, .-Vpril 27. 1918. 



July 27, 1918] 



MEDICAL RECORD. 



14S 



saiy to revise some of our conceptions when we have 
come to apply more recent methods of investigation 
to the solution of these problems. The Wassermann 
test of the blood has shed new light upon many of 
the obscurities with which the subject was sur- 
rounded, and, it must be confessed, in some in- 
stances has added new factors to complicate it. 
While the Wassermann test has its limitations and 
is not infallible, it undoubtedly affords at the present 
time one of our most valuable means of determining 
whether the individual has at some time been in- 
fected with syphilis. It is coming to be believed. 
I think, that further than this we can make no 
positive statements regarding the value of the Was- 
sermann test. It will probably be some time and 
require much more e.xtended observation to make 
definite statements as to its value as an aid in 
prognosis or as a guide to treatment. 

Since the Wassermann test has come into general 
use as a diagnostic aid in s\-philis, greater interest 
has been taken in the family history of the syphilitic 
individual. Great assistance along these lines has 
been given by the social workers who in the past few 
years have been attached to many of our hospitals 
and dispensaries. With their aid we have been able 
to come into closer touch with the families of those 
who apply for treatment and to investigate many 
cases in a way that would otherwise be almost im- 
possible. 

By a brief review of some case histories we may 
perhaps be best able to bring out some of the prob- 
lems which confront us in considering hereditary 
syphilis. 

Case I. — Mrs. D., aged 19 years, came to the New 
York Hospital in July, 1917, gi%ang the following his- 
tory: She had been well previous to her marriage in 
1914. In 1916 her husband was a patient in Bellevue 
Hospital. She says he had "boils on the privates," and 
received one injection of 606. Her first child was born 
in 1915 and is alive and healthy now. One week after 
her husband was discharged from BelleNTie, Mrs. D. 
entered the same hospital and remained there for two 
weeks with "an eruption on the privates." No salvarsan 
was given, as it was said she was "too weak." A speci- 
men of blood was taken but she is unable to say what 
the report was. She comes to the hospital with her 
second child, a girl, five weeks old. The baby is fairly 
well nourished, being breast fed, but is suffering from 
snuffles and a marked onychia of both hands and feet. 

This woman was undoubtedly infected subsequent 
to the birth of her first child and had probably been 
syphilitic for about a year before the second child 
was born. The mother had no manifest symptoms 
of syphilis except a general adenitis and a four plus 
Wassermann. The mother was treated with salvar- 
san and mercury, and the baby with mercury by in- 
unction. After several months they discontinued 
coming for treatment and the nurse reported on 
visiting their home that she was probably prevented 
from attending by the husband, who resented hav- 
ing her call. The people were dreadfully poor and, 
of course, ignorant, and the question involved in 
the case is not one of treatment but the fate of the 
first child, who is probably sooner or later bound to 
be infected if allowed to remain in the home, and 
whether such individuals should be allowed to con- 
tinue to bring into the world a line of syphilitic 
progeny. 

Case II. — Mr. O.. 34 years old, referred to me in 
May, 1917. In April, 1917, two ulcerated patches de- 



veloped on the soft palate, one of which had resulted in 
a perforation. He had been treated for a short time by 
applications of silver nitrate and a specimen of the 
blood had shown a four plus Wassermann. Under the 
use of salvarsan, mercury, and iodides the perforation 
closed and no further symptoms developed. The man 
denied ever having had any primary or secondary symp- 
toms and was greatly astonished when told the trouble 
was due to sjiJhilis. In 1902, a pimple appeared on the 
forehead over the left eye and was opened several 
times and treated in various ways but never entirely 
healed. In 1904, 1906, and 1907 it was excised, and in 
1908 was treated by .i-ray for several weeks. In 1910 
it broke down again and a more extensive operation 
was undertaken for its removal. At this time three 
specimens were examined and all pronounced by com- 
petent pathologists as epithelioma. For three weeks 
after the operation he was treated by .r-ray. Healing 
took place and since that time there has been no 
recurrence of the trouble. A large scar shows where 
the lesion was situated, otherwise there is no evidence 
of abnormality. Mr. O had been married two years and 
his wife being two months advanced in her first pi-eg- 
nancy and both being most desirous of having a child, 
he wished to know what the probability was of the child 
being infected. An examination of his wife's blood 
on two different occasions showed it to be negative, and 
clinically she gave no signs of infection. I did not wish 
to assume the responsibility of making too positive 
statements and tried to place the matter before him in 
all its aspects, leaving the decision to him. After get- 
ting the advice of several other physicians, they decided 
to have the pregnancy terminated. 

Mr. O.'s Wassermann, in spite of the vigorous treat- 
ment with salvarsan, mercury by inunction and by in- 
tramuscular injections, and iodide of potassium, still 
remained four plus until mixed treatment was substi- 
tuted, when, in a short time, the Wassermann was re- 
ported doubtful, and subsequently became negative on 
continuing the use of this treatment. After the admin- 
istration of one dose of 0.4 salvarsan, the Wassermann 
again became positive. The lesion in the mouth, nine 
months after treatment was begun, remains closed, a 
depressed scar being the only evidence remaining. 

Several features of this case might well be con- 
sidered in more detail were it not for the fact that 
this paper has to do more particularly with ques- 
tions relating to hereditary transmission of syphilis. 
There are two points, however, to which I should 
like to call attention. 

In our enthusiasm for newer remedies we are not 
infrequently apt to neglect the older ones which by 
long usage have shown their value, and I believe 
this is so to a large extent with iodide. of potassium. 
A striking example of the benefit to be obtained by 
the use of iodides in such cases was the rapid im- 
provement which took place as soon as its use was 
begun. The other point to which I wish to call 
attention was the change in the Wassermann pro- 
duced by the use of mixed treatment. 

In this case the patient was undoubtedly suffering 
from a tertiary lesion. His denial of all knowledge 
of primary or secondary manifestations may be 
questioned by some, but I have no hesitation in 
accepting his statement. It is not at all infrequent 
that we find a positive Wassermann with no history 
of either primary or secondary symptoms. While 
some of these people possibly are anxious to deceive 
the physician, in many instances their statements 
cannot be doubted. As the nature of the lesion was 
manifest in Mr. O.'s case and there was no evidence 
whatsoever to show that his wife had been infected, 
I did not feel that there was any likelihood of the 
child being syphilitic, yet I did not deem it right to 
urge too strongly against terminating the preg- 
nancy while believing that all cases of hereditary 



144 



mi-;dic.\l rix'ori). 



[July 27, 1918 



syphilis are transmitted through the infection of the 
mother. I am also of the conviction that in true 
tertiary syphilis the possibility of infection is not 
great. The former statement, while contrary to 
older teachings, is, I believe, warranted ijy recent 
investigation, while the views regaiding tertiary 
syphilis also held by many older writers receive 
additional confirmation. 

Case III. — M. B., 2(; year.s old, wa.s brought to the 
New York Hospital in the ambulance in a comatose con- 
(lition, Oct. 1, 1917. She remained in the wards for 
five weeks, during which time she had convulsive .seiz- 
ures at frequent intervals. These would begin as 
twitchings of the left side of the mouth, extending to 
the left arm. Under treatment with arsenobenzol, both 
intravenously and intraspinously, she gradually recov- 
ered consciousness and the convulsive seizures stopped. 
On Nov. 14, 1917, she entered the out patient depart- 
ment as a patient, giving the following history: In 
January, 1917, on account of severe headaches, she had 
consulted a physician. He secured a specimen of blood 
which on examination showed a four plus Wassermann. 
She received weekly injections of mercury until Oct. 1. 
when, while on the street, she suddenly became uncon- 
scious and was removed to the hospital as stated. The 
young woman was accompanied by her mother, who 
gave the additional information in regard to her daugh- 
ter's infection: Fifteen years previously, the mother 
had taken as a boarder a child of five months and had 
kept him until he was seven years old. She stated that 
he was at the present time in an institution and she 
had reason to believe that he was the source of infec- 
tion. To confirm her statement, I visited the institu- 
tion and was informed that the child was there as she 
had stated. He was suffering from keratitis, being 
nearly blind when he entered as well as having lost his 
hearing. The blood had been examined several times 
and on each examination had given a four plus Was- 
sermann. Specimens of blood fi-om the young woman 
taken while in the ward had given a four plus. A 
specimen of the mother's blood taken on her visit to the 
clinic gave a negative Wassermann. 

The history of these three cases will serve to show- 
some of the problems of hereditary .syphilis which 
we may be at any time asked to answer. In Case I, 
either the termination of pregnancy or a syphilitic 
child could be the only possible answer to a woman 
so recently infected. That the infection may con- 
tinue to exert its influence for a long period of time 
will be shown later, and, on the other hand, it seems 
evident that a four plus Wassermann does not 
of necessity indicate that the child may be syphilitic. 
How then are we to decide the question, for a Was- 
sermann certainly does not help u.-< in solving the 
problem ? 

As has been said, a surprisingly large number of 
men and women presenting undoubted manifesta- 
tions of late syphilis deny having had any primary 
or secondary symptoms. Leaving out of considera- 
tion those who willfully seek to hide their infection, 
there are no doubt a large number who are i)er- 
fectly truthful in their statements. The initial 
lesion may be .seemingly insignificant, and the pa- 
tient gives it little thought. In women, genital lesions 
are not infrequently so situated as to escape ob- 
servation. It is a well known clinical fact that a 
secondary rash has been unnoticed until attention 
is called to it by the physician, and even without 
treatment in some cases it may quickly fade. It has 
been proposed that all persons before marriage